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Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 30 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
This facility has areas of concern that warrant careful consideration. Registered Nurse hours are 62% of the EveryPlace reference benchmark; ask how RN coverage is allocated across shifts. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.
Avamere Rehabilitation of Oregon City receives highly polarized feedback, with some families praising the facility's cleanliness and the dedication of the administrative leadership. However, there are recurring, serious concerns regarding slow response times for call lights, inconsistent nursing care, and potential lapses in medication and safety protocols.
Quality Themes
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Concerns
Rating Trends
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Distribution · 34 analyzed
This facility actively engages with reviewer feedback.
Personalized based on this facility's data
Key Review Excerpts
“The staff and nursing there are great. I could move here closer to us but not sure of the care she would end up with. I love Lynn the social worker. Kathy the head nurse. And most of all the CNA's Mary, Shawnda,and Mo”
“Med aide completely ignored the huge signs on the wall saying NO STRAWS/ NO THIN LIQUIDS and gives meds with thin liquids and straw and leaves it at bedside.”
RN hours are below the EveryPlace reference benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
12
measures
2
measures
3
measures
Residents vaccinated for the flu
Residents whose bladder or bowel control got worse
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on anti-anxiety or sleep medication
Residents who lost too much weight
Residents on antipsychotic medication
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
Families filed multiple complaints that triggered inspections, revealing recurring issues with nursing staffing levels, medication management, and resident care planning. The facility has faced 76 deficiencies across six surveys, with problems persisting across multiple years including inadequate nursing staff, medication errors, and failures in resident assessments and care plans. While all deficiencies show correction dates, the pattern of repeated issues in core care areas warrants careful consideration before placement.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Resident Rights Deficiencies
Prepare residents for a safe transfer or discharge from the nursing home.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies
Provide appropriate foot care.
Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Nutrition and Dietary Deficiencies
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Quality of Life and Care Deficiencies
Provide or get specialized rehabilitative services as required for a resident.
Emergency Preparedness Deficiencies
Develop Emergency Preparedness policies and procedures.
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Smoke Deficiencies
Have an alternate power supply for its alarm system.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the installation and maintenance of electrical systems.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Federal Penalties
Fine
Feb 13, 2024
$85,768
Avamere Rehabilitation of Oregon City
for profit
Avamere
27 facilities nationwide
Chain avg rating: 2.9/5 · Rank 15 of 33
Owners
Ariso LLC
Owner · Organization
Ari Operations, LLC
Owner (parent company) · Organization
Avamere Group LLC
Owner (parent company) · Organization
Karl Rickard Miller Jr Revocable Trust
Owner (parent company) · Organization
Miller, Karl
Owner (parent company)
Kofstad, Mary
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Key personnel
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Google Reviews
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EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Some summaries, interpretations, suggested questions, and pricing research are AI-generated or AI-assisted and may contain errors or omit important context. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.
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