1400 Division Street, Oregon City, OR 97045 (opens Google Maps) · Clackamas County · (503) 656-0367· 111 certified beds · avg 62 residents/day · certified since Mar 28, 1975 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
Part of chain: AVAMERE (27 facilities, chain avg rating 3.0★)
New to these records? How to read an inspection report →
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5 · how star ratings work →
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and quality measures from resident assessments and claims.
▲ Actual harm, isolated · Aug 29, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Jun 26, 2025 (Past Non-Compliance)
▲ Actual harm, isolated · Feb 13, 2024 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Apr 2, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · Jan 13, 2023 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Feb 22, 2023 (Deficient, Provider has date of correction)
Showing the latest 3 of 61 inspection findings. Open the full record below to read every finding.
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint F-0689
The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. F-0761
The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. F-0552
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Aug 29, 2025 | ▲ G · Actual harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| Jun 6, 2025 | E · Potential for more than minimal harm, pattern | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · F-0761 |
| Jun 6, 2025 | D · Potential for more than minimal harm, isolated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · F-0552 |
| Jun 6, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584 |
| Jun 6, 2025 | D · Potential for more than minimal harm, isolated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610 |
| Jun 6, 2025 | D · Potential for more than minimal harm, isolated | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · F-0644 |
| Jun 6, 2025 | D · Potential for more than minimal harm, isolated | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. · F-0685 |
| Jun 6, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · F-0688 |
| Jun 6, 2025 | D · Potential for more than minimal harm, isolated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| Jan 17, 2025 | D · Potential for more than minimal harm, isolated | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint · F-0624 |
| Jan 17, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684 |
| Jan 17, 2025 | D · Potential for more than minimal harm, isolated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint · F-0804 |
| Feb 13, 2024 | ▲ G · Actual harm, isolated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint · F-0686 |
| Feb 13, 2024 | F · Potential for more than minimal harm, widespread | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint · F-0867 |
| Feb 13, 2024 | E · Potential for more than minimal harm, pattern | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684 |
| Feb 13, 2024 | E · Potential for more than minimal harm, pattern | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint · F-0725 |
| Feb 13, 2024 | E · Potential for more than minimal harm, pattern | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint · F-0730 |
| Feb 13, 2024 | E · Potential for more than minimal harm, pattern | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint · F-0732 |
| Feb 13, 2024 | E · Potential for more than minimal harm, pattern | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · from a complaint · F-0947 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint · F-0554 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint · F-0578 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint · F-0602 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint · F-0609 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. · F-0636 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. · from a complaint · F-0637 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint · F-0641 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint · F-0656 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint · F-0657 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint · F-0658 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint · F-0677 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. · from a complaint · F-0685 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint · F-0687 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · from a complaint · F-0688 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint · F-0695 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint · F-0697 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint · F-0698 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint · F-0759 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. · from a complaint · F-0791 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. · from a complaint · F-0810 |
| Feb 13, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · from a complaint · F-0825 |
| Jan 13, 2023 | ▲ G · Actual harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684 |
| Jan 13, 2023 | F · Potential for more than minimal harm, widespread | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · F-0725 |
| Jan 13, 2023 | F · Potential for more than minimal harm, widespread | The facility did not have enough support staff to safely and effectively run its food and nutrition service. · F-0802 |
| Jan 13, 2023 | F · Potential for more than minimal harm, widespread | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · F-0804 |
| Jan 13, 2023 | F · Potential for more than minimal harm, widespread | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Jan 13, 2023 | F · Potential for more than minimal harm, widespread | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · F-0867 |
| Jan 13, 2023 | E · Potential for more than minimal harm, pattern | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · F-0565 |
| Jan 13, 2023 | E · Potential for more than minimal harm, pattern | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · F-0679 |
| Jan 13, 2023 | E · Potential for more than minimal harm, pattern | The facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials. · F-0680 |
| Jan 13, 2023 | E · Potential for more than minimal harm, pattern | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · F-0732 |
| Jan 13, 2023 | E · Potential for more than minimal harm, pattern | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. · F-0813 |
| Jan 13, 2023 | D · Potential for more than minimal harm, isolated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · F-0558 |
| Jan 13, 2023 | D · Potential for more than minimal harm, isolated | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · F-0561 |
| Jan 13, 2023 | D · Potential for more than minimal harm, isolated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · F-0657 |
| Jan 13, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · F-0744 |
| Jan 13, 2023 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · F-0757 |
| Jan 13, 2023 | D · Potential for more than minimal harm, isolated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · F-0759 |
| Jan 13, 2023 | D · Potential for more than minimal harm, isolated | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · F-0806 |
Citations from standard inspections decreased between the last two inspection cycles (31 → 8).
All bars start at zero. Exact values and supporting details remain below.
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 18 | 1 | G ▲ |
| 2024 | 31 | 1 | G ▲ |
| 2025 | 12 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
How to file a complaint about care →
1 fine totaling $85,768.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
| Date | Type | Amount / length |
|---|---|---|
| Feb 13, 2024 | Fine | $85,768 |
What these staffing numbers mean →
All bars start at zero. Exact values and supporting details remain below.
| Measure | This facility | Oregon avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.70 | 5.42 | 3.95 | top 26% in Oregon; top 6% in the U.S. |
| Registered Nurse hours | 0.50 | 0.78 | 0.69 | bottom 21% in Oregon; bottom 38% in the U.S. |
| Weekend total nurse staffing | 5.11 | 4.85 | 3.50 | top 26% in Oregon; top 5% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.36 | 0.48 | 0.48 | bottom 43% in Oregon; bottom 44% in the U.S. |
| Total nursing staff turnover (%) | 52.6 | 47.4 | 45.8 | bottom 33% in Oregon; bottom 30% in the U.S. |
| RN turnover (%) | 70.0 | 51.6 | 42.9 | bottom 23% in Oregon; bottom 12% in the U.S. |
Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.26, RN 0.47, weekend 4.72.Comparing with Medicare Care Compare? Care Compare shows the raw figure (5.26 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 4/5.
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 4/5
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Avamere Rehabilitation of Oregon City. CMS inspection and staffing records do not tell us what this home will charge you.
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Understand who pays for care · How we handle price evidence · Report an incorrect price
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ari Operations, LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 01/06/2006 |
| Ariso LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 01/06/2006 |
| Avamere Group LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 01/06/2006 |
| Karl Rickard Miller Jr Revocable Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 07/11/2011 |
| Miller, Karl | Individual | Indirect Ownership Interest | NOT APPLICABLE | 07/20/2001 |
| Angerhofer, Nicole | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2023 |
| Angerhofer, Nicole | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2023 |
| Avamere Health Services LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2005 |
| Avamere Health Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/10/2025 |
| Avamere Skilled Advisors LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2005 |
| Avamere Skilled Advisors LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/14/2025 |
| Cavallo, Glen | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2025 |
| Dana, Jennifer | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2022 |
| Dana, Jennifer | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2022 |
| Davis, Julie | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2024 |
| Doepker, Andrea | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/28/2023 |
| Doepker, Andrea | Individual | ADP of the SNF | NOT APPLICABLE | 09/08/2023 |
| Feakin, Cody | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2025 |
| Feakin, Cody | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/15/2025 |
| Feakin, Cody | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
Showing 20 of 67 parties CMS has on file for this facility; 47 are not displayed. The full list is in the CMS Ownership dataset.
CMS lists this facility under the chain Avamere — 27 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.
Listed by state, then facility name — not a ranking. Showing 8 of the 26 others, continuing from this facility's own place in that list.
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Rivercrest Post Acute | 1.2 mi | Oregon City, OR | ★★☆☆☆ | 2/5 | |
| Marquis Oregon City Post Acute Rehab | 1.5 mi | Oregon City, OR | ★★★★★ | 4/5 | |
| Avamere Rehabilitation of Clackamas | 2.0 mi | Gladstone, OR | ★★★★☆ | 3/5 | |
| Rose Linn Care Center | 3.4 mi | West Linn, OR | ★★★☆☆ | 4/5 | |
| Stanley Post Acute | 5.7 mi | Milwaukie, OR | ★★★☆☆ | 3/5 | |
| Fernwood Supportive Living at Madrona Grove | 5.7 mi | Portland, OR | ★★★★☆ | 3/5 | |
| Willamette View Health Center | 5.8 mi | Milwaukie, OR | ★★★★★ | 5/5 | |
| The Pearl at Kruse Way | 7.7 mi | Lake Oswego, OR | ★★★★☆ | 4/5 | |
| Marquis Hope Village | 8.8 mi | Canby, OR | ★★★★☆ | 4/5 | |
| Marquis Tualatin Post Acute Rehab | 8.9 mi | Tualatin, OR | ★★★★★ | 4/5 | |
| Gracelen Care Center | 9.1 mi | Portland, OR | ★☆☆☆☆ | 1/5 | |
| Cascade Terrace Post Acute | 9.1 mi | Portland, OR | ★☆☆☆☆ | 1/5 | SFF |
Compare this facility with the 3 closest →
CMS records place this facility in Clackamas, OR — 13 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.
Listed by facility name — not a ranking. Homes already in the table above are not repeated here.
Facility data as of CMS processing date 2026-08-01. CCN 385125.
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