Oregon ›Oregon City

Avamere Rehabilitation of Oregon City

1400 Division Street, Oregon City, OR 97045 · Clackamas County · 111 certified beds · avg 62 residents/day · certified since Mar 28, 1975

Part of chain: AVAMERE (27 facilities, chain avg rating 3.0★)

2/5
Health inspection rating (on-site)
3
Serious findings on record
$85,768
Fines, last 3 years
5.70
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5

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 self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · 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): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jun 26, 2025 (Past Non-Compliance)

▲ Actual harm, one-off · 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): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Apr 2, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · 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): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Feb 22, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (61)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Aug 29, 2025▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jun 6, 2025E · Potential for harm, repeatedThe 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.
Jun 6, 2025D · Potential for harm, one-offThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Jun 6, 2025D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jun 6, 2025D · Potential for harm, one-offThe 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
Jun 6, 2025D · Potential for harm, one-offThe 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.
Jun 6, 2025D · Potential for harm, one-offThe facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Jun 6, 2025D · Potential for harm, one-offThe 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.
Jun 6, 2025D · Potential for harm, one-offThe 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.
Jan 17, 2025D · Potential for harm, one-offThe 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
Jan 17, 2025D · Potential for harm, one-offThe 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
Jan 17, 2025D · Potential for harm, one-offThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Feb 13, 2024▲ G · Actual harm, one-offThe 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
Feb 13, 2024F · Potential for harm, facility-wideThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint
Feb 13, 2024E · Potential for harm, repeatedThe 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
Feb 13, 2024E · Potential for harm, repeatedThe 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
Feb 13, 2024E · Potential for harm, repeatedThe facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint
Feb 13, 2024E · Potential for harm, repeatedThe 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
Feb 13, 2024E · Potential for harm, repeatedThe 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
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe 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.
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. · from a complaint
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint
Feb 13, 2024D · Potential for harm, one-offThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe 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
Feb 13, 2024D · Potential for harm, one-offThe facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · from a complaint
Jan 13, 2023▲ G · Actual harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jan 13, 2023F · Potential for harm, facility-wideThe 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.
Jan 13, 2023F · Potential for harm, facility-wideThe facility did not have enough support staff to safely and effectively run its food and nutrition service.
Jan 13, 2023F · Potential for harm, facility-wideThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Jan 13, 2023F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jan 13, 2023F · Potential for harm, facility-wideThe facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Jan 13, 2023E · Potential for harm, repeatedThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Jan 13, 2023E · Potential for harm, repeatedThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Jan 13, 2023E · Potential for harm, repeatedThe facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials.
Jan 13, 2023E · Potential for harm, repeatedThe 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.
Jan 13, 2023E · Potential for harm, repeatedThe facility did not have a policy covering how food brought in by family and visitors is used and stored safely.
Jan 13, 2023D · Potential for harm, one-offThe 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.
Jan 13, 2023D · Potential for harm, one-offThe 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.
Jan 13, 2023D · Potential for harm, one-offThe 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.
Jan 13, 2023D · Potential for harm, one-offThe 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.
Jan 13, 2023D · Potential for harm, one-offThe 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.
Jan 13, 2023D · Potential for harm, one-offThe 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.
Jan 13, 2023D · Potential for harm, one-offThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (31 → 8).

YearCitationsSerious (G–L)Worst severity that year
2023181G ▲
2024311G ▲
2025121G ▲

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.

Fines and enforcement (last 3 years)

1 fine totaling $85,768.

DateTypeAmount / length
Feb 13, 2024Fine$85,768

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityOregon avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)5.705.423.95top 26% in Oregon; top 6% in the U.S.
Registered Nurse hours0.500.780.69bottom 21% in Oregon; bottom 38% in the U.S.
Weekend total nurse staffing5.114.853.50top 26% in Oregon; top 5% in the U.S.
Weekend RN hours (not acuity-adjusted)0.360.480.48bottom 43% in Oregon; bottom 44% in the U.S.
Total nursing staff turnover (%)52.647.445.8bottom 33% in Oregon; bottom 30% in the U.S.
RN turnover (%)70.051.642.9bottom 23% in Oregon; bottom 12% in the U.S.

Hours are per resident per day, 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. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 4/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Ari Operations, LLCOrganizationIndirect Ownership InterestNOT APPLICABLE01/06/2006
Ariso LLCOrganizationDirect Ownership InterestNOT APPLICABLE01/06/2006
Avamere Group LLCOrganizationIndirect Ownership InterestNOT APPLICABLE01/06/2006
Karl Rickard Miller Jr Revocable TrustOrganizationIndirect Ownership InterestNOT APPLICABLE07/11/2011
Miller, KarlIndividualIndirect Ownership InterestNOT APPLICABLE07/20/2001
Angerhofer, NicoleIndividualOperational/Managerial ControlNOT APPLICABLE12/01/2023
Angerhofer, NicoleIndividualADP of the SNFNOT APPLICABLE12/01/2023
Avamere Health Services LLCOrganizationOperational/Managerial ControlNOT APPLICABLE01/01/2005
Avamere Health Services LLCOrganizationADP of the SNFNOT APPLICABLE07/10/2025
Avamere Skilled Advisors LLCOrganizationOperational/Managerial ControlNOT APPLICABLE01/01/2005
Avamere Skilled Advisors LLCOrganizationADP of the SNFNOT APPLICABLE07/14/2025
Cavallo, GlenIndividualManaging Control - Governing BodyNOT APPLICABLE06/01/2025
Dana, JenniferIndividualOperational/Managerial ControlNOT APPLICABLE05/01/2022
Dana, JenniferIndividualADP of the SNFNOT APPLICABLE05/01/2022
Davis, JulieIndividualADP of the SNFNOT APPLICABLE08/01/2024
Doepker, AndreaIndividualOperational/Managerial ControlNOT APPLICABLE09/28/2023
Doepker, AndreaIndividualADP of the SNFNOT APPLICABLE09/08/2023
Feakin, CodyIndividualManaging Control - Governing BodyNOT APPLICABLE06/01/2025
Feakin, CodyIndividualOperational/Managerial ControlNOT APPLICABLE07/15/2025
Feakin, CodyIndividualADP of the SNFNOT APPLICABLE01/01/2025

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Rivercrest Post Acute1.2 miOregon City, OR★★☆☆☆2/5
Marquis Oregon City Post Acute Rehab1.5 miOregon City, OR★★★★★4/5
Avamere Rehabilitation of Clackamas2.0 miGladstone, OR★★★★☆3/5
Rose Linn Care Center3.4 miWest Linn, OR★★★☆☆4/5
Stanley Post Acute5.7 miMilwaukie, OR★★★☆☆3/5
Fernwood Supportive Living at Madrona Grove5.7 miPortland, OR★★★★☆3/5
Willamette View Health Center5.8 miMilwaukie, OR★★★★★5/5
The Pearl at Kruse Way7.7 miLake Oswego, OR★★★★☆4/5
Marquis Hope Village8.8 miCanby, OR★★★★☆4/5
Marquis Tualatin Post Acute Rehab8.9 miTualatin, OR★★★★★4/5

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 385125.