The Vardell Report.Avamere Rehabilitation of Oregon City

Across 5 inspections from January 2023 to August 2025, state surveyors documented 61 findings at Avamere Rehabilitation of Oregon City; 61 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

5

2023–2025, complaint and standard

Findings

61

Deficiencies cited by state inspectors

Corrected

61

Of 61 findings, with a recorded correction date

Penalties

1

1 fine; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Aug 292025

   Complaint investigation

   1 finding

   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Jun 26, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Jun 62025

   Standard health inspection

   8 findings

   The same visit included a complaint investigation.

   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Jul 2, 2025
   • F552Ensure that residents are fully informed and understand their health status, care and treatments.Level DNo actual harm, potential for moreCorrected Jul 2, 2025
   • F584Honor 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.Level DNo actual harm, potential for moreCorrected Jul 2, 2025
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Jul 2, 2025
   • F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Jul 2, 2025
   • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Jul 2, 2025
   • F688Provide 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.Level DNo actual harm, potential for moreCorrected Jul 2, 2025
   • F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jul 2, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Jan 172025

   Complaint investigation

   3 findings

   • F624Prepare residents for a safe transfer or discharge from the nursing home.Level DNo actual harm, potential for moreCorrected Feb 28, 2025
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Feb 28, 2025
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level DNo actual harm, potential for moreCorrected Feb 28, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

4. Feb 132024

   Standard health inspection

   31 findings

   The same visit included a complaint investigation.

   • F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level GActual harmCorrected Apr 2, 2024
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level FNo actual harm, potential for moreCorrected Apr 2, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Apr 2, 2024
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Apr 2, 2024
   • F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Apr 2, 2024
   • F732Post nurse staffing information every day.Level ENo actual harm, potential for moreCorrected Apr 2, 2024
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level ENo actual harm, potential for moreCorrected Apr 2, 2024
   • F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F578Honor 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.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F584Honor 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.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F685Assist a resident in gaining access to vision and hearing services.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F687Provide appropriate foot care.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F688Provide 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.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F697Provide safe, appropriate pain management for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F791Provide or obtain dental services for each resident.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F825Provide or get specialized rehabilitative services as required for a resident.Level DNo actual harm, potential for moreCorrected Apr 2, 2024

   Enforcement Action

   Civil money penalty, $85,768 imposed February 13, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 13, 2024, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

5. Jan 132023

   Standard health inspection

   18 findings

   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Feb 22, 2023
   • F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Feb 22, 2023
   • F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Level FNo actual harm, potential for moreCorrected Feb 22, 2023
   • F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Level FNo actual harm, potential for moreCorrected Feb 22, 2023
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Feb 22, 2023
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level FNo actual harm, potential for moreCorrected Feb 22, 2023
   • F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Feb 22, 2023
   • F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Feb 22, 2023
   • F680Ensure the activities program is directed by a qualified professional.Level ENo actual harm, potential for moreCorrected Feb 22, 2023
   • F732Post nurse staffing information every day.Level ENo actual harm, potential for moreCorrected Feb 22, 2023
   • F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Level ENo actual harm, potential for moreCorrected Feb 22, 2023
   • F558Reasonably accommodate the needs and preferences of each resident.Level DNo actual harm, potential for moreCorrected Feb 22, 2023
   • F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Feb 22, 2023
   • F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Feb 22, 2023
   • F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level DNo actual harm, potential for moreCorrected Feb 22, 2023
   • F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Feb 22, 2023
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Feb 22, 2023
   • F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Level DNo actual harm, potential for moreCorrected Feb 22, 2023

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Quality of Care, Cited in Three Inspections

   Inspectors cited F684 in January 2023, February 2024 and January 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324252525F684 across all 5 inspections, oldest to newest
2. 2

   A Clean, Homelike Setting, Cited in Two Inspections

   Inspectors cited F584 in February 2024 and June 2025. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324252525F584 across all 5 inspections, oldest to newest
3. 3

   Investigating Alleged Violations, Cited in Two Inspections

   Inspectors cited F610 in February 2024 and June 2025. This citation covers how the home responds to and investigates an allegation of abuse, neglect or mistreatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324252525F610 across all 5 inspections, oldest to newest
4. 4

   Care Plan Timing and Review, Cited in Two Inspections

   Inspectors cited F657 in January 2023 and February 2024. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324252525F657 across all 5 inspections, oldest to newest
5. 5

   Citation F685, Cited in Two Inspections

   Inspectors cited F685 in February 2024 and June 2025. The agency describes it this way: Assist a resident in gaining access to vision and hearing services. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324252525F685 across all 5 inspections, oldest to newest
6. 6

   Mobility and Range of Motion, Cited in Two Inspections

   Inspectors cited F688 in February 2024 and June 2025. This citation covers care that keeps or improves a resident’s movement and mobility. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324252525F688 across all 5 inspections, oldest to newest
7. 7

   Accident Hazards and Supervision, Cited in Two Inspections

   Inspectors cited F689 in February 2024 and August 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324252525F689 across all 5 inspections, oldest to newest
8. 8

   Nursing Staff Levels, Cited in Two Inspections

   Inspectors cited F725 in January 2023 and February 2024. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324252525F725 across all 5 inspections, oldest to newest
9. 9

   Post nurse staffing information every day, Cited in Two Inspections

   Inspectors cited F732 in January 2023 and February 2024. The agency describes it this way: Post nurse staffing information every day. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   2324252525F732 across all 5 inspections, oldest to newest
10. 10

    Medication Error Rate, Cited in Two Inspections

    Inspectors cited F759 in January 2023 and February 2024. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324252525F759 across all 5 inspections, oldest to newest
11. 11

    Food Quality and Temperature, Cited in Two Inspections

    Inspectors cited F804 in January 2023 and January 2025. This citation covers whether food and drink are palatable, attractive and served at a safe temperature. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324252525F804 across all 5 inspections, oldest to newest
12. 12

    Citation F867, Cited in Two Inspections

    Inspectors cited F867 in January 2023 and February 2024. The agency describes it this way: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

    2324252525F867 across all 5 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in three inspections, most seriously at level G.

2. 02

   What was done about the cleanliness citation, and how are rooms and shared spaces checked now?

   A Clean, Homelike Setting: cited in two inspections, most seriously at level D.

3. 03

   When an allegation is made, who investigates it, and how are residents protected in the meantime?

   Investigating Alleged Violations: cited in two inspections, most seriously at level D.

4. 04

   How often are care plans revised, and who takes part in the review?

   Care Plan Timing and Review: cited in two inspections, most seriously at level D.

5. 05

   What changed after F685 was cited, and how do you check it now?

   Citation F685: cited in two inspections, most seriously at level D.

6. 06

   What do you do to keep residents moving, and who provides range-of-motion care?

   Mobility and Range of Motion: cited in two inspections, most seriously at level D.

7. 07

   What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?

   Accident Hazards and Supervision: cited in two inspections, most seriously at level G.

8. 08

   How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

   Nursing Staff Levels: cited in two inspections, most seriously at level F.

9. 09

   What changed after F732 was cited, and how do you check it now?

   Post nurse staffing information every day: cited in two inspections, most seriously at level E.

10. 10

    How are medication passes checked, and what happens when an error is found?

    Medication Error Rate: cited in two inspections, most seriously at level D.

11. 11

    May we try a meal, and how do you check food temperature by the time it reaches residents?

    Food Quality and Temperature: cited in two inspections, most seriously at level F.

12. 12

    What changed after F867 was cited, and how do you check it now?

    Citation F867: cited in two inspections, most seriously at level F.

13. 13

    What led to the 2024 fine, and has it been paid?

    An $85,768 civil money penalty was imposed February 13, 2024. CMS publishes the fine, not whether it has been paid.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Oregon state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oregon state survey agency

  Inspection Jan 13, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oregon state survey agency

  Inspection Feb 13, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oregon state survey agency

  Inspection Jan 17, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oregon state survey agency

  Inspection Jun 6, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Oregon state survey agency

  Inspection Aug 29, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 385125

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.