Avamere Rehabilitation of King City
Tigard, Oregon · CCN 385132
24 surveys since 2010, 12 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 156
- Surveys
- 24
- Harm or worse
- 12
- Immediate jeopardy
- 4
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 148
- Ownership
- For profit - Limited Liability company
- Chain
- AVAMERE
- County
- Washington
- Medicare-certified since
- 1976
CMS ratings
- Overall
- 4
- Health inspection
- 3
- Staffing
- 4
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat more weighted findings than its peer group.
Weighted by harm level, against 111 for-profit facilities in Oregon.
Last survey on record
Feb 20, 2026
262 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.27 | 4.93 |
| Registered-nurse hours per resident day | 0.75 | — |
| Annual nurse turnover | 39.8% | 41.5% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D2575.8% | E721.2% | F13.0% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6562×
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- F6572×
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- F6792×
Provide activities to meet all resident's needs.
- F6842×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F6882×
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.
In the surveyor’s words
From the most serious findings on record at Avamere Rehabilitation of King City, in the surveyor’s own words.
- Immediate jeopardy, patternF689Oct 12, 2021
1. Based on observation, interview, and record review it was determined the facility failed to provide supervision for swallowing safety for 1 of 13 residents (#1) identified at risk for aspiration and who was to be supervised while eating. Resident 1 was observed to be left unattended with her/his meal and/or fluids two times during continuous observations. Resident 1 was able to independently feed her/himself. This failure resulted in an immediate jeopardy situation. This placed residents at risk for aspiration and death. Findings include: The 9/2021 Dysphagia Diets and Aspiration Precautions policy statement indicated residents who were identified as close supervision and 1:1 supervision levels were not to be left unattended with the food tray. […]
- Immediate jeopardy, patternF867Oct 12, 2021
Based on interview and record review it was determined the facility failed to ensure a program of systemic identification, analysis and action was in place related to residents at risk for aspiration and falls for 1 of 1 QAA (Quality Assessment and Assurance) committee reviewed for quality assurance. This failure resulted in Resident 1 who was identified as an aspiration risk with a previous history of aspiration to be observed alone with food and liquids on 9/20/21. Additionally, twelve residents were identified as an aspiration risk and 33 residents were identified to be at risk for falls and hospitalization . This was determined to be an Immediate Jeopardy (IJ) situation. […]
- Immediate jeopardy, isolatedF610Mar 23, 2023
Based on observation, interview and record review it was determined the facility failed to thoroughly investigate and rule out incidents of potential sexual abuse without adequate evidence for 1 of 2 sampled residents (#100) reviewed for abuse. This deficient practice was determined to be an immediate jeopardy situation and placed Resident 100 at risk of sexual abuse. Findings include: Resident 100 was admitted to the facility in 2/2022 with diagnoses including hypertensive chronic kidney disease (a condition caused by damage to the blood flow of the kidneys). Resident 100's 2/6/23 MDS identified resident with a BIMS score of 5 (severe cognitive impairment). […]
- Actual harm, widespreadF868Oct 12, 2021
Based on interview and record review it was determined the facility failed to have the QAA (Quality Assessment and Assurance) committee meet quarterly for 1 of 1 QAA Committees reviewed for quality assurance. This failure resulted in falls with hospitalization and a fracture, and placed residents at increased risk of aspiration. Findings include: The Quality Assurance and Performance Improvement Program policy and procedure revealed the QAA committee was to meet monthly to review reports, evaluate data, monitor QA related activities and make adjustments to the plan. Review of the facility documents revealed from 1/2020 through 10/4/21 the QAA committee met on 1/28/20, 10/21/20 and 4/1/21. […]
- No harm, potential for more than minimal, widespreadF725Jul 19, 2024
Based on interview and record review it was determined the facility failed to ensure there were sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: On 7/25/24 the facility had a census of 62 residents. On 7/18/24, Staff 1 (Administrator) provided a list of residents who: -Required two-person mechanical lift transfers: 23; -Required one or two-person extensive or total assistance for bathing: 47; -Required one or two-person extensive or total assistance for toileting: 47; -Required one or two-person extensive or total assistance for dressing: 49; -Required two person assistance at all times for all care: 11; -Had behavioral… […]
Read 32 findings in full →The most serious and the most recent: 32 of 156 on record.
Every survey on record
FindingsAt actual harm or above
- Aug 13, 2026Complaint4 findings
- Feb 20, 2026Complaint2 findings
- Dec 5, 2025Standard8 findings
- Jan 10, 2025Complaint1 finding
- Jul 19, 2024Standard and complaint12 findings
- Apr 10, 2023Standard and complaint10 findings
- Mar 23, 2023Complaint2 findings · 1 harm
- Sep 29, 2022Complaint1 finding
Show the 16 earlier surveys
- Feb 24, 2022Standard4 findings
- Oct 12, 2021Complaint20 findings · 3 harm
- Aug 3, 2020Complaint2 findings
- Feb 28, 2020Standard and complaint18 findings
- Jan 15, 2020Complaint1 finding · 1 harm
- Jun 18, 2019Complaint2 findings
- Apr 30, 2018Standard and complaint16 findings · 4 harm
- Mar 13, 2017Standard14 findings
- Feb 2, 2016Standard and complaint10 findings
- Dec 22, 2014Standard2 findings
- Oct 31, 2013—2 findings
- Jul 31, 2013—10 findings
- Mar 21, 2012—6 findings
- Aug 29, 2011—3 findings · 2 harm
- Feb 11, 2011—1 finding · 1 harm
- Aug 13, 2010—5 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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