Avamere Rehabilitation of Oregon City: Fall Injury - OR
The incident happened in late June. The resident, identified in inspection records as Resident 8, had been at the facility since May 2025, and her care plan had been clear since at least May 27: limited mobility from a neck fracture, two-person assist required for toileting transfers. She was cognitively sharp, scoring a perfect 15 out of 15 on a standard cognitive assessment.
None of that stopped Staff 20, a certified nursing assistant, from attempting the transfer alone.
Resident 8 described what happened when inspectors spoke with her on August 20. Staff 20 tried to help her up from the commode. She slipped. She hit the floor. Her right arm fractured. A hospital discharge summary dated June 27 confirmed the fracture and its cause.
The facility completed its own investigation the day before that discharge summary, on June 26. Inspectors obtained the report. It said Staff 20 had not followed the resident's care plan. The facility's own root cause analysis reached the same conclusion: someone failed to follow what was written down.
Staff 20 was unreachable. Inspectors tried to interview the aide on August 26 and again on August 27. Both times, nothing. The aide who caused the injury never spoke with surveyors.
The facility's resident care manager, identified as Staff 3, confirmed on August 27 that the two-person requirement was in place and that Staff 20 failed to follow it. The administrator, Staff 1, said the same thing two days later. There was no dispute about what happened or why.
What the facility did afterward was document. A care plan revision for Resident 8. A facility-wide audit of fall risk plans. Re-education for all nursing staff on following individualized care plans. Supervisors conducting random spot checks. The director of nursing services running weekly audits for three months, with results fed into quality assurance committee meetings.
The violation was classified as past noncompliance, meaning inspectors determined the facility had identified and addressed the problem before the August inspection. The harm level was listed as actual harm.
That classification matters because of what it does not resolve. A resident arrived at a rehabilitation facility already carrying a neck fracture. She was there, presumably, to recover. Her care plan recognized how vulnerable she was and specified exactly what staff needed to do to keep her safe during one of the most routine moments of a nursing home day. That plan was ignored. She left the commode with a broken arm.
The resident said it herself, plainly, when inspectors asked: her care plan required two people, and Staff 20 came alone.
Facilities write care plans because individual residents have individual risks. A two-person transfer requirement is not bureaucratic formality. It exists because someone assessed the resident, recognized she could not safely be moved by one person, and wrote that down so every staff member who entered her room would know it. The system worked exactly as designed, right up until the moment Staff 20 decided not to use it.
Avamere Rehabilitation of Oregon City is a skilled nursing facility. Residents arrive after hospitalizations, surgeries, fractures. They are, by definition, people whose bodies have already failed them in some way. Resident 8 came in with a broken neck. She left a routine trip to the bathroom with a broken arm.
The aide who transferred her alone was never interviewed by state surveyors. Whether Staff 20 still works at the facility, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avamere Rehabilitation of Oregon City from 2025-08-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
AVAMERE REHABILITATION OF OREGON CITY in OREGON CITY, OR was cited for violations during a health inspection on August 29, 2025.
The incident happened in late June.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.