Inspection Reports for Avamere Rehabilitation of King City

16485 SW Pacific Highway, Tigard, OR, 97224

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Inspection Report Summary

The most recent inspection on December 5, 2025, identified multiple deficiencies related to resident rights, pain management, behavioral health services, pharmacy procedures, and nursing staffing. Earlier inspections showed a pattern of issues including insufficient nursing staff, care planning, activities, nutrition, medication management, and infection control. Complaint investigations found deficiencies but no enforcement actions or fines were listed in the available reports. A notable prior inspection in March 2023 identified immediate jeopardy related to sexual abuse allegations, which was addressed with investigation and removal plans. The facility’s deficiencies have persisted over time with no clear pattern of improvement or worsening.

Deficiencies (last 4 years)

Deficiencies (over 4 years) 17.8 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

166% worse than Oregon average
Oregon average: 6.7 deficiencies/year

Deficiencies per year

16 12 8 4 0
2022
2023
2024
2025

Inspection Report

Capacity: 148 Deficiencies: 12 Date: Dec 5, 2025

Deficiencies (12)
F0000 - INITIAL COMMENTS
F0550 - Resident Rights/Exercise of Rights
F0552 - Right to be Informed/Make Treatment Decisions
F0558 - Reasonable Accommodations Needs/Preferences
F0605 - Right to be Free from Chemical Restraints
F0679 - Activities Meet Interest/Needs Each Resident
F0697 - Pain Management
F0740 - Behavioral Health Services
F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records
F9999 - FINAL OBSERVATIONS
M0000 - Initial Comments
M0183 - Nursing Services: Minimum CNA Staffing

Inspection Report

Capacity: 148 Deficiencies: 2 Date: Nov 3, 2025

Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments

Inspection Report

Capacity: 148 Deficiencies: 2 Date: Jul 31, 2025

Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments

Inspection Report

Complaint Investigation
Capacity: 148 Deficiencies: 5 Date: Jan 10, 2025

Visit Reason
Facility failed to ensure sufficient nursing staff to meet residents' needs, resulting in missed showers and unmet care needs. Staffing shortages were documented and complaints received. Multiple residents affected by inadequate care and staffing.

Findings
Facility failed to ensure sufficient nursing staff to meet residents' needs, resulting in missed showers and unmet care needs. Staffing shortages were documented and complaints received. Multiple residents affected by inadequate care and staffing.

Deficiencies (5)
F0000 - INITIAL COMMENTS
F0725 - Sufficient Nursing Staff
M0000 - Initial Comments
M0183 - Nursing Services: Minimum CNA Staffing
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Complaint Investigation
Capacity: 148 Deficiencies: 2 Date: Sep 16, 2024

Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments

Inspection Report

Complaint Investigation
Capacity: 148 Deficiencies: 16 Date: Jul 19, 2024

Visit Reason
Facility failed to accurately assess residents, implement care plans, provide sufficient nursing staff, and ensure appropriate activities and nutrition. Multiple residents affected by unmet needs and risks. Staffing shortages and inadequate care documented.

Findings
Facility failed to accurately assess residents, implement care plans, provide sufficient nursing staff, and ensure appropriate activities and nutrition. Multiple residents affected by unmet needs and risks. Staffing shortages and inadequate care documented.

Deficiencies (16)
F0000 - INITIAL COMMENTS
F0641 - Accuracy of Assessments
F0645 - PASARR Screening for MD & ID
F0656 - Develop/Implement Comprehensive Care Plan
F0657 - Care Plan Timing and Revision
F0676 - Activities Daily Living (ADLs)/Mntn Abilities
F0677 - ADL Care Provided for Dependent Residents
F0679 - Activities Meet Interest/Needs Each Resident
F0684 - Quality of Care
F0688 - Increase/Prevent Decrease in ROM/Mobility
F0725 - Sufficient Nursing Staff
F0805 - Food in Form to Meet Individual Needs
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
M0000 - Initial Comments
M0183 - Nursing Services: Minimum CNA Staffing
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Complaint Investigation
Capacity: 148 Deficiencies: 16 Date: Apr 10, 2023

Visit Reason
Facility failed to provide written information about advance directives, maintain a clean environment, ensure timely grievance filing, develop comprehensive care plans, revise care plans timely, ensure range of motion and mobility equipment use, maintain RN coverage, ensure medication regimen free from unnecessary drugs, prevent medication errors, and maintain sanitary food storage. Multiple residents affected.

Findings
Facility failed to provide written information about advance directives, maintain a clean environment, ensure timely grievance filing, develop comprehensive care plans, revise care plans timely, ensure range of motion and mobility equipment use, maintain RN coverage, ensure medication regimen free from unnecessary drugs, prevent medication errors, and maintain sanitary food storage. Multiple residents affected.

Deficiencies (16)
F0000 - INITIAL COMMENTS
F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0585 - Grievances
F0656 - Develop/Implement Comprehensive Care Plan
F0657 - Care Plan Timing and Revision
F0688 - Increase/Prevent Decrease in ROM/Mobility
F0727 - RN 8 Hrs/7 days/Wk, Full Time DON
F0757 - Drug Regimen is Free from Unnecessary Drugs
F0759 - Free of Medication Error Rts 5 Prcnt or More
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
M0000 - Initial Comments
M0141 - Employees Reference Checks and Verifications
M0182 - Nursing Services:Minimum Licensed Nurse Staff
M0183 - Nursing Services: Minimum CNA Staffing
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Complaint Investigation
Capacity: 148 Deficiencies: 5 Date: Mar 23, 2023

Visit Reason
Facility failed to develop and implement policies for reporting suspected crimes, thoroughly investigate allegations of abuse, and ensure resident safety. Immediate jeopardy was identified related to sexual abuse allegations. Investigation and removal plans were implemented.

Findings
Facility failed to develop and implement policies for reporting suspected crimes, thoroughly investigate allegations of abuse, and ensure resident safety. Immediate jeopardy was identified related to sexual abuse allegations. Investigation and removal plans were implemented.

Deficiencies (5)
F0000 - INITIAL COMMENTS
F0609 - Reporting of Alleged Violations
F0610 - Investigate/Prevent/Correct Alleged Violation
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Complaint Investigation
Capacity: 148 Deficiencies: 4 Date: Sep 29, 2022

Visit Reason
Facility failed to notify resident representatives timely of changes in condition and falls. Multiple residents affected by lack of timely communication.

Findings
Facility failed to notify resident representatives timely of changes in condition and falls. Multiple residents affected by lack of timely communication.

Deficiencies (4)
F0000 - INITIAL COMMENTS
F0580 - Notify of Changes (Injury/Decline/Room, etc.)
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Re-licensure
Capacity: 148 Deficiencies: 7 Date: Feb 24, 2022

Visit Reason
Facility failed to timely follow dietician recommendations, maintain sanitary food handling and storage, ensure infection prevention and control including PPE use and designate a qualified infection preventionist. Multiple residents at risk for nutrition and infection control issues.

Findings
Facility failed to timely follow dietician recommendations, maintain sanitary food handling and storage, ensure infection prevention and control including PPE use and designate a qualified infection preventionist. Multiple residents at risk for nutrition and infection control issues.

Deficiencies (7)
F0000 - INITIAL COMMENTS
F0692 - Nutrition/Hydration Status Maintenance
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0880 - Infection Prevention & Control
F0882 - Infection Preventionist Qualifications/Role
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

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