Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Junction City during CMS and state inspections, most recent first.
Two residents, one with chronic pain and another with Alzheimer's disease, were subjected to verbal abuse and derogatory remarks by another resident. Staff and the DNS confirmed the inappropriate behavior, which included profanity, name-calling, and offensive comments, but the facility failed to prevent or adequately address these incidents.
A resident with quadriplegia and neuropathic bladder experienced a traumatic Foley catheter placement, followed by infection and hospitalization. The facility did not thoroughly investigate the incident, as the staff member who performed the catheter change was not identified and no witness statement was obtained. Staff interviews revealed uncertainty about who completed the procedure, and the DNS confirmed that a witness statement should have been included.
A resident with dementia and dysphagia, care planned for total assistance and supervision during meals due to behavioral issues, was left unsupervised in the dining room, resulting in a verbal altercation with another resident. Staff interviews confirmed multiple occasions where no CNA was present during meals, despite the care plan requirement for supervision.
The facility did not ensure proper infection control in laundry services, as staff failed to separate soiled and clean linens, used a fabric gown multiple times before cleaning, and lacked training on PPE and disinfectant use. The workflow required staff to move through clean areas after handling soiled linen, and key information on disinfectant dwell times was not accessible.
A resident admitted with an unstageable pressure ulcer and pain was not accurately assessed, as the MDS failed to document the number of unstageable pressure ulcers and left relevant sections incomplete. Documentation did not reflect that the resident was receiving care for a pressure ulcer, and the DNS acknowledged the inaccuracy.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed and documented by surveyors.
A resident did not receive the necessary behavioral health care and services required to meet their needs, as the facility failed to provide appropriate behavioral health interventions and support.
Two residents did not receive their scheduled medications, including an antidiabetic and a movement disorder medication, because the drugs were not available at the time of administration. Staff reported that the medications had been ordered from the pharmacy but had not arrived, resulting in a medication error rate above 5%.
Staff did not deliver care or services that were trauma informed or culturally competent, failing to meet required standards for addressing residents' trauma histories or cultural needs.
Two residents in a LTC facility experienced significant medication errors. One resident received an incorrect dosage of apixaban, leading to a GI bleed and hospitalization. Another resident was mistakenly given another's medications, including antipsychotics and blood pressure meds, but showed no adverse effects. These incidents highlight lapses in medication administration protocols.
A resident with congestive heart failure gave $1200 to a CNA, who admitted to accepting the money despite knowing it was against facility rules. The resident intended $1000 as a loan and $200 as a gift, motivated by the CNA's financial struggles. The incident was reported by another staff member, leading to the CNA's termination.
The facility failed to ensure an RN was available for at least eight consecutive hours, seven days a week for 19 of 60 days reviewed. This deficiency was identified through a review of the facility's Direct Care Daily Staff Reports, and the Scheduling Coordinator acknowledged the lack of RN coverage on these dates, placing residents at risk for inadequate RN oversight and nursing assessments.
The facility failed to maintain appropriate medication storage temperatures for one medication storage refrigerator, which contained tuberculin, influenza vaccines, insulin, and an emergency medicine kit. The temperature logs revealed multiple instances of temperatures below the required range of 36-46 degrees F over a three-month period. Staff acknowledged the issue and stated that staff were expected to readjust the temperature, recheck it later, and contact management if temperatures were out of range.
The facility failed to store and handle food in a sanitary manner, with observations of unsealed freezer bags, expired food items, and undated condiments in two unit refrigerators and freezers. The Dietary Manager confirmed that expired items were not discarded.
The facility failed to follow CDC-recommended infection control standards for a resident with head lice. The resident was placed on Enhanced Barrier Precautions instead of contact precautions, and their personal items were not properly laundered or treated. Housekeeping staff did not follow correct PPE protocols, placing other residents at risk.
The facility failed to assist a resident with the formulation of an advance directive, despite the resident's request for assistance. The resident, admitted with depression and bipolar disorder, requested help in November 2023, but no assistance was provided as confirmed by the resident and staff.
The facility failed to maintain clean and functional equipment for two residents. One resident's walker had a loose wheel and worn handle, while another's wheelchair was dirty and had torn armrests. Both issues were acknowledged by staff but remained unaddressed, compromising the residents' environment.
A resident with vascular dementia and bipolar disorder was diagnosed with head lice, but the facility failed to update the care plan promptly. The diagnosis was made on April 2, 2024, and treatment was applied the same day, but the care plan was not updated until April 4, 2024. The DNS acknowledged the delay.
A resident with dementia and muscle weakness, who was moderately cognitively impaired, was found smoking unsupervised despite a care plan requiring supervision. The resident sustained a burn injury after receiving a cigarette from another resident and smoking it independently. The Director of Nursing Services acknowledged that the care plan was not followed.
Failure to Protect Residents from Verbal Abuse by Another Resident
Penalty
Summary
The facility failed to protect residents from verbal abuse by another resident, resulting in two residents being subjected to inappropriate and abusive language. One resident, who was cognitively intact and admitted with chronic pain and muscle weakness, reported that another resident entered their room, used profanity, and called them names. This resident also described a separate incident where the same individual made a derogatory comment while the resident was going to the shower. Staff confirmed that the abusive resident verbally attacked this resident and made fat jokes, and the Director of Nursing Services acknowledged the behavior as inappropriate. Another resident, admitted with Alzheimer's disease and a cognitive communication deficit, was also subjected to verbal abuse by the same resident. During an incident, staff overheard the abusive resident making derogatory statements, including saying that "you people need to go to fucking jail" and referring to others as "fucking crazies." Staff described the behavior as rude and verbally abusive, and the Director of Nursing Services confirmed the inappropriateness of the conduct. The facility did not prevent or adequately address these incidents, resulting in residents being exposed to verbal abuse.
Failure to Investigate Catheter-Related Injury
Penalty
Summary
The facility failed to thoroughly investigate a treatment-related injury involving a resident with quadriplegia and neuropathic bladder who experienced a traumatic Foley catheter placement. The resident was admitted with significant medical needs and was cognitively intact at the time of the incident. On the night the catheter was changed, the resident later developed symptoms of infection, including nausea and elevated temperature, and subsequently became nonresponsive, requiring emergency hospitalization for septic shock. The facility's investigation did not include documentation identifying the staff member who performed the catheter placement or a witness statement from that staff member. Interviews with staff revealed uncertainty about who completed the procedure, and attempts to contact the suspected staff member were unsuccessful. The Director of Nursing Services acknowledged that the investigation should have included a witness statement from the staff involved.
Failure to Provide Supervision During Meals for Resident with Behavioral Needs
Penalty
Summary
Staff failed to provide care and treatment as outlined in the care plan for a resident with dementia and dysphagia who required total assistance and supervision during meals. The care plan specified that the resident was to eat in a designated dining room under supervision due to an easy-chew diet and a history of behavioral issues, including agitation and verbal aggression. On one occasion, the resident and another individual engaged in a verbal altercation in the dining room, and it was confirmed that no CNA was present to supervise at the time, despite the care plan requirement. Multiple staff interviews revealed that there were several instances where no CNA was present in the dining room during meals, including during the incident involving the verbal altercation. Staff acknowledged that supervision was required for the resident's safety, but CNAs alternated supervision due to other responsibilities, leading to lapses in coverage. Facility leadership confirmed that staff should have been present to supervise the resident as outlined in the care plan.
Infection Control Deficiency in Laundry Services
Penalty
Summary
The facility failed to implement proper infection control standards in its laundry services, as evidenced by observations and staff interviews. Soiled and clean linens were not adequately separated, and staff did not consistently follow standard precautions. A fabric gown used for handling soiled linen was hung in the clean area next to washing machines, and staff would walk through the clean area to access the sink for handwashing after sorting soiled linen. The gown was only cleaned once daily despite being used multiple times a day. Staff were not provided with procedures for the use of personal protective equipment (PPE) in the laundry room, nor were they informed about the required dwell time for the disinfectant cleaner used in the area. Further, staff responsible for laundry services had not received training on handling biohazard waste or soiled linens, and there was a lack of clear guidance regarding the use and effectiveness of the disinfectant cleaner. The Housekeeping Manager acknowledged the need for increased training, and the Director of Nursing Services recognized that the workflow between clean and soiled areas in the laundry room was problematic. The expected information about disinfectant dwell times was not readily available to staff, contributing to improper infection control practices.
Inaccurate Assessment of Pressure Ulcer on Admission
Penalty
Summary
The facility failed to accurately assess a resident admitted with an unstageable pressure ulcer to the buttocks and pain. Upon review, the admission Minimum Data Set (MDS) indicated the resident was at risk for developing pressure ulcers and had one or more unhealed pressure ulcer injuries, but did not document the number of unstageable pressure ulcers due to non-removable dressings or devices. The section of the MDS addressing unstageable pressure ulcers present on admission or re-entry was left incomplete. Additionally, the skin and ulcer treatment section noted the use of a pressure reducing device and surgical wound care, but there was no documentation reflecting that the resident was receiving care for a pressure ulcer. The Director of Nursing Services acknowledged the inaccuracy of the MDS assessment.
Failure to Follow Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the established care plan or the expressed wishes and clinical needs of the resident involved.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to ensure that each resident received necessary behavioral health care and services. This deficiency was identified when it was observed that the facility did not provide the required behavioral health interventions or support to meet the needs of its residents, as mandated by regulations. The lack of appropriate behavioral health care and services was noted during the survey, indicating a failure to address residents' behavioral health requirements.
Medication Error Rate Exceeds Acceptable Threshold Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by two medication errors out of 25 observed medication administration opportunities, resulting in an 8 percent error rate. Specifically, one resident with diabetes and obesity did not receive their scheduled dose of Jardiance because the medication was not available, despite a physician's order for daily administration. Another resident with muscle weakness did not receive their prescribed Ingrezza for a movement disorder, also due to the medication not being available at the time of administration. In both cases, staff reported that the medications had been ordered from the pharmacy but had not yet arrived, leading to missed doses.
Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to provide care or services that were trauma informed and/or culturally competent. This deficiency indicates that staff did not consider or incorporate trauma-informed approaches or cultural competence into the care or services provided to residents, as required. The report does not specify the number of residents affected or provide additional details about their medical history or condition at the time of the deficiency.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by two separate incidents involving residents. In the first case, a resident was readmitted to the facility with a diagnosis of pulmonary embolism and was prescribed apixaban, an anticoagulant medication. The physician's orders specified a dosage adjustment from 10 mg BID to 5 mg BID after six days. However, the facility failed to implement this dosage change, resulting in the resident receiving an excessive dose of apixaban for an extended period. This error was not identified until a nurse practitioner discovered it, by which time the resident had developed a gastrointestinal bleed, requiring hospitalization and a blood transfusion due to acute blood loss and anemia. In the second incident, a resident with a diagnosis of diabetes was mistakenly administered another resident's medications. The error occurred when a CMA, after being distracted by a request for assistance, inadvertently gave the wrong medications to the resident. The medications included several that the resident was not prescribed, such as antipsychotics and blood pressure medications. Although the resident was monitored and showed no significant adverse effects, the error highlighted a lapse in medication administration protocols. Both incidents underscore the facility's failure to adhere to proper medication administration procedures, resulting in significant medication errors. The first incident involved a failure to adjust medication dosages as per physician orders, leading to a serious health complication for the resident. The second incident involved a mix-up in medication administration, which, although not resulting in immediate harm, posed a potential risk to the resident's health. These deficiencies indicate a need for improved medication management and staff training to prevent future occurrences.
Misappropriation of Resident's Financial Resources
Penalty
Summary
The facility failed to protect a resident from financial exploitation, resulting in a deficiency related to the misappropriation of financial resources. A resident, who was admitted in 2022 with a diagnosis of congestive heart failure, gave $1200 to a CNA at the facility. The resident stated that $1000 was intended as a loan and $200 as a gift. The CNA, identified as Staff 3, admitted to discussing her financial difficulties with the resident and accepting the money, despite knowing it was against facility rules. The incident was reported by another staff member, Staff 5, who was informed by the resident about the transaction. Interviews revealed that Staff 3 was aware of the wrongdoing but felt compelled to accept the money due to her financial situation. The resident expressed a desire to help the CNA, who had mentioned her struggles with paying rent and having three small children. Staff 3 initially claimed to have refused the money but eventually accepted it after the resident insisted. The facility's investigation confirmed the misappropriation, and Staff 3 was subsequently terminated. The incident was reported to the Oregon Board of Nursing and law enforcement.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was available for at least eight consecutive hours, seven days a week for 19 of 60 days reviewed. This deficiency was identified through a review of the facility's Direct Care Daily Staff Reports from February 1, 2024, through March 31, 2024. The specific dates without RN coverage were February 3, 4, 10, 11, 17, 18, 24, 25, and March 2, 3, 9, 10, 16, 17, 23, 24, 29, 30, and 31. On April 5, 2024, the Scheduling Coordinator acknowledged the lack of RN coverage on these dates, which placed residents at risk for inadequate RN oversight and nursing assessments.
Failure to Maintain Appropriate Medication Storage Temperatures
Penalty
Summary
The facility failed to ensure appropriate medication storage temperatures were maintained within parameters for one medication storage refrigerator. The refrigerator, which contained tuberculin, influenza vaccines, insulin, and an emergency medicine kit, was observed to have temperatures below the required range of 36-46 degrees F on 19 occasions between January 1, 2024, and April 2, 2024. The temperature logs indicated that the temperatures were to be checked twice daily, but the logs revealed multiple instances of temperatures below 36 degrees F. Staff 2 acknowledged the issue and stated that staff were expected to readjust the temperature, recheck it later, and contact management if temperatures were out of range, as cold temperatures could reduce the efficacy of insulin and vaccines.
Failure to Store and Handle Food Safely
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in two unit refrigerators and freezers. Observations revealed unsealed freezer bags of waffles, expired applesauce cups, ice cream with visible freezer burn, and undated or expired condiments and dairy products. The Dietary Manager acknowledged these observations and confirmed that the expired food items were not discarded as required.
Failure to Follow Infection Control Standards for Head Lice
Penalty
Summary
The facility failed to ensure appropriate infection control standards for a resident diagnosed with head lice. The resident, who was admitted with vascular dementia and bipolar disorder, was found to have live head lice. Despite receiving treatment, the resident was placed on Enhanced Barrier Precautions instead of the CDC-recommended contact precautions. Observations revealed that the resident continued to wear a fabric hat and leather jacket, which were not appropriately laundered or treated as per CDC guidelines. Additionally, housekeeping staff were observed entering the resident's room without following the correct PPE protocols for contact precautions. The Infection Preventionist and Director of Nursing Services acknowledged that the facility did not follow CDC recommendations for managing head lice. The resident's laundry and linens were washed with other residents' items, and the leather jacket and fabric hat were not properly treated. This failure to adhere to infection control standards placed other residents at risk for head lice infestation.
Failure to Assist Resident with Advance Directive
Penalty
Summary
The facility failed to assist Resident 10 with the formulation of an advance directive, despite the resident's request for assistance. Resident 10, who was admitted in January 2021 with diagnoses including depression and bipolar disorder, requested help from facility staff to establish an advance directive during a Comprehensive Plan of Care Review in November 2023. However, a review of the resident's clinical record from November 2023 through April 2024 revealed no indication that the facility staff provided the requested assistance. This was confirmed by Resident 10 on April 1, 2024, and acknowledged by Staff 13 on April 2, 2024.
Failure to Maintain Clean and Functional Resident Equipment
Penalty
Summary
The facility failed to ensure resident equipment was clean and in good repair for two residents. Resident 22, who was readmitted with diagnoses including dementia and muscle weakness, was observed using a walker with a loose front wheel and a worn handle missing foam. Despite the resident's statement that the physical therapist was aware of the issues, the walker remained unrepaired. The occupational therapist confirmed the need for repairs, and the administrator acknowledged the deficiencies, including non-functional brakes on the walker. Resident 14, admitted with multiple sclerosis, was observed using a wheelchair that was dirty with dried food debris and had torn armrests exposing the metal underneath. A CNA noted the dirty condition of the wheelchair days prior and was informed that the night shift was responsible for cleaning it. The administrator confirmed the observations of the dirty and damaged wheelchair. These deficiencies placed residents at risk for living in an unhomelike environment.
Failure to Timely Update Care Plan for Head Lice
Penalty
Summary
The facility failed to update the care plan for a resident diagnosed with head lice in a timely manner. The resident, who was admitted in February 2024 with vascular dementia and bipolar disorder, was found to have live head lice on April 2, 2024. The resident's provider was notified, and treatment was prescribed and applied the same day. Despite this, the resident's comprehensive care plan did not include information about the head lice diagnosis until April 4, 2024. The Director of Nursing Services acknowledged that the care plan was not updated promptly.
Failure to Ensure Supervised Smoking
Penalty
Summary
The facility failed to ensure supervision and safety interventions were in place to prevent smoking-related accidents for a resident with a history of dementia and muscle weakness. The resident, who was moderately cognitively impaired, had a documented history of smoking in the building, burning herself/himself, and not following smoking rules. Despite the care plan indicating that the resident was to smoke only under supervision and that tobacco and fire materials were to be stored by the facility, the resident was found smoking unsupervised in the courtyard with another resident. This incident resulted in the resident singeing her/his hair and sustaining a burn mark above her/his right eye. On the day of the incident, staff observed the resident smoking unsupervised and noted the burn injury. The resident admitted to receiving a cigarette from another resident and smoking it independently. Staff found several cigarette butts and a pack of cigarettes in the resident's possession. The burn on the resident's forehead was treated and resolved by the following day. The Director of Nursing Services acknowledged that the resident's care plan for supervised smoking was not followed, leading to the incident where the resident burned herself/himself.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Junction City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Riverpark Of Eugene | 10.6 mi | — | 14 | 0 |
| Green Valley Rehabilitation Health Center | 11.3 mi | — | 25 | 0 |
| Valley West Health Care Center | 13.2 mi | — | 0 | 0 |
| Avamere Rehabilitation Of Eugene | 13.4 mi | — | 17 | 1 |
| Hillside Heights Rehabilitation Center | 14 mi | — | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.