Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avamere Rehabilitation Of Clackamas during CMS and state inspections, most recent first.
Resident rooms were used to store new furniture and past resident belongings, including stacked mattresses, bed frames, side tables, floor mats, and other items placed in occupied and unoccupied spaces. Residents and CNAs confirmed the rooms were being used for storage, and the Administrator acknowledged that storing furniture in occupied resident rooms was not a homelike environment.
A resident with stroke and dysphagia was dependent on staff for personal hygiene and grooming, but was repeatedly observed with visible facial hair. The resident stated a desire to be shaved and relied on staff for that care, while CNAs and the DNS acknowledged the resident's dependence and the visible facial hair.
A resident with stroke and left-sided weakness had a care plan requiring 2 staff for all transfers and toileting due to high fall risk and multiple falls. A former NA transferred the resident to the toilet and tried to change the brief while the resident was seated; the resident jerked suddenly and hit the head on a mobility bar, causing a large bump. The DNS later confirmed the care plan was not followed.
A resident with DM2 and MRSA had wound dressings and an open wound on the feet and ankles, but the room was not identified for contact precautions and staff reported not using PPE beyond gloves for dressing changes. The room also contained a trash bag, an open bag of briefs, and sterile wound care supplies stored on the floor, which staff confirmed was not consistent with expected practice.
A resident with dementia and a history of elopement was sent unaccompanied to a medical appointment, despite care plan requirements for supervision. The resident arrived disoriented, and the clinic had to assign staff to monitor them. Facility staff assumed the transport driver would escort the resident, leading to a deficiency citation.
A facility failed to properly disinfect a shared glucometer between resident uses, leading to an Immediate Jeopardy situation. A staff member used alcohol wipes instead of EPA-registered disinfectant wipes and did not adhere to the required contact time, risking bloodborne illness transmission. A resident with HIV was among those affected, requiring frequent blood glucose checks with the shared device.
A licensed nurse failed to adhere to infection control standards by using alcohol wipes instead of EPA-registered wipes to clean a glucometer, and did not allow proper drying time between uses, risking bloodborne illness transmission. The facility's DNS confirmed the expectation for proper disinfection and rotation of glucometers.
A resident reported inadequate lighting in the dining room, affecting their participation in activities. Observations confirmed non-functioning ceiling lights and disrepair in the dining room floor. Shared bathrooms had stained caulking, and room four had peeling wall paneling. The Maintenance Director and Administrator acknowledged these issues, with no plan in place for repairs.
A facility failed to implement a resident-centered care plan for a resident with dementia, leading to a deficiency in maintaining the resident's well-being. The care plan included generic interventions that were not specific to the resident's needs, and refusals of ADLs and showers were inadequately addressed. Staff interviews confirmed that the care plan was not resident-centered, and some interventions were attempted but not documented.
A resident with dementia and diabetes repeatedly eloped from the facility due to inadequate care plan interventions and supervision. Despite being identified as a high elopement risk, the facility failed to update the care plan effectively, and door alarms did not alert staff. Staff interviews revealed a lack of awareness and communication about the resident's risk, leading to multiple unwitnessed exits.
Resident Rooms Used for Furniture Storage
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment by using resident rooms one, two, and four in the [NAME] Hall for storage of new furniture and past resident belongings. During observations from 9/29/25 through 10/1/25, the rooms contained multiple items not related to resident use, including five mattresses stacked on an unoccupied bed, a metal rack, floor mats, a knee wedge, hangers, a bath basin, a gown, a bag of tortillas, side tables, a drawer of unknown origin, blue blankets, bed frames, and additional side tables placed in random locations. One room also had a sign above an unoccupied bed stating, emergency overflow bed only. Residents and staff confirmed the rooms were being used for storage. One resident stated the room was an overflow room for staff to store furniture, another said extra furniture had been there since admission, and a third said the furniture in the room bothered them and that they kept the curtain closed to avoid seeing the mess. A CNA stated resident rooms were used for extra furniture, another CNA stated unoccupied areas in resident rooms were used for extra furniture, and the Administrator stated unoccupied resident rooms were used for temporary storage of new furniture. The Administrator also stated he was unaware new furniture was stored in occupied resident rooms and acknowledged that storing furniture in occupied resident rooms was not a homelike environment.
Failure to Provide Required Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure a dependent resident received required assistance with ADLs, specifically personal hygiene and grooming, for 1 of 3 sampled residents reviewed for ADLs. The resident was admitted with diagnoses including stroke and dysphagia, and the Quarterly MDS indicated the resident was dependent on staff for personal hygiene and grooming. The care plan dated 8/28/25 stated the resident required total assistance with personal hygiene. The resident was observed on multiple occasions with a significant amount of visible facial hair, and stated that he/she did not want facial hair and relied on staff to shave unwanted facial hair. A CNA acknowledged noticing the resident's visible facial hair and stated the resident was dependent on staff to shave him/her, and another CNA confirmed the resident's shaving preferences should be followed and that the resident had noticeable facial hair. The DNS also confirmed the resident was dependent on staff for ADL care and that the resident's shaving preferences were expected to be followed.
Failure to Follow Two-Staff Toileting Care Plan
Penalty
Summary
The facility failed to implement care plan interventions to prevent an injury during toileting for one resident who was admitted in 5/2025 with diagnoses including stroke with left-sided weakness. The resident’s care plan dated 4/29/25 stated that two staff members were required for all transfers and toileting because of high fall risk and multiple falls since admission. A facility investigation signed by the DNS on 5/13/25 stated that a former NA transferred the resident to the toilet and attempted to change the resident’s brief while the resident was seated on the toilet. During that care, the resident jerked suddenly and hit his/her head on the mobility bar along the wall, causing a large bump on the side of the head. On 12/4/25, the DNS confirmed that the former NA did not follow the resident’s care plan requiring two staff assistance for toileting.
Failure to Use Contact Precautions and Store Wound Supplies Properly
Penalty
Summary
The facility failed to implement appropriate contact precautions and failed to properly store wound care supplies for a resident admitted with diagnoses including type 2 diabetes and MRSA. The CDC guidance cited in the report states that Contact Precautions require use of PPE, including gloves and gown, for interactions involving the patient or the patient’s environment, and the facility’s Transmission-Based Precautions policy required the Infection Preventionist to identify the type of precautions, duration, PPE, and signage for staff and visitors. Resident 24’s room was observed on multiple occasions with a full trash bag on the floor behind the door, an open bag of incontinence briefs on the floor, and multiple sterile treatment supplies opened and stored in a box on the floor. Staff confirmed the trash bag and sterile wound treatment supplies were on the floor, and the RNCM and IP stated sterile supplies should be stored appropriately and off the floor. The resident was also observed with scabs and wound dressings on the feet and bilateral ankles, and staff stated the room was not identified for contact precautions. A CNA stated no PPE was worn while providing care, an RN stated gloves only were used for dressing changes, and staff later identified an open wound on the resident’s feet and stated the resident should have been on contact precautions once the open wound was identified.
Failure to Follow Elopement Care Plan for Resident
Penalty
Summary
The facility failed to adhere to care plan interventions for a resident identified as an elopement risk, resulting in an Immediate Jeopardy situation. The resident, who had diagnoses including dementia and congestive heart failure, was admitted to the facility with a care plan that required accompaniment by a responsible party for any off-premises activities. Despite this, the resident was sent alone to a new medical appointment via medical transport, arriving disoriented and unattended. The receiving clinic had to assign a staff member to monitor the resident due to the risk of elopement. Interviews with facility staff revealed a lack of understanding and communication regarding the resident's need for supervision during transport. Staff members assumed that the medical transport driver would escort the resident, despite the resident's known cognitive impairments and history of elopement. The facility's failure to ensure the resident was accompanied by a responsible party, as outlined in the care plan, placed the resident at risk and led to the deficiency being cited.
Removal Plan
- The care plan for Resident 32 has been reviewed and revised to include an escort for all appointments. The resident will continue to receive 15-minute checks.
- All staff on evening shift have been educated on the facility's elopement policy, with a special emphasis on transportation for appointments.
- All remaining staff will be educated on the facility's elopement policy before the start of their shift, with a special emphasis on transportation for appointments. All staff with no scheduled shift will have been educated.
- All residents in the facility have been reassessed for elopement risk, and care plans have been updated as necessary.
- To ensure ongoing compliance the DNS/designee will audit and assess all new admissions for risk of elopement, weekly for three weeks, and then monthly until substantial compliance is achieved.
- All findings to be reported to the Quality Assurance and Performance Improvement Committee.
Improper Glucometer Disinfection Between Resident Uses
Penalty
Summary
The facility failed to ensure proper cleaning and sanitization of a community-use glucometer between resident uses, which was identified as an Immediate Jeopardy situation. During an observation, Staff 3 was seen using alcohol wipes instead of the required EPA-registered disinfectant wipes to clean the glucometer after checking a resident's blood glucose level. Furthermore, Staff 3 did not allow the glucometer to dry for the manufacturer's recommended contact time before proceeding to use it on another resident. This improper practice was observed despite the facility's policy and manufacturer instructions requiring the use of specific disinfectant wipes and adherence to contact time. The deficiency involved a resident with a diagnosis of human immunodeficiency virus (HIV) who required blood glucose checks three times a day using a shared glucometer. The facility's failure to properly disinfect the glucometer placed residents at significant risk for bloodborne illnesses. The Director of Nursing Services (DNS) confirmed that the expectation was for staff to use microkill bleach wipes and rotate glucometers to ensure proper dwell times were reached, which was not followed by Staff 3.
Removal Plan
- Glucometers in the facility have been collected and disinfected using an EPA-approved disinfectant for bloodborne pathogens.
- Staff 3 was suspended, will receive 1:1 education/training on glucometer disinfection between uses, and dedicating CBG equipment for residents with diagnoses of bloodborne pathogens.
- Licensed nurses will be educated on the proper procedure for disinfecting blood glucose monitors and complete a Blood Glucose Monitoring Competency and will have dedicated CBG equipment for residents with bloodborne pathogens.
- Resident 15 was provided with dedicated blood glucose monitoring equipment.
- Residents in the facility will be audited for diagnoses of bloodborne pathogens and provided with dedicated blood glucose monitoring equipment if indicated.
- The Medical Director was notified. Residents potentially exposed also notified. Testing will be offered as requested.
- To ensure ongoing compliance, the DNS/designee will observe blood glucose monitor disinfection for routine blood glucose checks to ensure proper disinfection.
- All findings to be reported to the QAPI Committee.
Inadequate Disinfection of Glucometers
Penalty
Summary
The facility failed to ensure that staff adhered to professional standards related to the disinfection of common use glucometers, which placed residents at significant risk for bloodborne illness. During an observation, a licensed nurse, identified as Staff #3, was seen using alcohol wipes to clean a glucometer after obtaining a capillary blood glucose (CBG) reading for a resident. This action was contrary to the manufacturer's instructions, which specified the use of EPA-registered wipes for disinfection. The nurse then attempted to use the same glucometer for another resident without proper disinfection, prompting intervention by a State Surveyor. Further investigation revealed that Staff #3 was not allowing the glucometer to dry for the required contact time after using bleach wipes, as per the manufacturer's instructions. The Director of Nursing Services (DNS), identified as Staff #2, confirmed that the facility's expectation was for staff to use microkill bleach wipes between each glucometer use and to rotate glucometers to ensure proper dwell times were reached. This deficiency was noted under F880, indicating a failure in infection control practices.
Deficiencies in Facility's Physical Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike environment, as evidenced by several deficiencies in the physical environment. Resident 24, who was cognitively intact and had been admitted to the facility in 2019 with diagnoses including hypertension and depression, reported inadequate lighting in the dining room, which affected their ability to participate in activities. During a Resident Council meeting, members also noted that several light bulbs in the dining room had been out for a while, making it difficult to see. Observations confirmed that three out of six ceiling lights in the dining room were not functioning, and the floor was in disrepair with black tape and buckling near the soda machine. Further observations revealed additional issues in the facility's physical environment. The shared bathrooms between rooms one and three, and rooms two and four, had brown and yellow stained caulking around the base of the toilets and appeared dirty. Room four had paneling peeling away from the wall under the window. The Maintenance Director confirmed these issues and stated that there was no plan in place to address the lighting, flooring, bathroom caulking, or wall paneling problems. The Administrator also acknowledged the need for repairs in these areas.
Failure to Implement Resident-Centered Care Plan for Dementia
Penalty
Summary
The facility failed to implement resident-centered care plan interventions for a resident diagnosed with dementia, leading to a deficiency in maintaining the resident's highest practicable level of well-being. The resident, admitted in 2020, had diagnoses including dementia with agitation and depression. The resident's care plan, revised in 2018, was supposed to be resident-centered to maximize function and quality of life. However, the care plan interventions were generic and not tailored to the resident's specific needs. The care plan included interventions such as giving chocolate to calm the resident, separating them from others, and notifying a physician if behaviors interfered with medical needs. However, these interventions were not specific to the resident and were not consistently documented or implemented. The resident's care plan also failed to address refusals of activities of daily living (ADLs) and showers adequately. The interventions for these refusals were limited to documenting refusals and re-approaching at a different time, with no other strategies documented. Staff interviews revealed that the resident often exhibited behaviors and ate meals in their room due to these behaviors, with staff keeping the resident away from others. The Director of Nursing Services acknowledged that the care plan was not resident-centered and that some interventions were attempted but not documented or included in the care plan.
Failure to Prevent Repeated Elopements
Penalty
Summary
The facility failed to re-evaluate and revise care plan interventions for a resident with a history of elopement, leading to multiple unwitnessed exits from the facility. The resident, diagnosed with dementia and Type 2 diabetes, was initially assessed as a moderate risk for elopement, which later increased to a high risk. Despite this, the care plan interventions were not adequately updated to prevent further elopements. The facility's door alarms failed to alert staff during these incidents, and staff were unaware of the resident's whereabouts or the need for increased supervision. The resident's care plan included interventions such as a Code Pink protocol and 15-minute checks, but these measures proved ineffective. Staff interviews revealed a lack of awareness and communication regarding the resident's elopement risk and the need for additional interventions. The facility's administration acknowledged the failure to implement further interventions or reassess the resident's risk, resulting in repeated elopements and placing the resident at risk of harm.
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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 Gladstone
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Rehabilitation Of Oregon City | 2 mi | ★★★★★ | 1 | 0 |
| Rivercrest Post Acute | 3.1 mi | ★★★★★ | 20 | 0 |
| Marquis Oregon City Post Acute Rehab | 3.5 mi | ★★★★★ | 5 | 0 |
| Stanley Post Acute | 3.7 mi | ★★★★★ | 12 | 0 |
| Rose Linn Care Center | 4 mi | ★★★★★ | 12 | 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 July 2026) and official state health department websites.