Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Clackamas during CMS and state inspections, most recent first.
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.
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 | — | 0 | 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 | — | 3 | 0 |
| Rose Linn Care Center | 4 mi | — | 0 | 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.