Avamere Rehabilitation of Clackamas
220 E. Hereford, Gladstone, OR 97027 · Clackamas County · 87 certified beds · avg 43 residents/day · certified since Aug 3, 1989
Part of chain: AVAMERE (27 facilities, chain avg rating 3.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Sep 24, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 7, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Jul 19, 2024 · F-0880
The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Aug 27, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (16)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 4, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Dec 4, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Dec 4, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 4, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 24, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 19, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 19, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Jul 19, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jul 19, 2024 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Jun 20, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 5, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| May 5, 2023 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| May 5, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 5, 2023 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| May 5, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| May 5, 2023 | D · Potential for harm, one-off | The facility did not dispose of garbage and refuse properly. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (4 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 6 | 0 | E |
| 2024 | 6 | 2 | K ▲ |
| 2025 | 4 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $175,773.
| Date | Type | Amount / length |
|---|---|---|
| Sep 24, 2024 | Fine | $10,036 |
| Jun 20, 2024 | Fine | $30,976 |
| Nov 14, 2023 | Fine | $134,761 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Oregon avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.44 | 5.42 | 3.95 | top 42% in Oregon; top 8% in the U.S. |
| Registered Nurse hours | 1.02 | 0.78 | 0.69 | top 14% in Oregon; top 15% in the U.S. |
| Weekend total nurse staffing | 4.83 | 4.85 | 3.50 | top 47% in Oregon; top 8% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.72 | 0.48 | 0.48 | top 15% in Oregon; top 15% in the U.S. |
| Total nursing staff turnover (%) | 47.5 | 47.4 | 45.8 | bottom 46% in Oregon; bottom 43% in the U.S. |
| RN turnover (%) | 22.2 | 51.6 | 42.9 | top 9% in Oregon; top 17% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.15, RN 0.97, weekend 4.57. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 2/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ari CBC LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 01/06/2006 |
| Ari Operations, LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 01/06/2006 |
| Avamere Group LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 01/06/2006 |
| Angerhofer, Nicole | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2023 |
| Angerhofer, Nicole | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2023 |
| Avamere Health Services LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2005 |
| Avamere Health Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/26/2025 |
| Avamere Skilled Advisors LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2005 |
| Avamere Skilled Advisors LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/07/2025 |
| Cavallo, Glen | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2025 |
| Dana, Jennifer | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2022 |
| Dana, Jennifer | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2022 |
| Davis, Julie | Individual | ADP of the SNF | NOT APPLICABLE | 08/01/2024 |
| Doepker, Andrea | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/28/2023 |
| Doepker, Andrea | Individual | ADP of the SNF | NOT APPLICABLE | 09/28/2023 |
| Feakin, Cody | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2025 |
| Feakin, Cody | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/15/2025 |
| Feakin, Cody | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Funderberg, Michelle | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2025 |
| Funderberg, Michelle | Individual | ADP of the SNF | NOT APPLICABLE | 12/31/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What specific dementia training do your staff receive, and how do you handle difficult moments without medication?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avamere Rehabilitation of Oregon City | 2.0 mi | Oregon City, OR | ★★☆☆☆ | 2/5 | |
| Rivercrest Post Acute | 3.1 mi | Oregon City, OR | ★★☆☆☆ | 2/5 | |
| Marquis Oregon City Post Acute Rehab | 3.5 mi | Oregon City, OR | ★★★★★ | 4/5 | |
| Stanley Post Acute | 3.7 mi | Milwaukie, OR | ★★★☆☆ | 3/5 | |
| Rose Linn Care Center | 4.0 mi | West Linn, OR | ★★★☆☆ | 4/5 | |
| Fernwood Supportive Living at Madrona Grove | 4.1 mi | Portland, OR | ★★★★☆ | 3/5 | |
| Willamette View Health Center | 4.2 mi | Milwaukie, OR | ★★★★★ | 5/5 | |
| The Pearl at Kruse Way | 6.8 mi | Lake Oswego, OR | ★★★★☆ | 4/5 | |
| Gracelen Care Center | 7.2 mi | Portland, OR | ★☆☆☆☆ | 1/5 | |
| Cascade Terrace Post Acute | 7.2 mi | Portland, OR | ★☆☆☆☆ | 1/5 | SFF |
| Cedar Crossings | 7.4 mi | Portland, OR | ★★★☆☆ | 2/5 | |
| Secora Rehabilitation of Cascadia | 7.5 mi | Portland, OR | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 385203.