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Part of chain: AVAMERE (27 facilities, chain avg rating 3.0★)
3/5
Health inspection rating (on-site)
inspected Dec 4, 2025
2
Serious findings on record
most recent Sep 24, 2024
$175,773
Fines, last 3 years
5.44
Nurse hours/resident/day (adjusted)
Every record stays on this page.
What health inspectors found (on-site government inspections — the most independent evidence available)
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 quality measures from resident assessments and claims.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, isolated · 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): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Oct 7, 2024 (Deficient, Provider has date of correction)
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): Immediate jeopardy to resident health or safety was cited. The scope was a pattern: more than a limited occurrence, without being widespread. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Aug 27, 2024 (Deficient, Provider has date of correction)
Inspection findings in the public record
Showing the latest 3 of 16 inspection findings. Open the full record below to read every finding.
D · Potential for more than minimal harm, isolated
The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaintF-0584
D · Potential for more than minimal harm, isolated
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. F-0677
D · Potential for more than minimal harm, isolated
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaintF-0689
View all 16 inspection findingsShow only the latest 3 findings
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
Date
Severity
What the facility was cited for
Dec 4, 2025
D · Potential for more than minimal harm, isolated
The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584
Dec 4, 2025
D · Potential for more than minimal harm, isolated
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. · F-0677
Dec 4, 2025
D · Potential for more than minimal harm, isolated
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 · F-0689
Dec 4, 2025
D · Potential for more than minimal harm, isolated
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. · F-0880
Sep 24, 2024
▲ J · Immediate jeopardy, isolated
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 · F-0689
Jul 19, 2024
▲ K · Immediate jeopardy, pattern
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. · F-0880
Jul 19, 2024
E · Potential for more than minimal harm, pattern
The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584
Jul 19, 2024
E · Potential for more than minimal harm, pattern
The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658
Jul 19, 2024
D · Potential for more than minimal harm, isolated
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. · F-0744
Jun 20, 2024
D · Potential for more than minimal harm, isolated
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 · F-0689
May 5, 2023
E · Potential for more than minimal harm, pattern
The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584
May 5, 2023
E · Potential for more than minimal harm, pattern
The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · F-0804
May 5, 2023
D · Potential for more than minimal harm, isolated
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. · F-0695
May 5, 2023
D · Potential for more than minimal harm, isolated
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. · F-0756
May 5, 2023
D · Potential for more than minimal harm, isolated
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. · F-0757
May 5, 2023
D · Potential for more than minimal harm, isolated
The facility did not dispose of garbage and refuse properly. · F-0814
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (4 → 4).
Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2023
All citations:
6
Serious citations (G–L):
0
2024
All citations:
6
Serious citations (G–L):
2
2025
All citations:
4
Serious citations (G–L):
0
All bars start at zero. Exact values and supporting details remain below.
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.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
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)
Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilityOregon averageU.S. average
Total nurse staffing (hours per resident per day)
This facility:
5.44
Oregon average:
5.42
U.S. average:
3.95
Registered Nurse hours
This facility:
1.02
Oregon average:
0.78
U.S. average:
0.69
Weekend total nurse staffing
This facility:
4.83
Oregon average:
4.85
U.S. average:
3.50
All bars start at zero. Exact values and supporting details remain below.
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 for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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.Comparing with Medicare Care Compare? Care Compare shows the raw figure (5.15 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 5/5.
Quality measures: assessments & claims
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
No verified facility-specific private-pay price is available in our data for Avamere Rehabilitation of Clackamas. CMS inspection and staffing records do not tell us what this home will charge you.
Calculate a stay from a quote you receive
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Before you compare prices
Request the room type, effective date and itemized daily rate in writing.
Ask about therapy, medicines, supplies, care-level charges, deposits, refunds and annual increases.
Confirm insurance or Medicaid eligibility and bed availability directly; certification alone does not guarantee either.
Showing 20 of 65 parties CMS has on file for this facility; 45 are not displayed. The full list is in the CMS Ownership dataset.
Other facilities in the same chain
CMS lists this facility under the chain Avamere — 27 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.
CMS records place this facility in Clackamas, OR — 13 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.
Facility data as of CMS processing date 2026-08-01. CCN 385203.
This page is the printable visit checklist. If your browser did not open the print dialog automatically, use File → Print (Ctrl/⌘-P).
The Care File
Visit checklist — Avamere Rehabilitation of Clackamas
220 E. Hereford, Gladstone, OR 97027 · (503) 656-0393
Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $175,773
Most serious findings on record:
▲ Sep 24, 2024 (F-0689, Immediate jeopardy, isolated): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ Jul 19, 2024 (F-0880, Immediate jeopardy, pattern): 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.
Questions for the administrator:
☐ "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 plan of correction for the findings in your most recent state inspection?"
☐ "CMS reports 48% total nursing staff turnover here — who on the care team has been with you longest?"
☐ "The ownership record on file lists 65 owning or managing parties — who makes the decisions about staffing levels?"
☐ "Can I visit again unannounced, at a mealtime or on a weekend?"
While you're there, notice:
☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)
Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 385203 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)