Cycle 1
Health 2025-12-04 · Fire 2025-12-04
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Gladstone, OR
Avamere Rehabilitation Of Clackamas
3-star overall rating with 3-star inspections with $175,773 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
220 E. Hereford, Gladstone, OR
(503) 656-0393
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
87
Certified beds
Average residents
42
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avamere
Operator or chain grouping
Approved since
1989-08-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.83
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.59
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
5.14
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.50
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.91
CMS adjusted RN staffing hours
Adjusted total hours
5.64
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,824
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.66% · Performance 21.38% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.10
Baseline 5.16% · Performance 6.91% · Measure score 3.10 · Achievement 3.10 · Improvement 0
Total nurse turnover
1.07
Baseline 42.10% · Performance 59.32% · Measure score 1.07 · Achievement 1.07 · Improvement 0
Adjusted total nurse staffing
4.79
Baseline 4.66 hours · Performance 4.44 hours · Measure score 4.79 · Achievement 4.79 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.91% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 8.43% · Lower 95% interval 6.39% |
| Discharge to community | 57.57% |
50.57%
7 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 50.52% · Lower 95% interval 49.05% |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 97.83% |
95.27%
2.6 pts better
|
Numerator 45 · Denominator 46 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 46 |
| Discharge self-care score | 44.44% |
53.69%
9.2 pts worse
|
Numerator 16 · Denominator 36 |
| Discharge mobility score | 36.11% |
50.94%
14.8 pts worse
|
Numerator 13 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 46 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.91% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 46 · Observed rate 6.52% · Lower 95% interval 4.01% |
| Staff COVID-19 vaccination coverage | 6.15% |
8.2%
2 pts worse
|
Numerator 4 · Denominator 65 |
| Staff flu vaccination coverage | 30.12% |
42%
11.9 pts worse
|
Numerator 25 · Denominator 83 |
| Discharge function score | 36.11% |
56.45%
20.3 pts worse
|
Numerator 13 · Denominator 36 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 9.52% |
25.2%
15.7 pts worse
|
Numerator 2 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.0% |
95.5%
11.5 pts worse
|
93.4%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.7% · Q2 78.1% · Q3 86.7% · Q4 100.0% · 4Q avg 84.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.9% |
95.2%
6.3 pts worse
|
95.5%
6.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
2.4%
0.8 pts worse
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.2% · Q3 0.0% · Q4 0.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.8% |
4.7%
8.1 pts worse
|
11.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 21.4% · Q3 4.2% · Q4 10.7% · 4Q avg 12.8% |
| Percentage of long-stay residents who lose too much weight | 10.4% |
5.0%
5.4 pts worse
|
5.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.9% · Q3 17.2% · Q4 11.1% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.0% |
12.5%
7.5 pts worse
|
19.6%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 17.2% · Q3 20.7% · Q4 25.9% · 4Q avg 20.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.2% |
14.7%
5.5 pts worse
|
16.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 23.8% · Q4 20.0% · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.3% |
24.1%
2.2 pts worse
|
16.3%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.6% |
15.8%
5.8 pts worse
|
14.9%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 32.1% · Q3 10.7% · Q4 19.2% · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
2.0%
1.2 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 3.3% · Q4 6.7% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
22.2%
2.3 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.2% · Q2 21.9% · Q3 19.6% · Q4 15.4% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
6.5%
0.1 pts better
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 4.9% · Q3 8.2% · Q4 6.9% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.5% |
85.4%
2.9 pts worse
|
81.7%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 73.4% · Q2 77.9% · Q3 84.6% · Q4 91.7% · 4Q avg 82.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.8% |
15.1%
8.3 pts better
|
12.0%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 6.2% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.7%
0.9 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 1.4% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.8% |
81.2%
2.6 pts better
|
79.7%
4.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.9% |
21.6%
4.3 pts worse
|
23.9%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.9% · Observed 21.9% · Expected 20.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-19 · Fire 2024-07-19
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-05-05 · Fire 2023-05-05
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-12-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-12-04
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2026-01-13
F · Potential for more than minimal harm
2024-07-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-27
L · Immediate jeopardy
2023-11-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-11-15
F · Potential for more than minimal harm
2023-11-14
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-11-15
D · Potential for more than minimal harm
2023-11-14
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2024-01-03
D · Potential for more than minimal harm
2023-11-14
K255 · Egress Deficiencies
Fire Safety
Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-11-14
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-12-21
F · Potential for more than minimal harm
2023-05-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-13
F · Potential for more than minimal harm
2023-05-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-13
F · Potential for more than minimal harm
2023-05-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-05-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-05-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-05-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-04
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-12-04
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-12-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-13
J · Immediate jeopardy
2024-09-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-07
K · Immediate jeopardy
2024-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-27
E · Potential for more than minimal harm
2024-07-19
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-08-27
E · Potential for more than minimal harm
2024-07-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-07-19
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-06-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-18
E · Potential for more than minimal harm
2023-05-05
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-06-13
E · Potential for more than minimal harm
2023-05-05
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-05-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-05-05
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-05-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-06-13
D · Potential for more than minimal harm
2023-05-05
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-06-13
Penalties and ownership
What sits behind the stars
$10,036
2024-09-24
Fine
Fine · fine $10,036
Fine
$30,976
2024-06-20
Fine
Fine · fine $30,976
Fine
$134,761
2023-11-14
Fine
Fine · fine $134,761
Fine
Ownership
Ariso LLC
5% Or Greater Direct Ownership Interest · Organization
Ari Operations, LLC
5% Or Greater Indirect Ownership Interest · Organization
Avamere Group LLC
5% Or Greater Indirect Ownership Interest · Organization
Avamere Health Services LLC
Operational/Managerial Control · Organization
Avamere Skilled Advisors LLC
Operational/Managerial Control · Organization
Dillon, Richard
5% Or Greater Indirect Ownership Interest · Individual
Lockwood, Ryan
W-2 Managing Employee · Individual
Miller, Karl
5% Or Greater Indirect Ownership Interest · Individual
Miller, Karl
Corporate Officer · Individual
Odermott, Ronald
5% Or Greater Indirect Ownership Interest · Individual
Odermott, Ronald
Corporate Officer · Individual
Tomlinson, Kevin
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Avamere Rehabilitation Of Oregon City
Oregon City, OR
3-star overall rating with 2-star inspections with $85,768 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Rivercrest Post Acute
Oregon City, OR
3-star overall rating with 3-star inspections with $18,075 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Marquis Oregon City Post Acute Rehab
Oregon City, OR
4-star overall rating with 2-star inspections with abuse icon flag with 6 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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