Inspection Reports for Avamere Rehabilitation of Clackamas
220 E. Hereford, OR, 97027
Back to Facility ProfileDeficiencies per Year
20
15
10
5
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Inspection Report
Capacity: 87
Deficiencies: 17
Dec 4, 2025
Visit Reason
State-compiled facility profile showing 9 inspections from 2021 to 2025 with deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility demonstrated repeated deficiencies related to infection control, care planning, environmental safety, staffing, and supervision, with several Immediate Jeopardy situations identified and corrected. Deficiencies spanned issues such as elopement risk management, infection prevention, physical environment maintenance, medication management, and staff background checks.
Complaint Details
Multiple inspections included complaint investigations related to elopement risks, infection control, staffing, and care plan compliance, with Immediate Jeopardy situations identified and resolved.
Deficiencies (17)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to maintain safe, clean, comfortable, and homelike environment including lighting, flooring, and bathroom conditions |
| F0656 - Develop/Implement Comprehensive Care Plan |
| F0677 - ADL Care Provided for Dependent Residents |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to follow care plan and re-evaluate elopement risks, resulting in unsafe elopements |
| F0744 - Treatment/Service for Dementia: Failed to implement resident-centered care plan interventions for dementia |
| F0756 - Drug Regimen Review, Report Irregular, Act On: Failed to address pharmacy recommendations timely |
| F0757 - Drug Regimen is Free from Unnecessary Drugs: Failed to withhold bowel medication as indicated |
| F0804 - Nutritive Value/Appear, Palatable/Prefer Temp: Failed to provide palatable meals |
| F0814 - Dispose Garbage and Refuse Properly: Failed to maintain garbage storage areas in sanitary manner |
| F0880 - Infection Prevention & Control: Failed to ensure proper cleaning and disinfection of glucometers between resident use |
| F0884 - Reporting - National Health Safety Network: Failed to report complete COVID-19 information to NHSN |
| M0000 - Initial Comments |
| M0143 - Employees: Criminal Record Checks: Failed to implement active supervision for staff with pending background checks |
| M0183 - Nursing Services: Minimum CNA Staffing: Failed to maintain state minimum CNA staffing ratios |
| M0481 - Electrical System: Nurse Call System: Failed to ensure audible and visual call signals for resident call lights |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
Report Facts
Inspections on page: 9
Total deficiencies: 22
Total surveys: 9
Licensing violations: 20
Abuse violations: 0
Notices: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Named in multiple findings including elopement risk, staffing, nurse call system, and garbage storage deficiencies |
| Staff 2 | DNS (Director of Nursing Services) | Named in findings related to elopement risk, infection control, staffing, and care plan compliance |
| Staff 3 | RNCM (Registered Nurse Care Manager) | Named in findings related to elopement risk and infection control |
| Staff 5 | LPN (Licensed Practical Nurse) | Named in fall with fracture finding |
| Staff 6 | CNA (Certified Nursing Assistant) | Named in fall with fracture finding |
| Staff 7 | Dietary Aide | Named in background check supervision finding |
| Staff 8 | CNA | Named in background check supervision finding |
| Staff 9 | Human Resources/Staffing | Named in background check supervision and staffing findings |
| Staff 10 | CNA | Named in dementia care and food quality findings |
| Staff 11 | Maintenance Director | Named in physical environment and lighting deficiencies |
| Staff 14 | Corporate Nurse Consultant | Named in food quality deficiency |
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