GLADSTONE, OR — Federal health inspectors identified four deficiencies at Avamere Rehabilitation of Clackamas during a standard health inspection on December 4, 2025, including a citation for failing to maintain an adequate infection prevention and control program.
Infection Prevention Program Found Deficient
The Centers for Medicare & Medicaid Services (CMS) cited the Gladstone facility under regulatory tag F0880, which requires nursing homes to provide and implement a comprehensive infection prevention and control program. The citation fell under the category of Infection Control Deficiencies, a critical area of nursing home oversight that has received heightened scrutiny since the COVID-19 pandemic reshaped long-term care facility regulations.
Inspectors assigned the violation a Scope/Severity Level D, indicating an isolated incident where no actual harm occurred but where the potential existed for more than minimal harm to residents. While this represents the lower end of the federal severity scale, infection control lapses in congregate care settings carry inherent risks that extend beyond what a single citation may suggest.
Why Infection Control Programs Matter in Nursing Homes
Nursing home residents represent one of the most vulnerable populations when it comes to infectious disease. The typical resident profile includes advanced age, multiple chronic conditions, and compromised immune function — all factors that increase susceptibility to infections and reduce the body's ability to fight them off.
A properly functioning infection prevention and control program includes several key components: hand hygiene protocols, proper use of personal protective equipment, environmental cleaning standards, surveillance of infection trends, and staff training. When any component of this system breaks down, even briefly, residents face elevated risk of exposure to pathogens that can cause urinary tract infections, respiratory illness, skin infections, and gastrointestinal disease.
In nursing home populations, infections that might cause mild illness in younger, healthier individuals can lead to hospitalization, sepsis, prolonged recovery periods, and in severe cases, death. According to federal data, infections remain among the leading causes of morbidity and mortality in long-term care facilities nationwide.
Federal Standards and Facility Expectations
Under 42 CFR §483.80, Medicare- and Medicaid-certified nursing facilities are required to establish and maintain an infection prevention and control program. This regulation mandates that facilities designate an Infection Preventionist (IP) — a qualified professional responsible for developing policies, conducting surveillance, and ensuring staff compliance with infection control practices.
The standard requires facilities to maintain a system for identifying, reporting, investigating, and controlling infections. This includes tracking antibiotic use, monitoring for outbreaks, and ensuring that all staff members receive training appropriate to their roles. Facilities must also establish written protocols that address how infections are prevented and managed across all departments.
The fact that Avamere Rehabilitation of Clackamas received a Level D citation — isolated with no documented harm — suggests the deficiency was limited in scope. However, infection control programs function as interconnected systems, and gaps in one area can quickly cascade into broader facility-wide exposure risks if not promptly addressed.
Correction Plan and Current Status
Following the inspection, Avamere Rehabilitation of Clackamas submitted a plan of correction to federal regulators. The facility reported that corrections were implemented as of January 13, 2026, approximately six weeks after the initial inspection.
The infection control citation was one of four total deficiencies identified during the December 2025 inspection. Plans of correction require facilities to outline specific steps taken to remedy the deficiency, measures to prevent recurrence, and a timeline for full compliance.
Broader Context for Oregon Facilities
Oregon nursing homes, like facilities across the country, operate under dual state and federal oversight. The Oregon Department of Human Services works alongside CMS to conduct inspections and enforce compliance. Facilities that fail to correct cited deficiencies within established timeframes may face progressive enforcement actions, including civil monetary penalties, denial of payment for new admissions, or in extreme cases, termination from Medicare and Medicaid programs.
Families with loved ones at Avamere Rehabilitation of Clackamas can review the complete inspection report through the CMS Care Compare website, which provides detailed findings for all federally certified nursing facilities. The full report contains additional information about the remaining deficiencies cited during this inspection cycle.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avamere Rehabilitation of Clackamas from 2025-12-04 including all violations, facility responses, and corrective action plans.
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