Inspection Reports for Avalon Care Center – Portland

12640 SE Bush, Portland, OR, 97236

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Inspection Report Summary

The most recent inspection on July 25, 2025, identified multiple deficiencies related to resident rights, PASARR screening, activities, accident hazards, drug regimen, and administrative rules, all of which were corrected by August 18, 2025. Earlier inspections showed a pattern of citations involving accident hazards, administrative rules, care planning, quality of care, and infection control, with many deficiencies noted in complaint investigations and some not corrected promptly. Complaint investigations did not result in substantiated complaints but revealed ongoing issues with accident hazards, medication management, and documentation. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to be addressing deficiencies over time, as the most recent inspection showed correction of all cited issues.

Deficiencies (last 4 years)

Deficiencies (over 4 years) 14.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

113% worse than Oregon average
Oregon average: 6.7 deficiencies/year

Deficiencies per year

16 12 8 4 0
2022
2023
2024
2025

Inspection Report

Routine
Capacity: 44 Deficiencies: 8 Date: Jul 25, 2025

Visit Reason
Multiple deficiencies including resident rights, PASARR screening, activities, accident hazards, drug regimen, and administrative rules. All deficiencies were corrected by 8/18/2025.

Findings
Multiple deficiencies including resident rights, PASARR screening, activities, accident hazards, drug regimen, and administrative rules. All deficiencies were corrected by 8/18/2025.

Deficiencies (8)
F0000 - INITIAL COMMENTS
F0550 - Resident Rights/Exercise of Rights
F0645 - PASARR Screening for MD & ID
F0679 - Activities Meet Interest/Needs Each Resident
F0689 - Free of Accident Hazards/Supervision/Devices
F0757 - Drug Regimen is Free from Unnecessary Drugs
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Complaint Investigation
Capacity: 44 Deficiencies: 2 Date: Jan 9, 2025

Visit Reason
Complaint investigation with 2 citations, both not corrected as of the visit date.

Findings
Complaint investigation with 2 citations, both not corrected as of the visit date.

Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments

Inspection Report

Complaint Investigation
Capacity: 44 Deficiencies: 4 Date: Oct 24, 2024

Visit Reason
Complaint investigation with 4 citations including accident hazards and administrative rules. Some deficiencies corrected, others not corrected upon revisit.

Findings
Complaint investigation with 4 citations including accident hazards and administrative rules. Some deficiencies corrected, others not corrected upon revisit.

Deficiencies (4)
F0000 - INITIAL COMMENTS
F0689 - Free of Accident Hazards/Supervision/Devices
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Complaint Investigation
Capacity: 44 Deficiencies: 15 Date: Jun 3, 2024

Visit Reason
Complaint investigation with 15 citations covering reasonable accommodations, advance directives, notification of changes, environment, abuse, care plans, quality of care, accident hazards, respiratory care, food safety, and administrative rules. Mixed correction status with many deficiencies not corrected upon revisit.

Findings
Complaint investigation with 15 citations covering reasonable accommodations, advance directives, notification of changes, environment, abuse, care plans, quality of care, accident hazards, respiratory care, food safety, and administrative rules. Mixed correction status with many deficiencies not corrected upon revisit.

Deficiencies (15)
F0000 - INITIAL COMMENTS
F0558 - Reasonable Accommodations Needs/Preferences
F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir
F0580 - Notify of Changes (Injury/Decline/Room, etc.)
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0600 - Free from Abuse and Neglect
F0655 - Baseline Care Plan
F0656 - Develop/Implement Comprehensive Care Plan
F0684 - Quality of Care
F0689 - Free of Accident Hazards/Supervision/Devices
F0695 - Respiratory/Tracheostomy Care and Suctioning
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0842 - Resident Records - Identifiable Information
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Complaint Investigation
Capacity: 44 Deficiencies: 2 Date: Feb 2, 2024

Visit Reason
Complaint investigation with 2 citations, both not corrected as of the visit date.

Findings
Complaint investigation with 2 citations, both not corrected as of the visit date.

Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments

Inspection Report

Complaint Investigation
Capacity: 44 Deficiencies: 15 Date: Mar 14, 2023

Visit Reason
Complaint investigation with 15 citations including psychotropic medication consent, advance directives, grievances, incident investigations, medication administration, accident hazards, respiratory care, staffing, food safety, and administrative rules. Mixed correction status with many deficiencies not corrected upon revisit.

Findings
Complaint investigation with 15 citations including psychotropic medication consent, advance directives, grievances, incident investigations, medication administration, accident hazards, respiratory care, staffing, food safety, and administrative rules. Mixed correction status with many deficiencies not corrected upon revisit.

Deficiencies (15)
F0000 - INITIAL COMMENTS
F0552 - Right to be Informed/Make Treatment Decisions
F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir
F0585 - Grievances
F0610 - Investigate/Prevent/Correct Alleged Violation
F0684 - Quality of Care
F0689 - Free of Accident Hazards/Supervision/Devices
F0695 - Respiratory/Tracheostomy Care and Suctioning
F0727 - RN 8 Hrs/7 days/Wk, Full Time DON
F0758 - Free from Unnec Psychotropic Meds/PRN Use
F0804 - Nutritive Value/Appear, Palatable/Prefer Temp
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
M0000 - Initial Comments
M0182 - Nursing Services:Minimum Licensed Nurse Staff
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Complaint Investigation
Capacity: 44 Deficiencies: 8 Date: Jul 13, 2022

Visit Reason
Complaint investigation with 8 citations including failure to provide bathing services and infection control issues. Some deficiencies corrected, others not corrected upon revisit.

Findings
Complaint investigation with 8 citations including failure to provide bathing services and infection control issues. Some deficiencies corrected, others not corrected upon revisit.

Deficiencies (8)
E0000 - Initial Comments
F0000 - INITIAL COMMENTS
F0677 - ADL Care Provided for Dependent Residents
F0725 - Sufficient Nursing Staff
F0880 - Infection Prevention & Control
F0885 - Reporting-Residents,Representatives&Families
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Capacity: 44 Deficiencies: 1 Date: Jul 5, 2022

Visit Reason
Focused infection control survey with 1 citation for failure to report complete COVID-19 information to CDC's NHSN. Citation not corrected as of visit date.

Findings
Focused infection control survey with 1 citation for failure to report complete COVID-19 information to CDC's NHSN. Citation not corrected as of visit date.

Deficiencies (1)
F0884 - Reporting - National Health Safety Network

Inspection Report

Capacity: 44 Deficiencies: 1 Date: Jun 27, 2022

Visit Reason
Focused infection control survey with 1 citation for failure to report complete COVID-19 information to CDC's NHSN. Citation not corrected as of visit date.

Findings
Focused infection control survey with 1 citation for failure to report complete COVID-19 information to CDC's NHSN. Citation not corrected as of visit date.

Deficiencies (1)
F0884 - Reporting - National Health Safety Network

Inspection Report

Capacity: 44 Deficiencies: 1 Date: Jun 21, 2022

Visit Reason
Focused infection control survey with 1 citation for failure to report complete COVID-19 information to CDC's NHSN. Citation not corrected as of visit date.

Findings
Focused infection control survey with 1 citation for failure to report complete COVID-19 information to CDC's NHSN. Citation not corrected as of visit date.

Deficiencies (1)
F0884 - Reporting - National Health Safety Network

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