Inspection Reports for
Avalon Care Center – Scappoose

The facility was found deficient in multiple areas including failure to maintain a safe and clean environment, failure to provide required documentation of bed hold policies, inaccurate completion of MDS assessments, incomplete care plans, inadequate assistance with hearing aids, poor grooming and hygiene care, lack of person-centered activities, improper pressure ulcer care, and failure to manage contractures and mobility.

The complaint was substantiated. The facility did not comply with the grievance resolution for Resident 401, allowing Staff 4 to provide care after a grievance requested otherwise.

The facility failed to honor a grievance resolution for one resident by allowing a staff member who was requested not to provide care to continue providing ADL care and vital assessments. This placed the resident at risk of not having their care preferences respected.

Resident grievance about staff providing care despite grievance resolution; staff placed on administrative leave and resigned. Education and systemic changes implemented to prevent recurrence.

Complaint and licensure investigation with no deficiencies corrected at time of visit.

The complaint investigation found that Resident 1 was pushed in a wheelchair without leg rests, contrary to the care plan, causing a fracture. The incident was substantiated and corrective actions were taken.

The facility failed to follow Resident 1's care plan by pushing the resident in a wheelchair without leg rests, resulting in a fractured left ankle. The facility completed a root cause analysis and implemented a plan of correction including staff education and monitoring.

The facility was found deficient in implementing a comprehensive person-centered care plan for communication services, failing to follow care plans leading to an avoidable resident fracture, serving cold food to residents, and not properly monitoring refrigerator cleanliness and temperature. Corrective actions and staff education were planned or implemented.

Multiple deficiencies including failure to implement comprehensive care plan, failure to prevent accidents resulting in fracture, failure to maintain proper food temperatures, and inadequate nursing staffing. Some deficiencies corrected, others not corrected at revisit.

Complaint and licensure complaint with no deficiencies corrected at time of visit.

Failure to report complete COVID-19 information to CDC's NHSN during required reporting period.

Failure to report complete COVID-19 information to CDC's NHSN during required reporting period.

Focused infection control and other state licensure survey with no deficiencies corrected at time of visit.

Failure to report complete COVID-19 information to CDC's NHSN during required reporting period.

Failure to report complete COVID-19 information to CDC's NHSN during required reporting period.

Failure to meet minimum CNA staffing ratios for multiple night shifts placing residents at risk for unmet needs. Some deficiencies corrected, others not corrected.

The investigation was complaint-driven, focusing on dignity concerns, resident-to-resident abuse, and fall prevention care plan adherence. The abuse allegation was substantiated with evidence of physical harm. The dignity and care plan issues were confirmed through observations and interviews.

The facility failed to ensure residents were treated with dignity, free from physical abuse, and that care plans were followed to prevent falls. Multiple incidents were documented including uncovered urinary drainage bags, a resident-to-resident physical abuse incident, and falls resulting from staff not following care plans.