Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avalon Care Center - Scappoose during CMS and state inspections, most recent first.
A resident with diabetes had a standing physician order and care plan for weekly diabetic nail care to be performed by licensed nurses, but staff interviews and observations showed that nail care, particularly to the left hand, had not been performed or maintained for an extended period. The resident’s left thumb nail was markedly thickened, elevated from the nail bed, and discolored, and another finger had minimal nail bed remaining. CNAs deferred nail care due to the resident’s diabetic status, RNs acknowledged not providing nail care to the left hand due to lack of skill and unclear documentation, and the DNS believed an outside insurer-managed service was responsible but could not produce documentation that such care occurred. This failure placed the resident at risk for unmet care needs and potential diabetes-related complications.
A resident with dementia and a femur fracture, whose POA requested a specific CNA be removed from their care following a grievance, continued to receive ADL care and vital sign assessments from that CNA despite a documented resolution. Facility records and staff interviews confirmed the CNA's ongoing involvement in the resident's care after the grievance was addressed.
A resident with dementia and moderate cognitive impairment sustained an avoidable ankle fracture when a CNA pushed them in a wheelchair without leg rests, contrary to the care plan. The resident, who often self-propelled, became tired and was assisted by the CNA, leading to the incident. Despite initial assessments showing no immediate swelling or bruising, an X-ray later confirmed a fracture. Interviews revealed the resident frequently removed leg rests to self-propel, and staff were supposed to replace them when assisting.
The facility failed to maintain proper food temperatures for meals served to residents on three halls. During a survey, residents complained about receiving cold food, and documentation from a Resident Council Meeting recorded similar complaints about cold breakfasts. The Dietary Manager confirmed these complaints, and during a Resident Council meeting, multiple residents expressed concerns about cold food on all halls. This issue was communicated to the Administrator, but no additional information was provided.
The facility did not monitor the cleanliness and temperature of a refrigerator used for resident snacks, risking food-borne illness. A yellow liquid was observed spilled inside, and no thermometer was present. The Dietary Manager confirmed the refrigerator's condition and the absence of a temperature log, contrary to facility guidelines.
A resident with aphasia and dysarthria was not provided with a communication board as outlined in their care plan. The board, intended to assist with communication, was found unused at the nurses' station. Staff were unaware of its existence, and the facility administrator acknowledged the failure to follow the care plan.
Failure to Provide Ordered Diabetic Nail Care
Penalty
Summary
The facility failed to provide appropriate diabetic nail care as ordered for one resident with diabetes. The resident was admitted with a diagnosis of diabetes and had a physician’s order dated 1/24/26 for diabetic nail care every week on Saturdays. The resident’s care plan dated 1/19/26 identified licensed nurses as responsible for providing this nail care. On 4/2/26 at 2:11 PM, observation showed the resident’s left thumb nail was approximately 3/4 inches thick, significantly elevated off the nail bed, and discolored, and the left index finger had minimal nail bed remaining. The resident denied pain in the left fingers at the time of observation. Staff interviews confirmed that ordered and care-planned nail care was not being provided to the resident’s left hand. A CNA stated they did not provide nail care to this resident due to the resident’s diabetic status and indicated that nail care was the responsibility of nursing staff. An RN reported they had not performed nail care for this resident and confirmed the left hand nails appeared not to have been maintained for at least a month, noting that nail care needs had been discussed among nursing staff and a note submitted to the provider, but no follow-up had occurred. Another RN stated they documented completion of nail care only for the right hand and had not performed care on the left hand due to lack of skill, knowledge, and comfort, and described the documentation instructions as vague while acknowledging the resident required specialized nail care. The DNS acknowledged concern about the condition of the left thumb nail, reported the resident had a history of ongoing fungal infection, and believed the resident’s health insurance provider was responsible for managing nail care, but could not provide documentation that nail care services had been completed. The report states this failure placed the resident at risk for unmet care needs and potential complications related to diabetes.
Failure to Honor Grievance Resolution Regarding Resident Care Assignment
Penalty
Summary
The facility failed to honor a grievance resolution for a resident with dementia and a femur fracture, who had significant cognitive impairments. A grievance was filed by the resident's Power of Attorney (POA) after a CNA forced the POA to leave the resident's room during care and subsequently left the room when the POA requested to stay. The POA requested that this CNA no longer provide care to the resident, and the Director of Nursing Services documented that the resolution was for the CNA to be removed from providing care to this resident. Despite this documented resolution, facility records showed that the CNA continued to provide ADL care, including brief changes, oral hygiene, showers, and vital sign assessments to the resident on multiple occasions after the grievance was resolved. The POA observed the CNA providing care on at least one occasion and reported this to facility staff. The Director of Nursing Services confirmed that records indicated the CNA continued to provide care to the resident after the grievance resolution.
Failure to Follow Care Plan Results in Resident's Ankle Fracture
Penalty
Summary
The facility failed to provide care in accordance with care planned interventions for a resident who was being pushed in a wheelchair, resulting in an avoidable fracture to the resident's left ankle. The resident, who was admitted to the facility in 2015 with a diagnosis of dementia and had a moderate cognitive impairment, was care planned to have leg rests on their wheelchair when being pushed by staff. However, on the day of the incident, the resident was pushed by a CNA without the leg rests, leading to the resident's foot dropping and causing a fracture. The incident occurred when the resident, who was self-propelling in their wheelchair, became tired and was assisted by a CNA. The CNA felt resistance while pushing the wheelchair and stopped when the resident cried out in pain. An LPN nearby assessed the resident's ankle, administered pain medication, and applied ice. Despite the initial assessment showing a normal range of motion, the resident later experienced moderate pain and swelling, and an X-ray confirmed an oblique fracture with mild displacement. Interviews with staff and the resident's representative revealed that the resident often removed the leg rests to self-propel and would request assistance when tired, at which point staff were supposed to place the leg rests back on. The CNA involved in the incident acknowledged pushing the resident without the leg rests, contrary to the care plan. The facility's investigation confirmed the failure to follow the care plan, which led to the resident's injury.
Removal Plan
- Staff education on placing leg rests onto resident wheelchairs and how to look at resident care plans and resident profiles.
- Create a notice for Resident 1's wheelchair to remind staff to put the leg rests on before pushing and what to do if Resident 1 declined the use of the leg rests.
- Licensed nursing staff to monitor use of leg rests on resident wheelchairs for residents who require assistance with mobilizing in wheelchairs.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to maintain proper food temperatures for meals served to residents on three halls, as observed during a survey. On August 12, 2024, during the tray pass, two residents complained about receiving cold food. Additionally, documentation from a Resident Council Meeting in May 2024 recorded complaints about cold breakfasts. On August 14, 2024, the Dietary Manager confirmed that residents had complained about cold food. During a Resident Council meeting on August 15, 2024, twelve residents expressed concerns about cold food on all halls. This issue was communicated to the Administrator on the same day, but no additional information was provided.
Failure to Monitor Refrigerator Cleanliness and Temperature
Penalty
Summary
The facility failed to monitor the temperatures and cleanliness of a unit refrigerator used for resident snacks and personal foods, which placed residents at risk for food-borne illness. During an observation, a yellow liquid was found spilled on a lower shelf of the refrigerator, and there was no thermometer present inside. The facility's guideline for Dietary Service Resident Community Refrigerator requires housekeeping staff or a designee to monitor the refrigerator daily for cleanliness and to have an approved thermometer inside, with designated staff recording the temperature at least daily. However, the Dietary Manager confirmed that the refrigerator needed cleaning, no thermometer was present, and there was no temperature log available.
Failure to Implement Communication Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with communication-sensory needs. The resident, who was admitted with diagnoses of aphasia and dysarthria following a non-traumatic subarachnoid hemorrhage, was observed to have impaired communication abilities. Despite the care plan indicating the use of a picture board for communication, the board was not present in the resident's room, and staff were unaware of its existence or its intended use. Observations and staff interviews revealed that the communication board, which was supposed to aid the resident in expressing their needs, was found under a pile of items at the nurses' station and had not been utilized. Staff members, including a CNA and the Activities/Recreation Director, were not informed about the communication board's role in the resident's care plan. The facility administrator acknowledged the oversight, noting that the care plan's instructions were not being followed, as the communication board was not accessible to the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Scappoose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Saint Helens Post Acute | 7.6 mi | — | 14 | 0 |
| Salmon Creek Post Acute & Rehabilitation | 11.3 mi | — | 27 | 0 |
| Woodland Convalescent Center | 11.4 mi | — | 1 | 0 |
| Bridge Crest Post Acute | 11.7 mi | — | 26 | 0 |
| The Oaks At Timberline | 12.3 mi | — | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.