Avalon Care Center - Portland
Portland, Oregon · CCN 38E173
16 surveys since 2012, 3 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 63
- Surveys
- 16
- Harm or worse
- 3
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 40
- Ownership
- For profit - Limited Liability company
- Chain
- Independent
- County
- Multnomah
- Medicare-certified since
- 1976
CMS ratings
- Overall
- 3
- Health inspection
- 2
- Staffing
- 4
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.
Weighted by harm level, against 32 for-profit facilities with fewer than 66 beds in Oregon.
Last survey on record
Apr 7, 2026
216 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 5.67 | 5.00 |
| Registered-nurse hours per resident day | 0.56 | — |
| Annual nurse turnover | 39.1% | 48.4% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Abuse icon
- Flagged by CMS on Care Compare
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G13.1% | H— | I— |
| No harm, potential for more than minimal | D2784.4% | E39.4% | F13.1% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6894×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F5782×
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
- F5802×
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- F6002×
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- F6842×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
In the surveyor’s words
From the most serious findings on record at Avalon Care Center - Portland, in the surveyor’s own words.
- Actual harm, isolatedF689Oct 24, 2024
Based on observation, interview, and record review it was determined the facility failed to ensure the facility's smoking policy was implemented and followed for 1 of 3 (#2) sampled residents reviewed for accidents and hazards. As a result, Resident 2 sustained a second degree burn to her/his left hand. Findings include: The facility's 1/20/23 Smoking Policy indicated the facility will furnish a supervised designated smoking area where smoking and smoking paraphernalia items will be managed and distributed by staff. The facility indicated residents who smoke must return all smoking and smoking paraphernalia items to the facilities centralized storage box. […]
- No harm, potential for more than minimal, widespreadF727Mar 14, 2023
Based on interview and record review it was determined the facility failed to ensure RN coverage for 8 consecutive hours per day 7 days per week for 30 out of 127 days reviewed for staffing. This placed residents at risk for lack of timely assessments and care. Findings include: Review of the Direct Care Staff Daily Reports from 7/1/22 through 9/30/22 and 2/1/23 through 3/7/23 revealed there was no RN coverage for eight consecutive hours on: -7/17, 7/31, 8/1, 8/7, 8/8, 8/9, 8/10, 8/14, 8/15, 8/16, 8/19, 8/20, 8/24, 8/31, 9/6, 9/9, 9/13, 9/20, 9/22, 9/27, 9/29, 9/30; -2/4, 2/11, 2/12, 2/13, 2/18, 2/20, 2/28, 3/6. On 3/8/23 at 9:46 AM Staff 1 (Administrator) was notified of the findings of this investigation. Staff 1 stated the facility had struggled to hire RN's.
- No harm, potential for more than minimal, widespreadF888Feb 18, 2022
Based on interview and record review it was determined the facility failed to develop additional precautions intended to mitigate the transmission and spread of COVID-19 for 8 of 9 unvaccinated staff (#s 2, 8, 10, 15, 16, 17, 18 and 19) reviewed for COVID-19 staff vaccinations. This placed residents at risk for potential exposure of the COVID-19 virus. Findings include: The facility's 10/2021 COVID-19 Vaccine Maintenance Plan indicated A non-vaccinated staff, with an approved exemption, will be subject to all of the existing accommodation protocols of a non-vaccinated employee, (including but not limited to, increased COVID-19 test). The facility's COVID-19 Staff Vaccination Status for Providers identified nine staff members who where unvaccinated due to non-medical exemptions. […]
- No harm, potential for more than minimal, widespreadF880May 25, 2021
Based on observations, interviews and record review it was determined the facility failed to maintain appropriate infection control practices to prevent the potential spread of the COVID-19 virus and other infectious diseases for 4 of 4 hallways, 1 of 1 breakrooms and 1 of 1 PPE storage areas reviewed for infection prevention. This placed residents at risk for exposure and contraction of the COVID-19 virus and other infectious diseases. Findings include: a. The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, last revised 2/23/21, instructed healthcare workers to perform hand hygiene before and after all patient contact, before and after removing PPE (Personal… […]
- No harm, potential for more than minimal, patternF628Apr 7, 2026
Based on interview and record review it was determined the facility failed to ensure residents were informed in writing of the facility's bed-hold policy and notice of transfer at the time of hospital transfer for 3 of 3 residents (#s 4, 7 and 8) reviewed for notification. This placed residents and responsible parties at risk for not being informed of transfer and bed-hold policy fees. Findings include: The facility's 7/2018 Notification of Changes of Condition Policy instructs the facility to promptly notify the resident representative when there was a decision to transfer a resident from the facility to the hospital.a. […]
Read 22 findings in full →The most serious and the most recent: 22 of 63 on record.
Every survey on record
FindingsAt actual harm or above
- Apr 7, 2026Complaint4 findings
- Jul 25, 2025Standard5 findings
- Oct 24, 2024Complaint1 finding · 1 harm
- Jun 3, 2024Standard12 findings
- Mar 14, 2023Standard and complaint11 findings
- Jul 13, 2022Complaint4 findings
- Feb 18, 2022Standard1 finding
- May 25, 2021Infection control1 finding
Show the 8 earlier surveys
- Jun 13, 2019Standard3 findings
- Dec 5, 2017Standard2 findings
- Nov 4, 2016Standard5 findings
- Oct 2, 2015Standard2 findings
- Aug 1, 2014Standard and complaint1 finding
- Sep 5, 2013—1 finding · 1 harm
- Feb 15, 2013—7 findings · 1 harm
- Jan 3, 2012—3 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction