Avalon Care Center - Scappoose

In the surveyor’s words

From the most serious findings on record at Avalon Care Center - Scappoose, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 16, 2024

  Based on interview and record review it was determined the facility failed to provide care in accordance with care planned interventions while pushing a resident in a wheelchair for 1 of 1 sampled resident (#1) reviewed for accidents. This failure resulted in an avoidable fracture to Resident 1's left ankle. Findings include: Resident 1 was admitted to the facility in 2015 with diagnoses including dementia. The 6/2023 Annual MDS revealed Resident 1 had a BIMS of 11 (moderate cognitive impairment). Resident 1's mobility care plan dated 12/9/22 instructed staff to promote Resident 1's independence with locomotion as tolerated without leg rests and revealed Resident 1 needed assistance with leg rests in place for wheelchair mobility when being pushed by staff. […]

• No harm, potential for more than minimal, patternF628Dec 19, 2025

  Based on interview and record review it was determined the facility failed to provide notice of bed hold policies for 2 of 2 sampled residents (#s 8 and 18) reviewed for hospitalizations. This placed residents at risk for miscommunication of the discharge process. Findings include:1.Resident 8 was readmitted to the facility in 9/2025 with diagnoses including mechanical complications of an indwelling ureteral stent (a tube from the kidney to the bladder to maintain drainage). Resident 8's medical record indicated she/he was transferred to the hospital on 5/18/25, 6/15/25, 7/23/25 and 9/18/25. […]

• No harm, potential for more than minimal, patternF804Aug 16, 2024

  Based on observation, interview, and record review it was determined the facility failed to ensure proper food temperatures were maintained for meals served to residents on 3 of 3 halls reviewed for dining. This placed residents at risk for increased risk for impaired nutrition. Findings include: Observation on 8/12/24 at 11:45 AM during tray pass Resident 1 complained of cold food. Observation on 8/12/24 at 11:47 AM during tray pass Resident 4 complained of cold food. Resident Council Meeting documentation from 5/2024 recorded residents complaints that breakfast was often cold. On 8/14/24 at 3:37 PM Staff (5) Dietary Manager confirmed the residents had complained about cold food. Twelve residents were interviewed during a Resident Council meeting on 8/15/24 at 10:21 AM. […]

• No harm, potential for more than minimal, patternF812Aug 16, 2024

  Based on observation, interview, and record review it was determined the facility failed to monitor temperatures and cleanliness of 1 of 1 unit refrigerator. This placed the residents at risk for food-borne illness. Findings include: The facility guideline for Dietary Service Resident Community Refrigerator stated: -Housekeeping staff/designee will monitor the refrigerator daily for cleanliness. Concerns will be delegated to the designated department. - Each refrigerator will have an approved thermometer inside the refrigerator. Designated staff will record the temperature at least daily. On 8/14/24 at 12:48 PM the unit refrigerator used for resident snacks and personal foods was observed to have yellow liquid spilled on a lower shelf. […]

• No harm, potential for more than minimal, isolatedF684Apr 3, 2026

  Based on observation, interview and record review it was determined the facility failed to ensure appropriate nail care services was provided for 1 of 4 sampled residents (#2) reviewed for nail care. This placed the resident at risk for unmet care needs and potential complications related to diabetes. Findings includeResident was admitted on 9/2024 with diagnosis of diabetes.A Physician's Order dated 1/24/26 directed Resident 2 to receive diabetic nail care every week on Saturdays.Resident 2's 1/19/26 Care Plan indicated licensed nurses were responsible for providing nail care to Resident 2.On 4/2/26 at 2:11 PM, observation revealed Resident 2's left thumb nail was approximately 3/4 inches thick, significantly elevated off nail bed and discolored. […]