Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 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.
Failure to provide written bed hold policy notice to two residents when they were transferred to the hospital. One resident had repeated hospitalizations and a ureteral stent complication, and the other had a hx of ischemic stroke and hemiplegia. Staff stated the usual transfer packet included a face sheet, orders, progress notes, and transfer notice, but the bed hold policy was not included or documented for the reviewed hospitalizations.
Damaged Bed Rail Padding Left Exposed A resident with Alzheimer's disease and a BIMS score of 0 had unkept bed rail padding in the room, with rusty metal and exposed sections of the mobility bars. Staff acknowledged the padding was ripped and needed replacement, but the damaged equipment was not reported through the facility's communication system, and the unit manager and maintenance director were unaware of the issue.
Inaccurate MDS Assessment for Hearing Needs: A resident admitted with metabolic encephalopathy and hearing loss had severe cognitive impairment documented on the admission and quarterly MDS, but the need to use hearing aids was not captured. The CAA for communication noted the resident was hard of hearing without hearing aids and staff should elevate their voices when speaking. The MDS Coordinator acknowledged the omission and stated accurate MDSs were needed so care plan interventions could be developed in a timely manner.
Inaccurate bowel care plan for a resident with quadriplegia. The care plan identified constipation risk and bowel incontinence, but it did not match the RN’s description of the resident’s actual bowel routine, including the expected BM frequency and normal loose consistency. The DNS confirmed the care plan did not accurately reflect the resident’s bowel care needs.
Failure to Assist Resident With Hearing Aids: A resident with hearing loss, severe cognitive impairment, and dependence for ADLs was not consistently assisted with hearing aids. The care plan noted a communication deficit, but staff were unaware the resident had hearing aids because they were not listed in the Kardex, and the resident was often observed without them. Staff reported the resident sometimes could not hear them, hearing aids were occasionally found on a windowsill, and the unit manager acknowledged staff did not provide adequate assistance because it was not reflected in the care plan.
Failure to provide nail care and hygiene assistance. A resident with Alzheimer’s disease and a BIMS of 0 required substantial to dependent assistance with personal hygiene, and the care plan directed staff to offer nail care twice weekly on shower days. A CNA completed a shower but did not provide nail care, and the resident’s nails were later observed to be untrimmed with debris under the nailbeds. Staff acknowledged the nails were dirty, unkept, and needed trimming, and stated nail care was expected after showers.
Failure to Provide Person-Centered Activities: A cognitively intact resident with chronic pain and muscle weakness had documented interests in music, animals, reading, and religious services, but was not provided an ongoing individualized activity program. The resident remained in bed, reported staff did not offer alternative in-room activities, and staff gave conflicting accounts about whether calendars, one-on-one visits, and in-room activities were actually provided.
A resident with quadriplegia developed a facility-acquired stage 3 pressure ulcer, but wound documentation was incomplete and inconsistent. Staff did not include wound descriptions, recorded changing measurements that were acknowledged as inaccurate, and used a wound app without formal education or policy guidance. When the area was later found closed and blanchable with no dressing, staff stated the wound had healed and wound care orders were discontinued.
Failure to maintain ROM and manage contractures: One resident with Alzheimer's disease, weakness, and pain was repeatedly observed with the L foot and ankle rotated inward while seated in a recliner, and CNAs reported the positioning issue had been raised months earlier without resolution. Another resident with quadriplegia had bilateral hand splint orders and care plan instructions to wear splints at night to prevent contractures, but the order was discontinued without documented reason and staff confirmed the splint instructions were missing and not being carried out.
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 Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to the representatives of 2 sampled residents when they were transferred to the hospital. Resident 8, who was readmitted in 9/2025 with diagnoses including mechanical complications of an indwelling ureteral stent, had hospital transfers on 6/15/25, 7/23/25, and 9/18/25, but no evidence was found in the clinical record that the resident’s representative received written bed hold policy notice for those transfers. Staff 9 stated the bed hold policy was completed by nurses or social services staff, but she did not complete it for this resident, and Staff 14 stated the policy had been provided once to the family representative but not on those hospitalization dates. Resident 18, admitted in 12/2024 with diagnoses including ischemic stroke and hemiplegia, was hospitalized multiple times and was not provided a physical copy of the bed hold policy on the listed transfer dates. Staff 14 confirmed the policy was to be provided when residents discharged to the hospital and were expected to return, but acknowledged it was not provided for this resident on the hospitalization dates reviewed. Staff 7 stated the paperwork given upon hospitalization included a face sheet, current orders, progress notes, and a transfer notice, and Staff 9 stated a bed hold policy form was not part of that paperwork. Staff 1 and Staff 2 confirmed Resident 18 should have received a bed hold policy each time she/he was hospitalized and expected to return.
Damaged Bed Rail Padding Left Exposed
Penalty
Summary
The facility failed to provide a safe and clean homelike environment for one sampled resident with Alzheimer's disease and a BIMS score of zero who was not cognitively intact. The resident was admitted in 4/2025, and the 4/15/24 care plan directed staff to notify maintenance when the padded mobility bars were damaged or removed. During observations on 12/15/25 through 12/16/2025 from 8:00 AM to 4:00 PM, the padding around the bed rails in the resident's room was unkept, the metal was rusty, and parts of the mobility bars were left uncovered with exposed metal. Staff interviews showed that staff were expected to report damaged equipment through the communication system, but the damaged padding in the resident's room was not reported. A CNA stated she told maintenance, nurses, and the administrator when equipment was damaged and made sure equipment was safe before use, but she did not report any damaged equipment in the resident's room. Another CNA acknowledged the padding on the bed rails was ripped and guessed it needed replacement. The unit manager stated she was unaware the padding in the room was damaged, and the maintenance director stated he had not been notified about damaged padding around the mobility bars in the resident's room.
Inaccurate MDS Assessment for Hearing Needs
Penalty
Summary
The facility failed to accurately complete MDS assessments for 1 of 1 resident reviewed for communication and sensory needs. The facility’s Resident Assessment policy stated that resident needs and strengths would be addressed regardless of whether the issue was included in the MDS or CAAs, and that resident observation and communication would be the primary source when completing assessments, with review of records and communication with staff and other sources as needed. Resident 19 was admitted with diagnoses including metabolic encephalopathy and hearing loss. The 6/5/25 admission MDS and 12/6/25 Quarterly MDS showed severe cognitive impairment and no hearing aids, while the CAA for communication indicated the resident was hard of hearing without hearing aids and staff were to elevate their voices when speaking. On 12/18/25, the MDS Coordinator stated she was responsible for completing the MDS assessments and acknowledged that information about the resident’s need to use hearing aids was not captured in the admission or quarterly MDS, and stated that accurate MDS assessments were necessary so care plan interventions would be developed in a timely manner.
Inaccurate bowel care plan
Penalty
Summary
The facility failed to ensure the care plan accurately reflected one resident’s bowel care needs. The resident was admitted in 7/2019 with diagnoses including quadriplegia. A revised care plan dated 9/6/25 identified the resident as at risk for constipation due to bowel incontinence and stated the resident was to have one bowel movement every three days, but it did not include the resident’s normal bowel movement consistency. During interview, an RN stated the resident was at risk for constipation due to quadriplegia, was monitored daily to ensure two bowel movements each day, and had normal bowel movements of loose consistency. The RN also stated that if the expected frequency or consistency did not occur, a bowel assessment was to be performed and a suppository given to prevent constipation and fecal impaction. The DNS confirmed the care plan did not accurately reflect the resident’s bowel care needs, including bowel movement frequency, consistency, and the resident’s normal bowel movements.
Failure to Assist Resident With Hearing Aids
Penalty
Summary
The facility failed to ensure staff assisted a resident with wearing hearing aids for Resident 19, who was admitted in 5/2025 with diagnoses including metabolic encephalopathy and hearing loss. The 6/5/25 admission MDS showed severe cognitive impairment, functional limitation in range of motion of both upper body sides, dependence on staff for ADLs, and no hearing aids listed. The CAA for communication stated the resident was hard of hearing without hearing aids and staff were to elevate their voices when speaking to the resident. The care plan identified a communication deficit related to being hard of hearing without hearing aids, but it did not include evidence that staff were to assist the resident with using the hearing aids. From 12/15/25 through 12/16/25, the resident was observed without hearing aids during multiple random observations. On 12/16/25, the resident was later observed wearing hearing aids and stated they were theirs, but they did not know who helped put them in or take them out, or who was supposed to place them in the charger at bedtime. Staff stated they were unaware the resident had hearing aids because they were not listed in the Kardex, and one CNA reported speaking louder when the resident said they could not hear. Another CNA stated hearing aids were sometimes found on the windowsill and placed in the charger, and the unit manager acknowledged the resident required hearing aids for hearing and communication but staff did not provide adequate assistance because this was not reflected in the care plan.
Failure to Provide Nail Care and Hygiene Assistance
Penalty
Summary
The facility failed to provide the necessary care and assistance to maintain good grooming and hygiene for one resident with Alzheimer's disease. The resident's care plan dated 4/15/24 indicated the resident required one person substantial to dependent assistance with personal hygiene and that staff were to offer and encourage nail care twice per week on shower days. The 12/8/25 Quarterly MDS showed a BIMS score of zero, indicating the resident was not cognitively intact and required maximum assistance with personal hygiene. The documentation and interviews showed that a CNA completed a shower for the resident on 12/16/25 but did not provide nail care. From 12/15/25 through 12/17/25, the resident's fingernails were observed to be untrimmed, with uneven trimming on the left hand and brown substance under two nailbeds, and untrimmed nails on the right hand with yellow and brown substance under four nailbeds. The resident stated staff had not performed nail care and would allow it when offered. The CNA stated she did not provide nail care and did not double check the resident's nails after the shower, while other staff stated CNAs could perform nail care for non-diabetic residents and expected nail care to be completed after showers. Staff also acknowledged the resident's nails were dirty, cracked, unkept, and needed trimming.
Failure to Provide Person-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing person-centered activities program for a resident who was admitted with chronic pain and muscle weakness and was cognitively intact. The resident’s care plan stated the resident wished to attend spiritual activities and that staff were to post a calendar in the room and remind and offer participation in activities. The MDS identified interests that included listening to music, being around animals, reading newspapers and magazines, and participating in religious services. However, the documentation survey report showed the resident did not participate in any in-room or out-of-room activities. From 12/15/25 through 12/18/25, the resident was observed in bed in the room, with no music, books, magazines, newspapers, activity calendar, or sound machine visible in the room. The resident stated staff did not offer an alternative activity to do in the room and said barriers to leaving bed included pain, use of a Hoyer lift, and frequent incontinence episodes. Staff gave conflicting statements about activity offerings: some said the resident participated in group activities when out of bed, some said one-on-one visits were offered, and others said in-room activities such as word searches, coloring pages, and card games were provided. Staff also acknowledged the resident was not offered in-room activities, and the activity director stated a calendar and sound machine were in the resident’s room even though they were not present when the room was entered.
Inaccurate wound documentation and incomplete pressure ulcer assessment
Penalty
Summary
Failure to provide pressure ulcer care consistent with professional standards of practice was identified for one resident with quadriplegia who was admitted to the facility with diagnoses including paralysis or significant weakness in both arms and legs. The resident developed a facility-acquired stage 3 pressure ulcer on the buttocks/coccyx area. The wound care plan called for monitoring and documenting wound size, depth, margins, peri-wound skin, exudate, edema, granulation, infection, necrosis, eschar, gangrene, and progress in healing, but the wound documentation repeatedly lacked a description of the wound characteristics. The skin and wound evaluation showed inconsistent measurements and documentation over time, including entries that described the wound as new, improving, and later healed and resolved, while the measurements changed in a way staff acknowledged was not accurate. On the day the wound was found closed and blanchable with no dressing present, staff stated the wound had healed and wound care orders were discontinued. Staff also stated they used a wound app for pictures and measurements, but no formal education or policy was provided on how to use it, and staff were unsure what the app measured when documenting the wound.
Failure to Maintain ROM and Manage Contractures
Penalty
Summary
The facility failed to manage contractures and provide continued treatment and services to prevent decreased ROM and mobility for 2 residents. One resident with Alzheimer's disease, generalized weakness, and pain was observed repeatedly seated in a recliner with the left foot and ankle resting on a footrest and rotated toward the midline of the body. CNAs stated the resident's left foot and ankle rotated inward when seated in the recliner, that the resident sat in the recliner often, and that the issue had been reported to nursing leadership months earlier but was not addressed. The Director of Rehabilitation stated the inward ankle rotation placed the ankle in an unstable position, brought the ankle bone close to the skin, and had developed gradually over time. A second resident with quadriplegia had an order for bilateral hand splints to be worn at night for four hours for skin care, and the care plan also included wearing the splints to prevent contractures. The splint order was discontinued, and staff could not locate documentation explaining why it was stopped. The resident stated being unaware of the splints and said staff did not assist with placing or removing them. A CNA, an LPN unit manager, and the DNS all confirmed the splint instructions were missing from the resident's orders and that there were no records showing the resident had been assisted with bilateral hand splints since the order was discontinued.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 402 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 36 | 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 | ★★★★★ | 29 | 0 |
| The Oaks At Timberline | 12.3 mi | ★★★★★ | 15 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avalon Care Center - Scappoose.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.