Avalon Care Center - Portland
12640 Se Bush, Portland, OR 97236 · Multnomah County · (503) 761-6621
40 certified beds, about 39 residents a day · For profit - Limited Liability company · Medicaid since 1976
CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid
Overall
3 of 5
Health inspections
2 of 5
Staffing
4 of 5
Quality measures
5 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 38E173 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on July 25, 2025, inspectors cited 5 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 32 health citations since March 2023, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 5.67 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.56 of those hours.
39.1% of nursing staff left within the year CMS measured (Oregon average 47.4%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1003/23
1206/24
110/24
507/25
404/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 32 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
27D
3E
1F
Potential for minimal harm
0A
0B
0C
April 7, 2026Complaint inspection · 4 citations
- E Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased 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.
- D Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to promote and facilitate resident self-determination to support a resident's preference for health care providers for 1 of 3 sampled residents reviewed for abuse. This placed residents at risk for lack of self-determination and autonomy.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to notify a resident's representative of a hospital transfer for 1 of 3 sampled residents (#4) reviewed for notification of changes. This placed residents and responsible parties at risk for not being informed of transfers:
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was free from sexual abuse for 1 of 3 sampled residents (#2) reviewed for abuse. This placed residents at risk for a decrease in their quality of life and at risk for psychosocial difficulties.
July 25, 2025Standard inspection · 5 citations
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident's right to a dignified existence with use of a power mobility device for 1 of 1 resident (# 19) reviewed for choices. This placed residents at risk for diminished independence and freedom of socialization with other residents.
- D PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure an appropriate PASARR (Preadmission Screening for individuals with a mental disorder and/or individuals with intellectual disability) was completed for 2 of 3 sampled resident (#s 8 and 34) reviewed for PASARR. This placed residents at risk for not receiving specialized services.
- D Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review the facility failed to ensure activities were honored for 1 of 1 sampled resident (#9) reviewed for activities. This placed residents at risk for boredom, and loneliness.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to implement care planned transfer interventions to prevent falls for 1 of 2 sample residents (#4) reviewed for accidents. This placed residents at risk for physical injury.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's prophylactic use of an antibiotic was reviewed and a rationale for continued use was documented when duplicate antibiotic treatment occurred for 1 of 1 sampled resident (#12) reviewed for antibiotic usage. This placed residents at risk for adverse medication consequences and drug-resistant infections.
October 24, 2024Complaint inspection · 1 citation
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased 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.
June 3, 2024Standard inspection, Complaint inspection · 12 citations
- E Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from physical and sexual abuse for 2 of 7 sampled residents (#s 3 and 12) reviewed for abuse. This placed residents at risk for physical and psychological harm.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview it was determined the facility failed to store and handle food in a sanitary manner for 1 of 2 facility kitchens (dining room kitchenette) reviewed for sanitary food storage and handling. This placed residents at risk for food-borne illness and contamination.
- D Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure resident needs and preferences related to lighting were accommodated for 1 of 3 sampled residents (# 13) reviewed for accommodation of needs. This placed residents at risk for lack of access to lighting and an unhomelike environment.
- D 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain copies of advance directives and inform residents of the right to formulate advance directives for 2 of 2 sampled residents (#s 8 and 13) reviewed for advance directives. This placed residents at risk of not having their health care decisions honored.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to notify a resident's representative of an appointment out of the facility for 1 of 1 sampled resident (#289) reviewed for notification of change. This placed residents at risk of their representatives being uninformed.
- D Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observation and interview it was determined the facility failed to maintain a homelike environment for 1 of 3 sampled residents (# 13) reviewed for environment. This placed residents at risk for living in an unkempt environment.
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure written summary of a baseline care plan was provided to residents within 48 hours of admission for 2 of 4 sampled residents (#s 7 and 241) reviewed for baseline care plans. This placed residents at risk for being uninformed about their plan of care.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review it was determined the facility failed to develop a person-centered comprehensive care plan for 1 of 4 residents (#16) reviewed for mood and behavior. This placed residents at risk for lack of care planning.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow physician orders regarding wound care for 1 of 1 resident (# 241) reviewed for wound care. This placed residents at risk of unmet care needs.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide adequate care and hazard removal for 2 of 2 residents (#s 239 and 240) reviewed for accidents. This placed residents at risk of injury.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to maintain oxygen equipment and ensure oxygen was administered as ordered for 2 of 3 sampled residents (#s 4 and 21) reviewed for oxygen therapy. This placed residents at increased risk for respiratory failure.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accurately document wound care being provided which followed physician's orders for 1 of 1 resident (# 241) reviewed for wound care. This placed residents at risk of unmet care needs.
March 14, 2023Standard inspection · 10 citations
- F Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased 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.
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a psychotropic medication consent was provided for 1 of 5 sampled residents (#30) reviewed for unnecessary medications. This placed residents at risk for not being informed of risks and benefits of medications.
- D 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were provided information related to the formulation of an Advance Directive for 3 of 3 sampled residents (#10, #23, #32) reviewed for Advance Directives. This placed residents at risk for not having their treatment decisions honored.
- D Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident grievances were documented and resolved in a timely manner for 1 of 1 sampled resident (#5) reviewed for personal property. This placed residents at risk for unaddressed concerns and unmet care needs.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to thoroughly investigate accidents for 1 of 1 sampled resident (# 21) reviewed for skin conditions. This placed residents at risk for abuse.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to administer oxygen and medications according to physician's orders for 2 of 6 sampled residents (#s 10 and 30) reviewed for medications and oxygen administration. This placed residents at risk for pain and unnecessary oxygen administration.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure adequate supervision for 1 of 1 sampled resident (#30) reviewed for accidents. This failure placed residents at increased risk for falls.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure respiratory equipment was properly maintained for 1 of 1 sampled resident (#28) reviewed for respiratory care. This placed residents at risk for infection.
- D Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure there was appropriate evaluation and monitoring of psychotropic medications for 1 of 5 sampled resident (#21) reviewed for unnecessary medications. This placed residents at risk for unnecessary medications.
- D Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to handle, label and store food in a sanitary manner for 1 of 1 kitchen and 1 of 1 dining room reviewed for sanitary food handling and serving practices. This placed residents at risk of cross contamination and foodborne illness.
Fire safety inspections
13 fire safety citations on file: 2 on July 25, 2025, 1 on November 1, 2024, 5 on June 3, 2024, 5 on March 14, 2023.
Every fire safety citation13 citations
- E Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
- E Ensure proper usage of power strips and extension cords.
- F Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have simulated fire drills held at unexpected times.
- E Have exits that are accessible at all times.
- E Have properly installed hallway dispensers for alcohol-based hand rub.
- D Have proper medical gas storage and administration areas.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have simulated fire drills held at unexpected times.
- F Have power receptacles that are properly grounded.
- F Have generator or other power source capable of supplying service within 10 seconds.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 5.67 | 5.03 | 3.86 |
| Registered nurses | 0.56 | 0.72 | 0.69 |
| All nursing staff on weekends | 5.13 | 4.51 | 3.42 |
| Nurse aides | 4.24 | ||
| Licensed practical nurses | 0.86 | ||
| Nursing staff turnover (share who left in a year) | 39.1% | 47.4% | 45.8% |
| Registered nurse turnover | 71.4% | 51.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.70 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.89 on weekdays and 5.13 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 3.1% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 6.00 in April to June 2025 to 5.67 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 5.67 | 0.56 | 5.89 | 5.13 | 3.1% | 0 of 90 | 39 |
| Oct to Dec 2025 | 5.77 | 0.50 | 5.97 | 5.28 | 2.7% | 1 of 92 | 39 |
| Jul to Sep 2025 | 5.59 | 0.49 | 5.80 | 5.04 | 6.1% | 0 of 92 | 39 |
| Apr to Jun 2025 | 6.00 | 0.61 | 6.33 | 5.18 | 4.9% | 0 of 91 | 38 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
Staff pay at this home
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
Official wage estimates for Oregon
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Oregon, all employers | |||
| CNAs (nursing assistants) | $23.96 | $22.83 to $28.40 | 14,800 |
| LPNs and LVNs | $38.69 | $35.11 to $43.60 | 4,260 |
| Registered nurses | $62.02 | $51.55 to $64.63 | 39,730 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 7.8 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.3 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.2 | 2.4 | 3.2 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 21.5 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 0.5 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 2.0 | 13.9 | 15.4 |
Short-term rehab results
For a stay to recover after a hospital visit, these are the results CMS publishes for Avalon Care Center - Portland's Medicare short-stay residents. How to read these, and what Medicare pays for.
CMS reports none of these results for this home: This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Owners and operators
Legal business name: Legal Business Name Not Available.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ownership data not available |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 11 problems in this area, most recently on April 7, 2026: "Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 9 problems in this area, most recently on July 25, 2025: "Provide activities to meet all resident's needs."
- When is the care plan meeting, and can family attend it?Inspectors cited 4 problems in this area, most recently on July 25, 2025: "PASARR screening for Mental disorders or Intellectual Disabilities"
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 3 problems in this area, most recently on April 7, 2026: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody."
Other nursing homes nearby
- Cascade Terrace Post Acute Portland, 1 mi · 1 of 5 stars · 46 citations
- Cedar Crossings Portland, 1.2 mi · 3 of 5 stars · 57 citations
- Secora Rehabilitation of Cascadia Portland, 1.5 mi · 3 of 5 stars · 37 citations
- Gracelen Care Center Portland, 1.6 mi · 1 of 5 stars · 58 citations
- Portland Health and Rehabilitation Portland, 1.8 mi · 1 of 5 stars · 55 citations
- Marquis Mill Park Portland, 1.9 mi · 3 of 5 stars · 17 citations
- Menlo Park Post Acute Portland, 2.4 mi · 2 of 5 stars · 36 citations
- Village Health Care Gresham, 2.4 mi · 2 of 5 stars · 44 citations
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is Avalon Care Center - Portland's Medicare star rating?
- CMS rates Avalon Care Center - Portland 3 out of 5 stars overall, with 2 for health inspections, 4 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Avalon Care Center - Portland get at its last inspection?
- 5 health deficiencies at the standard inspection on July 25, 2025. The Oregon average is 9.2.
- Has Avalon Care Center - Portland been fined?
- CMS lists no fines in the last three years.
- Does Avalon Care Center - Portland accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Avalon Care Center - Portland?
- CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.