ElderGrade

Inspection citations at Avalon Care Center - Portland

32 citations on record, 1 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 4 0
2025 5 0
2024 13 1
2023 10 0
D April 7, 2026 Tag F0600 Complaint investigation Corrected Apr 2026

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, potential for more than minimal harm

D April 7, 2026 Tag F0580 Complaint investigation Corrected Dec 2025

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

D April 7, 2026 Tag F0561 Complaint investigation Corrected Apr 2026

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

No actual harm, potential for more than minimal harm

E April 7, 2026 Tag F0628 Complaint investigation Corrected Apr 2026

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

No actual harm, potential for more than minimal harm

D July 25, 2025 Tag F0757 Corrected Aug 2025

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

No actual harm, potential for more than minimal harm

D July 25, 2025 Tag F0689 Corrected May 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D July 25, 2025 Tag F0679 Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

No actual harm, potential for more than minimal harm

D July 25, 2025 Tag F0645 Corrected Aug 2025

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

No actual harm, potential for more than minimal harm

D July 25, 2025 Tag F0550 Corrected Aug 2025

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

G October 24, 2024 Tag F0689 Complaint investigation Corrected Nov 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

D June 3, 2024 Tag F0842 Complaint investigation Corrected Jul 2024

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

D June 3, 2024 Tag F0695 Complaint investigation Corrected Jul 2024

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D June 3, 2024 Tag F0689 Complaint investigation Corrected Jul 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D June 3, 2024 Tag F0684 Complaint investigation Corrected Jul 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D June 3, 2024 Tag F0656 Complaint investigation Corrected Jul 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D June 3, 2024 Tag F0655 Complaint investigation Corrected Jul 2024

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

No actual harm, potential for more than minimal harm

D June 3, 2024 Tag F0584 Complaint investigation Corrected Jul 2024

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D June 3, 2024 Tag F0580 Complaint investigation Corrected Jul 2024

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

D June 3, 2024 Tag F0578 Complaint investigation Corrected Jul 2024

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D June 3, 2024 Tag F0558 Complaint investigation Corrected Jul 2024

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

E June 3, 2024 Tag F0812 Complaint investigation Corrected Jul 2024

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

E June 3, 2024 Tag F0600 Complaint investigation Corrected Jul 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, potential for more than minimal harm

D March 14, 2023 Tag F0812 Corrected Apr 2023

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D March 14, 2023 Tag F0758 Corrected Apr 2023

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D March 14, 2023 Tag F0695 Corrected Apr 2023

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D March 14, 2023 Tag F0689 Corrected Apr 2023

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D March 14, 2023 Tag F0684 Corrected Apr 2023

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D March 14, 2023 Tag F0610 Corrected Apr 2023

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

D March 14, 2023 Tag F0585 Corrected Apr 2023

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D March 14, 2023 Tag F0578 Corrected Apr 2023

Resident Rights Deficiencies

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.

No actual harm, potential for more than minimal harm

D March 14, 2023 Tag F0552 Corrected Apr 2023

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

No actual harm, potential for more than minimal harm

F March 14, 2023 Tag F0727 Corrected Apr 2023

Nursing and Physician Services Deficiencies

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.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.