Avalon Care Center: Staff Ignored Grievance Resolution - OR
The power of attorney for Resident 401 filed a grievance on June 19 after Staff 4 forced them to leave during care and then stormed out when asked to allow the family member to remain present. The family specifically requested that Staff 4 no longer provide care to their loved one, who had been admitted in March with dementia and a femur fracture.
Director of Nursing Staff 2 completed a grievance summary on June 24 confirming the resolution: Staff 4 would no longer provide care to Resident 401.
Documentation surveys from June and July revealed Staff 4 violated this agreement repeatedly. She provided activities of daily living care including brief changes, oral hygiene and showers to Resident 401 on June 25, June 27, July 2, July 3, July 4, July 5, July 16 and July 22. She also assessed the resident's vital signs on June 25 and July 22.
The family discovered the violation during a July 16 visit. The power of attorney observed Staff 4 providing one-on-one care to Resident 401 and reported the concern immediately. They raised the issue again during a care plan conference on July 23, where meeting notes included their insistence that Staff 4 not provide care to their family member.
When confronted by inspectors on August 26, Staff 4 acknowledged her initials appeared on care records for Resident 401 on all eight occasions between June 25 and July 22.
The director of nursing confirmed that records showed Staff 4 continued providing care following the grievance resolution but offered no additional explanation for the violation.
Resident 401's March admission assessment indicated significant cognitive impairments related to their dementia diagnosis. The resident required assistance with personal care activities that the family had specifically requested be provided by other staff members.
Federal regulations require nursing homes to establish grievance policies and make prompt efforts to resolve complaints. Facilities must honor residents' rights to voice concerns without facing discrimination or reprisal.
The violation placed residents at risk of not having their care preferences honored, according to the inspection report. When families request specific staff assignments or reassignments, facilities are required to accommodate those requests as part of honoring resident rights and maintaining trust between families and caregivers.
The original June 19 grievance described Staff 4's behavior during the care encounter that prompted the complaint. When the power of attorney requested to remain present during their family member's care, Staff 4's response was to storm out of the room rather than accommodate the request or discuss the situation professionally.
Staff 4's continued involvement in Resident 401's care occurred despite clear documentation of the grievance resolution. The nursing assistant provided intimate personal care including brief changes and bathing on multiple occasions while the facility's own records showed she was prohibited from caring for this resident.
The family's vigilance during their July 16 visit revealed the ongoing violation. Their immediate reporting and follow-up during the July 23 care conference demonstrated their commitment to ensuring their loved one's care preferences were respected.
The director of nursing's confirmation that records documented the violation, combined with her inability to provide any explanation for why it occurred, highlighted systemic failures in implementing grievance resolutions. The facility had established a clear resolution but failed to ensure staff compliance with the agreed-upon care assignments.
For nearly a month, Resident 401 received care from the same nursing assistant whose behavior had prompted their family to file a formal grievance. The resident's significant cognitive impairments meant they likely could not advocate for themselves or understand why the family had requested the staff change.
The violation continued even after the family discovered and reported it on July 16, with Staff 4 providing care again on July 22, six days after being observed and one day before the care conference where the family reiterated their concerns.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avalon Care Center - Scappoose from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AVALON CARE CENTER - SCAPPOOSE in SCAPPOOSE, OR was cited for violations during a health inspection on August 26, 2025.
The family specifically requested that Staff 4 no longer provide care to their loved one, who had been admitted in March with dementia and a femur fracture.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.