Deficiencies (last 3 years)
Deficiencies (over 3 years)
13.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
117% worse than Washington average
Washington average: 6.3 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Annual Inspection
Deficiencies: 11
Nov 21, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Avalon Care Center - Federal Way.
Findings
The facility was found deficient in multiple areas including failure to incorporate Level II PASRR recommendations into care plans, failure to update care plans as residents' conditions changed, medication administration errors, failure to provide appropriate assistance with activities of daily living, failure to maintain residents' communication abilities, failure to provide restorative range of motion exercises, failure to follow infection prevention and control protocols, and failure to implement pharmacy recommendations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure a Level II PASRR evaluation was incorporated into the Care Plan for 1 of 5 residents reviewed for PASRR. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update and/or revise Care Plans as needed for 3 of 25 residents reviewed, placing residents at risk for unmet care needs and inappropriate care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure services met professional standards of practice for 5 of 25 residents reviewed, including failure to clarify and follow physician orders and medication parameters. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents' ability to communicate was maintained for 2 of 3 residents reviewed for communication. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide assistance with activities of daily living for 3 of 5 sample residents and 1 supplemental resident reviewed for ADLs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide restorative/functional maintenance services for 2 of 4 residents reviewed for limited range of motion and mobility. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to assess gastrostomy tube placement prior to feeding, provide formula timely, and follow physician orders for 1 resident reviewed for tube feeding management. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement pharmacy recommendations for 2 of 6 residents reviewed for pharmacy recommendations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper storage and labeling of medications in 1 of 2 medication storage rooms and 1 of 3 medication carts reviewed for medication storage. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication error rate was less than 5 percent; improperly administered 6 of 32 medications for 3 of 4 residents observed during medication pass. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an infection prevention and control program; failed to follow precautions signs and hand hygiene practices for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 18.75
Residents reviewed for PASRR: 5
Residents reviewed for care plan updates: 25
Residents reviewed for professional standards: 25
Residents reviewed for communication: 3
Residents reviewed for ADLs: 5
Residents reviewed for ROM and mobility: 4
Residents reviewed for pharmacy recommendations: 6
Medication storage rooms reviewed: 2
Medication carts reviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Social Services Director | Named in failure to incorporate Level II PASRR recommendations into care plan |
| Staff J | Unit Manager | Named in failure to update care plans and medication order clarifications |
| Staff O | Dining Services Manager | Named in failure to provide small frequent meals as per care plan |
| Staff B | Director of Nursing | Named in multiple medication administration and care plan compliance failures |
| Staff F | Unit Manager | Named in medication administration and care plan compliance failures |
| Staff V | Certified Nursing Assistant | Named in communication barrier with Resident 13 |
| Staff X | Certified Nursing Assistant | Named in communication barrier and hearing device assistance failure |
| Staff L | Licensed Practical Nurse | Named in failure to provide nail care |
| Staff G | Registered Nurse | Named in failure to follow tube feeding orders and medication administration errors |
| Staff N | Registered Nurse | Named in medication administration errors |
| Staff K | Licensed Practical Nurse | Named in medication administration errors |
| Staff M | Registered Nurse | Named in failure to follow infection prevention protocols |
| Staff R | Certified Nursing Assistant | Named in failure to follow infection prevention protocols |
| Staff S | Licensed Practical Nurse | Named in failure to follow infection prevention protocols |
| Staff Q | Infection Preventionist | Named in failure to follow infection prevention protocols |
| Staff H | Recreation Director | Named in failure to provide meaningful activities and documentation |
Inspection Report
Deficiencies: 1
Nov 5, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding the assessment, consent, and safe use of bed rails for residents.
Findings
The facility failed to assess and obtain consent prior to implementing bed rails for 2 of 3 sampled residents, resulting in one resident sustaining a cut to their eyebrow and placing another at risk for injury. These failures placed all residents at risk for injury and other negative health outcomes.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to assess and obtain consent prior to implementing bed rails for Residents 1 and 2. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse | Interviewed regarding Resident 1's bed rail assessment and consent. |
| Staff B | Unit Manager | Reviewed Resident 1's record and confirmed lack of assessment and consent for bed rails. |
| Staff A | Administrator | Interviewed regarding expectations for assessments and consents for bed rails and Resident 1's room assignment. |
Inspection Report
Routine
Deficiencies: 18
Jul 24, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements including medication consent, advanced directives, grievance handling, resident transfers and discharges, care planning, medication management, infection control, and resident safety.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, incomplete advanced directives documentation, failure to initiate and investigate resident grievances, inadequate communication of resident information during transfers, lack of timely notification of transfers to residents, incomplete significant change assessments, inaccurate PASRR screenings, inaccurate and outdated care plans, failure to meet professional standards in medication administration and resident care, inadequate infection prevention and control practices, and failure to maintain sanitary food preparation and storage conditions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 17
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to inform residents or their representatives of risks and benefits of psychotropic medications and obtain consent prior to administration for 2 of 5 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents had appropriate Advanced Directives in place and to obtain guardianship when necessary for 2 of 7 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to initiate, log, investigate, and resolve grievances for 2 residents reviewed, precluding identification of grievance trends. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to document communication of necessary resident information to receiving healthcare institutions for 2 of 7 residents reviewed for hospitalizations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide timely written notification to residents or representatives before transfer or discharge for 7 of 7 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to notify residents or representatives in writing of bed hold duration upon hospital transfer or therapeutic leave for 2 of 7 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete Significant Change in Status Assessment within 14 days of determination for 1 resident reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accurate PASRR screening and referral for Level II evaluation when indicated for 1 of 5 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to accurately review and revise care plans to reflect current resident status and needs for 5 of 20 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure services met professional standards including clarifying physician orders, following orders, and notifying providers of resident refusals for 4 of 20 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a functional communication system for 1 of 3 residents reviewed for communication needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide restorative/rehabilitative treatment/services for 7 of 8 residents reviewed for limited range of motion and mobility. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers for 1 of 5 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain consent, assess safety risks, and attempt alternatives before using bed rails for 3 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure medication error rate was less than 5% due to improper administration of medications by one nurse for one resident observed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure drugs and biologicals were secured and labeled properly in resident rooms for 3 residents observed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure food was prepared, stored, and served under sanitary conditions including hand hygiene, labeling, dishwasher maintenance, and refrigerator food storage. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to establish and maintain an infection prevention and control program including hand hygiene, PPE use, transmission-based precautions, Legionella prevention, and antibiotic stewardship documentation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 8
Hospitalizations without written notification: 7
Residents with missing bed hold notification: 2
Residents with incomplete PASRR screening: 1
Residents with incomplete care plan revision: 5
Residents with incomplete restorative nursing program: 7
Dishwasher cycles with chlorine above recommended range: 30
Dishwasher cycles with temperature above recommended range: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Director of Nursing | Reviewed multiple resident records, confirmed deficiencies in medication consent, care plans, PASRR screening, medication administration, infection control, and other areas |
| Staff P | Unit Manager | Reviewed medication records, care plans, and confirmed medication administration errors and care plan deficiencies |
| Staff C | Infection Preventionist | Interviewed regarding infection prevention program and Legionella prevention |
| Staff H | Unit Manager | Interviewed regarding bed rail consent and grievance process |
| Staff D | Social Services Director | Interviewed regarding medication consent, advanced directives, and unnecessary medication use |
| Staff X | Certified Nursing Assistant | Observed providing care with double gloves and improper hand hygiene |
| Staff N | Licensed Practical Nurse | Observed medication administration error |
| Staff O | Registered Nurse | Interviewed regarding unsecured OTC medications in resident room |
| Staff V | Dietary Manager | Observed improper hand hygiene and food handling practices in kitchen |
Inspection Report
Routine
Deficiencies: 11
Apr 28, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident funds reimbursement, Medicare/Medicaid notices, discharge notifications, bed-hold notices, resident care and positioning, catheter care, medication management, food service quality, equipment maintenance, and staff training.
Findings
The facility was found deficient in multiple areas including delayed reimbursement of resident funds to the state, failure to provide required Medicare/Medicaid notices, inadequate discharge notification to the Long-Term Care Ombudsman, failure to provide bed-hold notices, improper wheelchair positioning and lack of hospice care coordination, inappropriate catheter care and medication management, poor food quality and temperature control, malfunctioning walk-in freezer, and insufficient staff training and orientation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure funds were reimbursed to the state Office of Financial Recovery within 30 days of resident discharge or death for 2 of 4 discharged residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide Skilled Nursing Facility Advance Beneficiary Notices (SNF-ABN) and/or Notice to Medicare Provider Non-Coverage (NOMNC) for 2 of 3 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide written notice of transfer/discharge to the State Office of the Long-Term Care Ombudsman for 2 of 3 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide bed-hold notice for 2 of 2 residents reviewed for hospitalization. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure correct wheelchair positioning for 1 of 1 residents reviewed and failed to coordinate care with hospice services for 1 of 1 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure appropriate catheter care and obtain physician orders for catheter changes for 2 of 4 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain accurate reconciliation of narcotic drugs for 1 of 3 medication carts. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to identify and monitor resident-specific behaviors for use of antipsychotic medication and document rationale for PRN use for 1 of 5 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature for 8 of 34 sampled residents and 22 residents attending the food committee. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain walk-in freezer in satisfactory working condition; freezer temperatures were elevated and ice buildup was present for over a month. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop, implement, and maintain an effective training program for all new and existing staff as identified in the Facility Assessment, including orientation, competency evaluations, and annual training on key topics for 9 of 10 staff reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident discharge delay: 2
Residents reviewed for SNF-ABN and NOMNC: 3
Residents reviewed for discharge notification: 3
Residents reviewed for bed-hold notice: 2
Residents reviewed for wheelchair positioning and hospice care: 1
Residents reviewed for catheter care: 4
Medication carts reviewed for narcotic reconciliation: 3
Residents reviewed for antipsychotic medication use: 5
Residents sampled for food quality: 34
Residents attending food committee: 22
Temperature logs above 20 degrees F: 36
Staff reviewed for training deficiencies: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff P | Business Office Coordinator | Confirmed delayed reimbursement of resident funds and failure to provide Medicare notices. |
| Staff A | Administrator | Acknowledged failures in Medicare notices, bed-hold notices, food quality, freezer issues, and staff training. |
| Staff Z | Licensed Practical Nurse | Observed wheelchair positioning issues and commented on resident comfort. |
| Staff Y | Certified Nursing Assistant | Observed wheelchair positioning and resident assistance needs. |
| Staff W | Physical Therapist | Provided wheelchair evaluation and instructions on footrest use. |
| Staff C | Regional Nurse Consultant | Reviewed catheter care, medication reconciliation, and antipsychotic medication use. |
| Staff D | Resident Care Manager | Observed catheter care issues and commented on medication documentation. |
| Staff E | Registered Nurse | Provided supervision for resident with behaviors and administered PRN antipsychotic medication. |
| Staff V | Dietary Manager | Measured food temperatures and reported freezer issues. |
| Staff X | Maintenance Director | Reported on freezer repairs and ice buildup. |
| Staff F | Staff Development Coordinator | Reported missing staff training records and ongoing development of training program. |
| Staff AA | Registered Dietitian | Conducted monthly sanitation audits and inspected freezer. |
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