4 CMS Surveys
Inspection Report — Nov 21, 2025
Routine
Date: Nov 21, 2025
Visit Reason
The inspection was a routine regulatory survey of Avalon Care Center - Federal Way to assess compliance with nursing home care standards, including care planning, medication administration, infection control, and resident quality of life.
Findings
The facility was found deficient in multiple areas including failure to incorporate mental health PASRR Level II recommendations into care plans, incomplete and outdated care plans for residents, medication errors and failure to follow physician orders, inadequate assistance with activities of daily living and hygiene, insufficient restorative care and range of motion exercises, failure to provide meaningful activities, improper tube feeding management, incomplete pharmacy recommendation implementation, medication administration errors exceeding 5%, improper medication storage and labeling, and failure to follow infection prevention and control protocols including PPE use and hand hygiene. These deficiencies placed residents at risk for unmet care needs, medication errors, infections, and diminished quality of life.
Deficiencies (12)
WAC 388-97-1915 (4) - The facility failed to ensure a Level II PASRR evaluation was incorporated into the care plan for 1 of 5 residents reviewed, placing residents at risk of not receiving necessary mental health services.
WAC 388-97-1020(2)(c)(d) - The facility failed to update or revise care plans as needed for 3 of 25 residents, resulting in unmet care needs and inappropriate care.
WAC 388-97-1620(2)(b)(i)(ii) - Nursing staff failed to clarify and follow physician medication orders for 5 of 25 residents, leading to medication errors and risk of harm.
WAC 388-97-1060(2)(a)(v)(3)(a) - The facility failed to maintain residents' ability to communicate by not providing interpreter services or hearing aids as needed for 2 of 3 residents reviewed.
WAC 388-97-1060(2)(c) - The facility failed to provide adequate assistance with activities of daily living including bathing, nail care, and shaving for 3 of 5 residents reviewed.
WAC 388-97-0940 (1) - The facility failed to provide meaningful activity programs meeting resident needs for 2 of 3 residents reviewed, placing residents at risk of boredom and diminished quality of life.
WAC 388-97-1060 (3)(d) - The facility failed to provide restorative and range of motion services as required for 2 of 4 residents reviewed, risking further decline in function.
WAC 388-97-1060(3)(f) - The facility failed to assess gastrostomy tube placement, provide formula timely, and follow physician orders for tube feeding for 1 resident reviewed.
WAC 388-97-1300(4)(c) - The facility failed to implement pharmacy recommendations timely for 2 of 6 residents reviewed, placing residents at risk of medication errors.
WAC 388-97-1060(3)(k)(ii) - The facility failed to ensure medication error rates were below 5%, with 6 of 32 medications improperly administered for 3 of 4 residents observed.
WAC 388-97-1300(2) - The facility failed to ensure proper storage and labeling of medications in medication rooms and carts, including expired medications and unlabeled multi-dose vials.
WAC 388-97-1320 (1)(a), (2)(b) - The facility failed to maintain an infection prevention and control program by not following transmission-based and enhanced barrier precautions, including PPE use and hand hygiene, placing residents at risk of infection.
Report Facts
Medication error rate: 18.75
Vitamin D3 dose: 50000
Vitamin D level: 47
Medication doses missed or incorrect: 6
Medication doses observed: 32
Inspection Report — Nov 5, 2024
Complaint Investigation
Date: Nov 5, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to assess and obtain consent prior to implementing bed rails for residents.
Complaint Details
The complaint investigation found that Resident 1 sustained a cut above the eyebrow due to bed rails left on the bed without assessment or consent. Resident 2 had bed rails installed without assessment or consent, placing them at risk. Staff interviews confirmed expectations for assessments and consents were not met.
Findings
The facility failed to assess and obtain consent for bed rails for 2 of 3 sampled residents, resulting in one resident sustaining a cut and another placed at risk for injury. These failures placed all residents at risk for injury and other negative health outcomes.
Deficiencies (1)
WAC 388-97-1060(3)(g) - The facility failed to assess and obtain consent prior to implementing bed rails for two residents. This failure resulted in injury to one resident and risk of injury to another.
Report Facts
Residents affected: 2
Inspection Report — Jul 24, 2024
Routine
Date: Jul 24, 2024
Visit Reason
The inspection was a routine survey to assess compliance with state and federal regulations related to resident care, medication management, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications and bed rails, incomplete care plans, inadequate medication regimen reviews, failure to implement gradual dose reductions for psychotropic medications, unsanitary food handling and storage practices, inadequate infection prevention and control practices including hand hygiene and PPE use, and failure to maintain safe resident environments. Some residents did not receive appropriate rehabilitative services or assistance with activities of daily living. The facility also failed to properly document and act on antibiotic stewardship and medication errors.
Deficiencies (19)
WAC 388-97-0260(1)(a)(b)(i)(ii)(iii) - The facility failed to inform residents or their representatives of the risks and benefits of psychotropic medications and obtain consent prior to administration for 2 of 5 residents reviewed.
WAC 388-97-0280(3)(c)(i-ii) - The facility failed to ensure residents had appropriate Advanced Directives in place for 2 of 7 residents reviewed.
WAC 388-97-0460 (1)(2) - The facility failed to initiate, log, investigate, and resolve grievances for 2 residents reviewed, placing residents at risk for unresolved concerns.
WAC 388-97-0120(3)(a)(b) - The facility failed to document communication of necessary resident information to receiving hospitals for 2 of 7 residents reviewed.
WAC 388-97-0120 (2)(a-d) - The facility failed to provide timely written notification of transfer/discharge rights to 7 of 7 residents reviewed.
WAC 388-97-0120(4) - The facility failed to notify 2 of 7 residents reviewed of bed hold rights upon hospital transfer or therapeutic leave.
WAC 388-97-1000(3)(b) - The facility failed to complete a Significant Change in Status Assessment within 14 days for 1 resident started on hospice services.
WAC 388-97-1915 (1) - The facility failed to ensure accurate PASRR screening for 1 of 5 residents reviewed, missing a diagnosis and failing to refer for Level II evaluation.
WAC 388-97-1020(5)(b) - The facility failed to accurately review and revise care plans to reflect current resident status and needs for 5 of 20 residents reviewed.
WAC 388-97-1060(2)(b)(i) - The facility failed to provide assistance with activities of daily living including shaving and nail care for 2 residents reviewed.
WAC 388-97-1060 (1) - The facility failed to accurately set an air mattress according to resident weight for 1 of 4 residents reviewed.
WAC 388-97-1060(3)(b) - The facility failed to provide appropriate pressure ulcer care and prevent new ulcers for 1 of 5 residents reviewed.
WAC 388-97-1060 (3)(d) - The facility failed to provide restorative nursing programs to maintain or improve range of motion and mobility for 7 of 8 residents reviewed.
WAC 388-97-1060(3)(k)(ii) - A medication error occurred when a nurse failed to notice two tablets dropped and not taken by a resident.
WAC 388-97-1300(2) - The facility failed to secure drugs and biologicals in resident rooms for 3 residents observed, including leaving medications and ointments unsecured.
WAC 388-97-1100(3), -2980 - The facility failed to maintain sanitary food preparation and storage conditions including poor hand hygiene by kitchen staff, unlabeled and expired food in unit refrigerators, and inadequate dishwasher maintenance and documentation.
WAC 388-97-0880 - The facility failed to establish and maintain an infection prevention and control program including hand hygiene compliance, PPE use, transmission based precautions, Legionella prevention, and antibiotic stewardship documentation.
WAC 388-97-0260, -1060(3)(g) - The facility failed to obtain consent, assess safety risks, and attempt alternatives before using bed rails for 3 residents reviewed.
WAC 388-97-1320(1)(c)(2)(b) - The facility failed to maintain an effective antibiotic stewardship program with complete and accurate documentation for 6 residents reviewed.
Report Facts
Medication error rate: 8
Dishwasher cycles: 74
Dishwasher chlorine test failures: 30
Resident refusals of medication: 20
Antibiotic stewardship missing MRRs: 3
Psychotropic medication as needed doses: 19
Inspection Report — Apr 28, 2023
Complaint Investigation
Date: Apr 28, 2023
Visit Reason
The inspection was conducted based on complaint investigations regarding multiple areas of care and compliance at Avalon Care Center - Federal Way.
Complaint Details
The inspection was complaint-driven, investigating multiple allegations including financial mismanagement, failure to provide required notices, inadequate care practices, medication management issues, food service complaints, equipment maintenance, and staff training deficiencies.
Findings
The facility was found deficient in multiple areas including delayed reimbursement of resident funds, failure to provide required Medicare notices, inadequate discharge notifications, failure to provide bed-hold notices, improper wheelchair positioning, lack of hospice care coordination, inappropriate catheter care, inaccurate narcotic reconciliation, improper use of psychotropic medications, poor food quality and temperature control, malfunctioning walk-in freezer, and inadequate staff training programs. All deficiencies posed risks to resident safety, rights, and quality of life.
Deficiencies (11)
WAC 388-97-0340(5) - The facility 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.
WAC 388-97-0300(1)(e), (5), (6) - The facility failed to provide Skilled Nursing Facility Advance Beneficiary Notices and/or Notice to Medicare Provider Non-Coverage for 2 of 3 residents reviewed, preventing residents from being informed of potential financial liability and appeal rights.
WAC 388-97-0120(2)(a-d) - The facility failed to provide timely written notice of transfer/discharge to the State Office of the Long-Term Care Ombudsman for 2 of 3 residents reviewed.
WAC 388-97-0120(4)(a-c) - The facility failed to provide bed-hold notices to 2 residents reviewed for hospitalization, placing residents at risk for being uninformed about bed-hold rights.
WAC 388-97-1016(1) - The facility failed to ensure correct wheelchair positioning for 1 resident and failed to coordinate care with hospice services for another resident, placing them at risk for discomfort and unnecessary care.
WAC 388-97-0690 - The facility failed to ensure appropriate catheter care for 2 of 4 residents reviewed, including lack of physician orders for catheter changes and inappropriate catheter changes, placing residents at risk for infection.
WAC 388-97-1300(1)(b)(ii), (3)(a), (4)(a)(i) - The facility failed to maintain accurate reconciliation of narcotic drugs for 1 of 3 medication carts, risking drug diversion and resident harm.
WAC 388-97-1060(3)(k)(i) - The facility failed to identify and monitor resident-specific behaviors for antipsychotic medication use and document rationale for PRN use for 1 resident, failing to implement non-pharmacological interventions.
WAC 388-97-1100(1)(2), -1120(4) - The facility failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature for 8 sampled residents and 22 food committee attendees, risking decreased intake and diminished quality of life.
WAC 388-97-2100 - The facility failed to maintain 1 walk-in freezer in satisfactory working condition, with temperature logs showing elevated temperatures and ice buildup due to a pipe leak, risking spoiled food.
WAC 388-97-1680 - The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, with multiple staff lacking documented orientation, competency evaluations, and required annual trainings.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 8
Residents affected: 9
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