Cycle 1
Health 2025-11-21 · Fire 2025-11-21
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Federal Way, WA
Avalon Care Center Federal Way, L.L.C.
4-star overall rating with 3-star inspections with 12 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
135 South 336th Street, Federal Way, WA
(253) 835-7453
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avalon Health Care
Operator or chain grouping
Approved since
2002-08-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.90
Registered nurse staffing · state 0.88 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.65
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.55
All reported nurse hours · state 4.39 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
4.01
Weekend nurse staffing · state 3.79 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.63 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
4.38
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,846
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9887
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.02
Baseline 15.49% · Performance 20.49% · Measure score 2.02 · Achievement 2.02 · Improvement 0
Healthcare-associated infections
3.11
Baseline 6.37% · Performance 6.91% · Measure score 3.11 · Achievement 3.11 · Improvement 0
Total nurse turnover
4.33
Baseline 61.86% · Performance 45.97% · Measure score 4.33 · Achievement 4.33 · Improvement 3.79
Adjusted total nurse staffing
4.46
Baseline 4.35 hours · Performance 4.35 hours · Measure score 4.46 · Achievement 4.46 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.26% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 190 · Observed rate 8.42% · Lower 95% interval 6.2% |
| Discharge to community | 58.47% |
50.57%
7.9 pts better
|
Better than the National Rate · Eligible stays 222 · Observed rate 48.65% · Lower 95% interval 52.2% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.41% |
95.27%
4.1 pts better
|
Numerator 169 · Denominator 170 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 170 |
| Discharge self-care score | 64.84% |
53.69%
11.2 pts better
|
Numerator 83 · Denominator 128 |
| Discharge mobility score | 63.28% |
50.94%
12.3 pts better
|
Numerator 81 · Denominator 128 |
| Pressure ulcers or injuries, new or worsened | 1.76% |
2.29%
0.5 pts better
|
Numerator 3 · Denominator 170 · Adjusted rate 1.47% |
| Healthcare-associated infections requiring hospitalization | 6.91% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 129 · Observed rate 7.75% · Lower 95% interval 4.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 120 |
| Staff flu vaccination coverage | 59.65% |
42%
17.6 pts better
|
Numerator 102 · Denominator 171 |
| Discharge function score | 67.97% |
56.45%
11.5 pts better
|
Numerator 87 · Denominator 128 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 41 · Denominator 41 |
| Transfer of health information to patient | 98.88% |
96.28%
2.6 pts better
|
Numerator 88 · Denominator 89 |
| Resident COVID-19 vaccinations up to date | 17.31% |
25.2%
7.9 pts worse
|
Numerator 18 · Denominator 104 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.1% |
96.0%
8.9 pts worse
|
93.4%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.3% · Q2 85.1% · Q3 81.7% · Q4 94.4% · 4Q avg 87.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
93.8%
1.1 pts better
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
2.6%
2.4 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.5% · Q3 5.6% · Q4 5.6% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
16.3%
15.9 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
5.8%
1.2 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 6.2% · Q3 4.5% · Q4 6.0% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.6% |
12.1%
4.5 pts better
|
19.6%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.4% · Q3 7.6% · Q4 4.5% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.8% |
15.9%
2.1 pts better
|
16.7%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 16.7% · Q3 15.3% · Q4 11.1% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.4% |
20.0%
5.6 pts better
|
16.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.5% |
15.8%
4.3 pts better
|
14.9%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 10.5% · Q3 10.5% · Q4 11.9% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
1.2%
1 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.7%
0.3 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.9% |
23.5%
3.6 pts better
|
19.8%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 26.5% · Q3 17.6% · Q4 17.3% · 4Q avg 19.9% |
| Percentage of long-stay residents with pressure ulcers | 8.4% |
4.7%
3.7 pts worse
|
5.1%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 11.6% · Q3 5.7% · Q4 7.5% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.9% |
87.7%
5.8 pts worse
|
81.7%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 75.6% · Q2 77.8% · Q3 85.1% · Q4 90.8% · 4Q avg 81.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
13.2%
5.4 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 8.7% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.4%
0.8 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.1% · Q3 0.6% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.6% |
82.0%
4.6 pts better
|
79.7%
6.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
19.9%
0.2 pts worse
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 23.6% · Expected 28.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-24 · Fire 2024-07-24
25 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2023-04-28 · Fire 2023-04-28
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
19 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-11-21
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-12-24
F · Potential for more than minimal harm
2025-11-21
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-12-24
F · Potential for more than minimal harm
2025-11-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-12-24
F · Potential for more than minimal harm
2025-11-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-24
F · Potential for more than minimal harm
2025-11-21
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-12-24
F · Potential for more than minimal harm
2025-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-24
F · Potential for more than minimal harm
2025-11-21
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-12-24
F · Potential for more than minimal harm
2025-11-21
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-12-24
F · Potential for more than minimal harm
2025-11-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-24
F · Potential for more than minimal harm
2025-11-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-12-24
F · Potential for more than minimal harm
2025-11-21
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-11-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-11-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-12-24
D · Potential for more than minimal harm
2025-11-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-12-24
F · Potential for more than minimal harm
2024-07-24
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-24
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-24
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-07-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-02
F · Potential for more than minimal harm
2024-07-24
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-07-17
D · Potential for more than minimal harm
2024-07-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-17
F · Potential for more than minimal harm
2023-04-28
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-28
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-28
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-28
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-04-28
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-04-28
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-04-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-04-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-04-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-04-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-04-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-04-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-04-28
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-05-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-04
E · Potential for more than minimal harm
2025-11-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-01-04
E · Potential for more than minimal harm
2025-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-04
D · Potential for more than minimal harm
2025-11-21
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2026-01-04
D · Potential for more than minimal harm
2025-11-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-01-04
D · Potential for more than minimal harm
2025-11-21
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2026-01-04
D · Potential for more than minimal harm
2025-11-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-01-04
D · Potential for more than minimal harm
2025-11-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2026-01-04
D · Potential for more than minimal harm
2025-11-21
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2026-01-04
D · Potential for more than minimal harm
2025-11-21
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2026-01-04
D · Potential for more than minimal harm
2025-11-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2026-01-04
D · Potential for more than minimal harm
2025-11-21
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2026-01-04
D · Potential for more than minimal harm
2024-11-05
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-07-24
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-07-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-07-24
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-07-24
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-07-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-07-24
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-29
D · Potential for more than minimal harm
2024-07-24
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-08-29
F · Potential for more than minimal harm
2023-04-28
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-06-07
E · Potential for more than minimal harm
2023-04-28
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-06-07
E · Potential for more than minimal harm
2023-04-28
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-06-07
E · Potential for more than minimal harm
2023-04-28
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-04-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-04-28
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-04-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-04-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-22
D · Potential for more than minimal harm
2023-04-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-04-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-06-07
D · Potential for more than minimal harm
2023-04-28
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-06-07
Penalties and ownership
What sits behind the stars
Ownership
Avalon Of Washington LLC
5% Or Greater Direct Ownership Interest · Organization
Ahmad, Atique
Operational/Managerial Control · Individual
Avalon Care LLC
5% Or Greater Indirect Ownership Interest · Organization
Avalon Health Care Management, Inc.
Operational/Managerial Control · Organization
Avalon Health Care, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Avalon Health Care, Inc.
Operational/Managerial Control · Organization
Avalon Holding, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Borisevich, Maria
Operational/Managerial Control · Individual
Borisevich, Maria
Corporate Officer · Individual
Dangerfield, David
Corporate Director · Individual
Hash, Alan
Operational/Managerial Control · Individual
Hash, Alan
Corporate Officer · Individual
Hyrum A Kirton Individual Tr
5% Or Greater Indirect Ownership Interest · Organization
K-Team LLC
5% Or Greater Indirect Ownership Interest · Organization
Kirton, Byron
5% Or Greater Indirect Ownership Interest · Individual
Kirton, Byron
Corporate Director · Individual
Kirton, Hyrum
5% Or Greater Indirect Ownership Interest · Individual
Kirton, Hyrum
Operational/Managerial Control · Individual
Kirton, Hyrum
Corporate Director · Individual
Kirton, Hyrum
Corporate Officer · Individual
Kirton, Spencer
5% Or Greater Indirect Ownership Interest · Individual
Kirton, Spencer
Corporate Director · Individual
Smith, Nicole
Operational/Managerial Control · Individual
Smith, Nicole
Corporate Officer · Individual
Spencer K Kirton Individual Tr
5% Or Greater Indirect Ownership Interest · Organization
Stoa, Inga
Operational/Managerial Control · Individual
The Byron A Kirton Individual Tr
5% Or Greater Indirect Ownership Interest · Organization
Wachowski, Samantha
Operational/Managerial Control · Individual
Woltil, Robert
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Garden Terrace Healthcare Center Of Federal Way
Federal Way, WA
5-star overall rating with 3-star inspections with 16 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
#2
Hallmark Manor
Federal Way, WA
3-star overall rating with 3-star inspections with $32,175 in total fines with 19 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
#3
Life Care Center Of Federal Way
Federal Way, WA
2-star overall rating with 2-star inspections with $98,970 in total fines with 29 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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