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Deficiency Records for Avalon Care Center - Federal Way
A list of the most recent deficiencies for Avalon Care Center - Federal Way. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Avalon Care Center - Federal Way. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2024-07-24 | 2024-09-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-07-24 | 2024-09-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-16 | 2024-09-02 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-07-24 | 2024-08-29 | N |
| 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. | Health | 2024-07-24 | 2024-08-29 | N |
| 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. | Health | 2024-07-24 | 2024-08-29 | N |
| 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. | Health | 2024-07-24 | 2024-08-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-07-24 | 2024-08-29 | N |
| 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. | Health | 2024-07-24 | 2024-08-29 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-07-24 | 2024-08-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-07-24 | 2024-08-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-07-24 | 2024-08-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-24 | 2024-08-29 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-07-24 | 2024-08-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-07-24 | 2024-08-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-24 | 2024-08-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-24 | 2024-08-29 | N |
| 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. | Health | 2024-07-24 | 2024-08-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-24 | 2024-08-29 | N |
| 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. | Health | 2024-07-24 | 2024-08-29 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-07-24 | 2024-08-29 | N |
| 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. | Health | 2024-07-24 | 2024-08-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-07-24 | 2024-08-29 | N |
| 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. | Health | 2024-07-24 | 2024-08-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-24 | 2024-08-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-07-16 | 2024-08-19 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-07-16 | 2024-08-19 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2024-07-16 | 2024-08-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-07-16 | 2024-07-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-07-16 | 2024-07-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-07-16 | 2024-07-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-28 | 2023-06-22 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-04-28 | 2023-06-22 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-04-28 | 2023-06-20 | N |
| 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. | Health | 2023-04-28 | 2023-06-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-28 | 2023-06-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-28 | 2023-06-20 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-04-28 | 2023-06-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-28 | 2023-06-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-28 | 2023-06-07 | N |
| 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. | Health | 2023-04-28 | 2023-06-07 | N |
| Keep all essential equipment working safely. | Health | 2023-04-28 | 2023-06-07 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-04-25 | 2023-05-03 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-03-16 | 2022-04-14 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-03 | 2021-12-17 | Y |
| Dispose of garbage and refuse properly. | Health | 2021-12-03 | 2021-12-17 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-11-09 | 2021-12-07 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-10-14 | 2021-12-07 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-10-14 | 2021-12-07 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2021-10-14 | 2021-12-07 | N |
| 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. | Health | 2021-10-14 | 2021-12-07 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-10-14 | 2021-12-07 | N |
| 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. | Health | 2021-10-14 | 2021-12-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-14 | 2021-12-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-14 | 2021-12-07 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-10-14 | 2021-12-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-10-14 | 2021-12-07 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-10-14 | 2021-12-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-10-14 | 2021-12-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-14 | 2021-12-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-14 | 2021-12-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-14 | 2021-12-07 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-10-14 | 2021-12-07 | N |
| 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. | Health | 2021-10-14 | 2021-12-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-14 | 2021-12-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-14 | 2021-12-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-14 | 2021-12-07 | N |
| 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. | Health | 2021-10-14 | 2021-12-07 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-10-14 | 2021-12-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-14 | 2021-12-07 | N |
| 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. | Health | 2021-10-14 | 2021-12-07 | N |
| Post nurse staffing information every day. | Health | 2021-10-14 | 2021-12-07 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-10-14 | 2021-12-07 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-10-14 | 2021-12-07 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-10-14 | 2021-12-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-10-14 | 2021-12-07 | N |
| 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. | Health | 2021-10-14 | 2021-12-07 | N |
| 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. | Health | 2021-10-14 | 2021-12-07 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-10-14 | 2021-12-07 | N |
| Provide or obtain dental services for each resident. | Health | 2021-10-14 | 2021-12-07 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-10-14 | 2021-12-07 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-10-14 | 2021-12-07 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2021-10-14 | 2021-12-07 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-10-14 | 2021-12-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-14 | 2021-12-07 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-10-14 | 2021-12-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-10-14 | 2021-12-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-14 | 2021-12-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-12 | 2021-10-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-10-12 | 2021-10-26 | N |
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