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Public Record

Avalon Care Center Federal Way, L.L.C.

Nursing HomeFederal Way, WACMS 505510
88 citations on record

From CMS

Facility profile

CMS overall rating
4 / 5

*CMS Five-Star

Certified beds
120

*CMS

Avg. residents per day
104.7

*CMS

Inspection record

On record from CMS

Citations on record
88

*CMS

Inspections on file
7

*CMS

Last inspection
2025-11-21

*CMS

Citations

88 citations on record

Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0644Generalpotential for harm

    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0676Generalpotential for harm

    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0679Generalpotential for harm

    Provide activities to meet all resident's needs.

  • 0324Generalpotential for harm

    Provide properly protected cooking facilities.

  • 0688Generalpotential for harm

    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.

  • 0693Generalpotential for harm

    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.

  • 0756Generalpotential for harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0759Generalpotential for harm

    Ensure medication error rates are not 5 percent or greater.

  • 0926Generalpotential for harm

    Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

  • 0921Generalpotential for harm

    Ensure that testing and maintenance of electrical equipment is performed.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0741Generalpotential for harm

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0711Generalpotential for harm

    Provide a written emergency evacuation plan.

  • 0354Generalpotential for harm

    Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0346Generalpotential for harm

    Follow proper procedures when the fire alarm was out of service for more than 4 hours.

  • 0345Generalpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0211Generalpotential for harm

    Keep aisles, corridors, and exits free of obstruction in case of emergency.

  • 0004Generalpotential for harm

    Develop and maintain an Emergency Preparedness Program (EP).

  • 0009Generalpotential for harm

    Include a process for Emergency Preparedness collaboration.

  • 0761Generalpotential for harm

    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.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0700Generalpotential for harm

    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.

  • 0759Generalpotential for harm

    Ensure medication error rates are not 5 percent or greater.

  • 0552Generalpotential for harm

    Ensure that residents are fully informed and understand their health status, care and treatments.

  • 0578Generalpotential for harm

    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.

  • 0585Generalpotential for harm

    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.

  • 0622Generalpotential for harm

    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.

  • 0623Generalpotential for harm

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0625Generalpotential for harm

    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.

  • 0637Generalpotential for harm

    Assess the resident when there is a significant change in condition

  • 0645Generalpotential for harm

    PASARR screening for Mental disorders or Intellectual Disabilities

  • 0657Generalpotential for harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0658Generalpotential for harm

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0676Generalpotential for harm

    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  • 0677Generalpotential for harm

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  • 0686Generalpotential for harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0688Generalpotential for harm

    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.

  • 0689Generalpotential for harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0700Generalpotential for harm

    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.

  • 0756Generalpotential for harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  • 0758Generalpotential for harm

    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.

  • 0761Generalpotential for harm

    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.

  • 0812Generalpotential for harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • 0880Generalpotential for harm

    Provide and implement an infection prevention and control program.

  • 0881Generalpotential for harm

    Implement a program that monitors antibiotic use.

  • 0036Generalpotential for harm

    Establish emergency prep training and testing.

  • 0037Generalpotential for harm

    Establish staff and initial training requirements.

  • 0039Generalpotential for harm

    Conduct testing and exercise requirements.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0511Generalpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0920Generalpotential for harm

    Ensure proper usage of power strips and extension cords.

  • 0921Generalpotential for harm

    Ensure that testing and maintenance of electrical equipment is performed.

  • 0625Generalpotential for harm

    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.

  • 0623Generalpotential for harm

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  • 0582Generalpotential for harm

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  • 0569Generalpotential for harm

    Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

  • 0712Generalpotential for harm

    Have simulated fire drills held at unexpected times.

  • 0741Generalpotential for harm

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  • 0914Generalpotential for harm

    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  • 0918Generalpotential for harm

    Have generator or other power source capable of supplying service within 10 seconds.

  • 0920Generalpotential for harm

    Ensure proper usage of power strips and extension cords.

  • 0921Generalpotential for harm

    Ensure that testing and maintenance of electrical equipment is performed.

  • 0926Generalpotential for harm

    Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

  • 0006Generalpotential for harm

    Conduct risk assessment and an All-Hazards approach.

  • 0036Generalpotential for harm

    Establish emergency prep training and testing.

  • 0037Generalpotential for harm

    Establish staff and initial training requirements.

  • 0039Generalpotential for harm

    Conduct testing and exercise requirements.

  • 0293Generalpotential for harm

    Have properly located and lighted "Exit" signs.

  • 0324Generalpotential for harm

    Provide properly protected cooking facilities.

  • 0345Generalpotential for harm

    Have approved installation, maintenance and testing program for fire alarm systems.

  • 0353Generalpotential for harm

    Inspect, test, and maintain automatic sprinkler systems.

  • 0363Generalpotential for harm

    Install corridor and hallway doors that block smoke.

  • 0372Generalpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0511Generalpotential for harm

    Have properly installed electrical wiring and gas equipment.

  • 0521Generalpotential for harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

  • 0940Generalpotential for harm

    Develop, implement, and/or maintain an effective training program for all new and existing staff members.

  • 0908Generalpotential for harm

    Keep all essential equipment working safely.

  • 0804Generalpotential for harm

    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  • 0758Generalpotential for harm

    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.

  • 0755Generalpotential for harm

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • 0690Generalpotential for harm

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  • 0684Generalpotential for harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

FAQ

Questions and answers

What is Avalon Care Center Federal Way, L.L.C.?
Avalon Care Center Federal Way, L.L.C. is a Medicare- and Medicaid-certified nursing home in Federal Way, WA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 505510.
What is the CMS rating for Avalon Care Center Federal Way, L.L.C.?
Avalon Care Center Federal Way, L.L.C. has a CMS overall rating of 4 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
How many beds does Avalon Care Center Federal Way, L.L.C. have?
Avalon Care Center Federal Way, L.L.C. is certified for 120 beds. It serves an average of 104.7 residents per day.
How many citations does Avalon Care Center Federal Way, L.L.C. have?
Avalon Care Center Federal Way, L.L.C. has 88 citations on record from CMS health inspections, each tied to a federal deficiency tag.
When was Avalon Care Center Federal Way, L.L.C. last inspected?
Avalon Care Center Federal Way, L.L.C. was last inspected on November 21, 2025. CMS surveys nursing homes about once a year and after complaints.
What can I do if I have concerns about care at this facility?
Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.

*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.

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