Avalon Healthcare - Tacoma

In the surveyor’s words

From the most serious findings on record at Avalon Healthcare - Tacoma, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 30, 2024

  Based on observation, interview, and record review, the facility failed to implement a hot food and beverage policy to protect 2 of 3 sample residents (Resident 1 & 2) reviewed for avoidable burns. Resident 1 experienced harm when they were served hot coffee without securing the lid/top of the coffee cup in a closed or locked position which spilled in their lap resulting in a second-degree burn (involves the first two layers of skin, may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin). Resident 2 experienced harm when they were served hot soup without being temperature checked which spilled in their lap resulting in second-degree burns to their thighs and groin. […]

• Actual harm, isolatedF684Apr 22, 2021

  Based on interview and record review, the facility failed to provide the necessary care and services for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure placed residents at risk for lack of or delay in initiating provider ordered treatments and/or recommendations related to wound management, unidentified worsening of wounds, wounds not identified or timely addressed in the residents' plan of care, and failure to consistently obtain measurements to accurately evaluate/assess wound healing progress. This resulted in harm to Resident 1 who developed eschar (dead tissue that is usually black in color) to the left great toe and pain, swelling, redness to the second and third toes, medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] Findings included . […]

• No harm, potential for more than minimal, widespreadF727Jul 16, 2026

  Based on interview and record review, the facility failed to maintain eight hours registered nurse (RN) coverage daily for 1 of 30 sampled days (07/04/2026) reviewed for eight-hour RN nurse staff coverage. This failure placed residents at risk of not having an RN available for resident assessment and treatment, a delay in emergency care, and a diminished quality of life. Findings included.Review of the 30-day staffing pattern, dated 06/13/2026 to 07/13/2026, showed there were no RN working on any shift on 07/04/2026. During an interview on 07/16/2026 at 12:25 PM, Staff A, Administrator, stated the facility ensured they had an RN available for at least eight hours a day by using agency RN staff when there was a call-off by regular staff. […]

• No harm, potential for more than minimal, widespreadF812Jul 16, 2026

  Based on observation, interview, and record review, the facility failed to ensure food was safely stored/prepared when reviewed for kitchen sanitation. This failure placed residents at risk of foodborne illness, avoidable decline in condition, and a diminished quality of life. Findings included.Observation on 07/13/2026 at 9:25 AM showed a standing rack in the dry storage area which held a pan of raw bacon and a pan of breaded chicken pieces. Observation showed the rack was near dry food goods, clean cooking implements, and clean food serving items. Review of the lunch menu for 07/13/2026 showed the main course was sweet and sour chicken with an alternate of a BLT sandwich. Observation on 07/15/2026 at 11:42 AM showed a rack with clean silverware and other clean food serving items. […]

• No harm, potential for more than minimal, widespreadF882Jul 16, 2026

  Based on interview and record review, the facility failed ensure that the infection prevention and control program (IPCP) was overseen by a qualified individual who had completed specialized training in infection prevention and control to properly assess, develop, implement, monitor, and manage the IPCP for the facility. This failure placed residents and staff at risk for communicable diseases and a decreased quality of life. Findings included.During an interview on 07/15/2026 at 9:30 AM, Staff N, Registered Nurse/Infection Preventionist (RN/IP), stated they had started the position as infection preventionist in October 2025 but had not completed any specialized training. […]