01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-11-21 | 12 | 2025-11-21 | 14 |
| Cycle 2 | 2024-07-24 | 25 | 2024-07-24 | 7 |
| Cycle 3 | 2023-04-28 | 11 | 2023-04-28 | 19 |
CMS CCN 5055102026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Avalon Care Center Federal Way, L.L.C.
135 South 336Th Street · Federal Way, WA 98003 · King County
Certified beds120CMS provider file
Recent citation rows88current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
88 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 27 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-11-21 · FIREE0004Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2025-12-242025-11-21 · FIREE0009Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Include a process for Emergency Preparedness collaboration.
Correction field: Deficient, Provider has date of correction · 2025-12-242025-11-21 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2026-01-042025-11-21 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2026-01-042025-11-21 · HEALTHF0658Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2026-01-042025-11-21 · HEALTHF0676Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Correction field: Deficient, Provider has date of correction · 2026-01-042025-11-21 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2026-01-042025-11-21 · HEALTHF0679Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2026-01-042025-11-21 · HEALTHF0688Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-01-042025-11-21 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-01-042025-11-21 · HEALTHF0756Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2026-01-042025-11-21 · HEALTHF0759Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2026-01-042025-11-21 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2026-01-042025-11-21 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-01-042025-11-21 · FIREK0211Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2025-12-242025-11-21 · FIREK0324Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-12-242025-11-21 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-12-242025-11-21 · FIREK0346Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Correction field: Deficient, Provider has date of correction · 2025-12-242025-11-21 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-12-242025-11-21 · FIREK0354Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Correction field: Deficient, Provider has date of correction · 2025-12-242025-11-21 · FIREK0711Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Correction field: Deficient, Provider has date of correction · 2025-12-242025-11-21 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-12-242025-11-21 · FIREK0741Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2025-12-242025-11-21 · FIREK0918Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-12-2403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- AVALON CARE LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 08/01/2004
- DANGERFIELD, DAVIDIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 04/05/2007
- KIRTON, BYRONIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/27/2024
- KIRTON, HYRUMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/27/2024
- KIRTON, SPENCERIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/27/2024
- WOLTIL, ROBERTIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/23/2012
- DANGERFIELD, DAVIDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/05/2007
- KIRTON, BYRONIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/27/2024
- KIRTON, HYRUMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/27/2024
- KIRTON, SPENCERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/27/2024
- WOLTIL, ROBERTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/23/2012
- BORISEVICH, MARIAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/08/2024
- HASH, ALANIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/15/2017
- KIRTON, HYRUMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/29/2022
- SMITH, NICOLEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/01/2023
- AVALON HEALTH CARE INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2003
- AVALON HEALTH CARE MANAGEMENT INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2003
- AHMAD, ATIQUEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/26/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.28per resident day
RN hours0.90per resident day
Weekend nurse hours3.75per resident day
Staff turnover38.3%CMS reported field