Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Avalon Healthcare - Tacoma
TACOMA, WA · 81 certified beds · Last Life Safety survey July 30, 2025
CMS Certification Number 505183 · first certified February 1968
Ownership
Operated by AVALON HEALTH CARE · For profit - Limited Liability company
- New ownershipOwnership changed March 12, 2025 (change of ownership)from HERITAGE REHAB, LLC
67
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
18
Tags cited more than once
Across separate surveys
15
Inspection & testing records
Of the citations on file
Position within WA
67 citations — more than 96% of the 193 certified nursing homes in WA. Compared within WA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
Slippingmore citations at the latest survey than at its earlier surveys in the window.
The latest survey found 41 citations; the earlier surveys in the window averaged 13. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: July 2026 to October 2026. This facility’s last Life Safety survey was July 2025. Facilities in WA are typically surveyed 12–15 months after the last one (median 13), measured over 320 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
28 of the 67 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
11 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 67 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
How that compares
Compared with the median facility in WA, and nationally. Surveyors differ markedly between states, so the WA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 67 |
| Median facility in WA | 31 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 9, 2023 | 9 |
| October 9, 2024 | 17 |
| July 30, 2025 | 41 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 3 | 2025-07-30 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2025-07-30 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 3 | 2025-07-30 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-07-30 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2025-07-30 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2025-07-30 |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | 2 | 2025-07-30 |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | 2 | 2025-07-30 |
What the citations cover
- Emergency Preparedness Deficiencies 28
- Smoke Deficiencies 20
- Gas, Vacuum, and Electrical Systems Deficiencies 9
- Miscellaneous Deficiencies 5
- Other 5
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 28 |
| Smoke Deficiencies | 20 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 9 |
| Miscellaneous Deficiencies | 5 |
| Egress Deficiencies | 4 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 30, 2025 — 41 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (August 28, 2025) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (August 28, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (September 19, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (September 19, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 19, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (August 28, 2025) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (August 28, 2025) |
October 9, 2024 — 17 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (November 4, 2024) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (November 4, 2024) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (November 4, 2024) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (November 4, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (December 6, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 3, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 4, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 4, 2024) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (November 4, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 3, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (November 4, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (November 4, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 4, 2024) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (December 6, 2024) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (December 6, 2024) |
November 9, 2023 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (December 6, 2023) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (December 6, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.