Avalon Health & Rehabilitation Center's own investigation records show Resident 2 fell on August 5, 2025, when their ordered wheelchair cushion was not in place. The facility's interdisciplinary team promised to update the care plan to ensure the cushion was placed before seating the resident.
On September 1, inspectors found Resident 2 on their knees in front of the nurse's station after another fall. The wheelchair cushion was missing again.
The facility conducted another investigation and made the same promise to update the care plan. But when state inspectors reviewed Resident 2's care plan dated March 5, 2025, they found no updates or interventions had been implemented following either fall.
A second resident experienced similar problems. Resident 1 fell on August 27, 2025, but the facility never completed an incident report for that fall.
Staff A, the Director of Nursing Services, admitted during a September 17 interview that the facility had failed multiple residents. "Upon review, they identified a failure in the implementation of fall prevention measures and care plan implementation and updates," according to the inspection report.
The director acknowledged that no incident report existed for Resident 1's August 27 fall, calling it "an issue they needed to investigate." She stated that "the correct process had not been followed for Resident 1 and 2."
Falls represent one of the most serious safety risks in nursing homes. Wheelchair cushions serve as critical safety equipment for residents who cannot maintain proper positioning independently. The cushions help prevent sliding, which can lead to falls and serious injuries including hip fractures and head trauma.
The facility's own fall prevention process required conducting risk assessments upon admission and developing care plans with resident-specific interventions. When falls occurred, staff were supposed to review and revise care plans to reduce future risk.
But Avalon's records show a pattern of promising improvements that never materialized. After Resident 2's first fall on August 5, the interdisciplinary team documented their plan to ensure wheelchair cushions were in place before seating. The same language appeared in investigation records after the September 1 fall.
Neither promise was kept.
The March care plan remained unchanged despite two documented falls and two facility investigations promising updates. The disconnect between what staff documented and what they actually implemented left residents at continued risk.
State inspectors cited the facility for failing to provide adequate supervision and assistive devices to prevent accidents. The violation fell under Washington's nursing home regulations requiring facilities to ensure residents receive proper care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
The Director of Nursing's admission that staff failed to follow correct procedures for two residents suggests the problems extended beyond simple oversight. The missing incident report for Resident 1's August 27 fall indicates gaps in the facility's basic documentation requirements.
Wheelchair falls can cause devastating injuries for elderly residents. Hip fractures occur in approximately 2% of nursing home falls, but the consequences can be life-altering for frail residents. Head injuries from falls represent another serious concern, particularly for residents taking blood-thinning medications.
The inspection found that few residents were affected by the violation, and the level of harm was classified as minimal or potential for actual harm. But for Resident 2, who fell twice in less than a month, the potential for serious injury was real each time they were placed in a wheelchair without their required safety equipment.
The facility's failure to complete promised care plan updates meant Resident 2 remained at risk for additional falls. Without proper interventions documented and implemented, staff lacked clear guidance on preventing future incidents.
Avalon Health & Rehabilitation Center's investigation records show staff recognized the problem and knew the solution. They documented the missing wheelchair cushions after each fall and promised to ensure proper placement going forward.
The promises were never kept. The care plans were never updated. And residents continued falling from wheelchairs missing their required safety equipment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avalon Health & Rehabilitation Center - Pasco from 2025-09-17 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Avalon Health & Rehabilitation Center - Pasco
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