Avalon Health & Rehabilitation Center - Pasco
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
members for ADLs. Record review of a facility investigation, dated 08/05/2025, showed Resident 2 had a fall and was found lying next to their wheelchair in front of the nurse's station. Further review of the investigation showed Resident 2's ordered wheelchair cushion was not in place at the time of the fall.
Further review of the investigation summary showed the IDT team updated the care plan to ensure the wheelchair cushion was in place prior to Resident 2 being placed in their chair. Record review of a facility investigation dated 09/01/2025, showed Resident 2 was found on their knees in front of the nurse's station.
Further review of the investigation showed Resident 2's ordered wheelchair cushion was not in place at the time of the fall. Further review of the investigation summary showed the IDT reviewed and updated Resident 2's care plan to ensure Resident 2's wheelchair cushion was in place prior to placing the resident
in their wheelchair. Review of the care plan dated 03/05/2025, showed no updates or interventions were implemented from the falls on 08/05/2025 and 09/01/2025 for the placement of the wheelchair cushion.During an interview on 09/17/2025 at 3:12 PM, Staff A, Director of Nursing Services, stated the facility fall prevention process involved conducting a Fall Risk Assessment upon admission and developing
a care plan with resident specific interventions for staff to follow. Staff A further stated if a resident experienced a fall, the care plan was reviewed and revised to reduce the risk of future incidents. Staff A stated upon review, they identified a failure in the implementation of fall prevention measures and care plan implementation and updates. Staff A stated they had noticed there was no completed incident report for Resident 1's 08/27/2025 fall and that was an issue they needed to investigate. Staff A stated the correct process had not been followed for Resident 1 and 2. Reference: WAC 388-97-1060 (3)(g)
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AVALON HEALTH & REHABILITATION CENTER - PASCO in PASCO, WA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PASCO, WA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AVALON HEALTH & REHABILITATION CENTER - PASCO or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.