Federal inspectors found no documentation that staff at Edmonds Post Acute completed the ordered safety checks for Resident 1 from October 29 through November 5. The resident had been placed on the intensive monitoring protocol after being identified as high-risk for falls.
The missing documentation emerged during a complaint investigation that also revealed the facility failed to complete required neurological assessments after an unwitnessed fall. Staff stopped the assessments after just 15 hours instead of the required 72 hours.
On October 30, nursing notes show the resident's family member arrived to find him "wandering around his side of room unsafe." The family representative was "very upset" and told staff he had been "promised" the resident would receive either one-on-one supervision or 15-minute checks.
A nurse explained that 15-minute monitoring was "ongoing," but the family member "expresses that he thinks that is unsafe" and said he was "very scared and worried" for the resident.
The resident was subsequently transferred to a hospital.
When inspectors reviewed the electronic health record, they found no evidence the 15-minute checks had actually been performed during the week-long period, despite the doctor's order and the family's safety concerns.
Staff D told inspectors that 15-minute checks were "performed on residents who were identified at risk for falls" and that "we do these safety checks." The staff member said a form was provided to nursing assistants to document the checks, and "once completed, documentation would be included in the resident's EHR."
But Licensed Practical Nurse Staff E told inspectors: "I have not seen that form for a while now."
Resident Care Manager Staff C acknowledged during the inspection that 15-minute checks were "documented using a form at the nurses' station." When inspectors reviewed the resident's electronic record with Staff C present, the manager stated: "documentation should be in Resident 1's EHR and that I don't see it here."
The documentation failures extended beyond the safety checks. After an unwitnessed fall on November 3, facility protocol required neurological assessments for 72 hours to monitor for potential brain injury.
Staff completed the assessments from 3:02 PM on November 3 until 6:02 PM on November 4 — a total of just 15 hours instead of the required 72.
Staff F stated the neurological assessment form "was not completed or dated beyond 11/03/2025."
Resident Care Manager Staff C confirmed it was "the facility's protocol to complete neurological assessments for a duration of 72 hours" following unwitnessed falls. During the inspection, Staff C acknowledged the assessments were incomplete, stating: "No, it was not completed, and that neurological assessments should have continued for Resident 1 until 6:00 PM on 11/04/2025."
Director of Nursing Staff B told inspectors that staff should follow "the instructions on the neurological assessment form" and that "Whatever our form says, we should be following that."
The inspection found that both safety protocols — the 15-minute checks and the post-fall neurological monitoring — were ordered by physicians but not properly executed or documented by nursing staff.
Staff C told inspectors they "expected neurological assessments would be completed according to the facility's protocol for unwitnessed falls." Similarly, Director of Nursing Staff B said they "expected completed 15-minute checks would be documented in Resident 1's EHR."
The violations occurred despite clear facility protocols and physician orders requiring both types of monitoring. The 15-minute safety checks were specifically ordered after the resident was identified as being at risk for falls, while the neurological assessments were required following an unwitnessed fall to detect potential brain injury.
The family member's documented concerns about the resident wandering unsafely in his room proved prescient — the safety monitoring system designed to protect him had broken down completely, with no documentation that required checks were ever performed during a critical week-long period.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Edmonds Post Acute from 2025-11-24 including all violations, facility responses, and corrective action plans.