Edmonds Post Acute
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
1's neurological assessment form did not show assessments were completed for a duration of 48 and/or 72 hours. Staff F stated the form was not completed or dated beyond 11/03/2025. In an interview and joint
record review on 11/19/2025 at 3:37 PM, Staff C, RN, Resident Care Manager, stated it was the facility's protocol to complete neurological assessments for a duration of 72 hours. In a follow up interview and joint
record review on 11/24/2025 at 12:52 PM, Staff C stated they expected neurological assessments would be completed according to the facility's protocol for unwitnessed falls. A joint record review of Resident 1's neurological assessment forms dated 11/03/2025 showed neurological assessments were completed starting on 11/03/2025 at 3:02 PM until 11/04/2025 at 6:02 PM (total of 15 hours). Staff C stated No, it was not completed, and that neurological assessments should have continued for Resident 1 until 6:00 PM on 11/04/2025, based on the [neurological assessment] forms. A joint record review and interview on 11/24/2025 at 1:24 PM with Staff B, Director of Nursing, showed Resident 1's incomplete neurological assessment forms dated 11/03/2025. Staff B stated that they expected neurological assessments would be completed in accordance with the instructions on the neurological assessment form and that Whatever our form says, we should be following that. 15-MINUTE CHECKSReview of a nursing progress note dated 10/29/2025, showed Resident 1 was initiated on 15-minute checks. Further review of Resident 1's nursing progress notes showed they were transferred to the hospital on [DATE REDACTED]. Review of a nursing progress note dated 10/30/2025 at 9:12 PM, showed Resident 1's representative was very upset upon arrival to [Resident 1's] room reports found resident wandering around his side of room unsafe. [Resident 1's representative] states, he was promised [Resident 1] would be on one-on-one or 15-minute checks at which time writer explains that 15min [minutes] monitoring is ongoing at which time [Resident 1's representative] expresses that he thinks that is unsafe for [Resident 1] and is very scared and worried for him.Review of Resident 1's EHR did not show documentation of 15-minute interval checks completed from 10/29/2025 through 11/05/2025. In an interview on 11/19/2025 at 2:55 PM, Staff D stated that 15-minute checks were performed on residents who were identified at risk for falls and that we do these safety checks. Staff D further stated that a form was provided to certified nursing assistants to document 15-minute interval safety checks and that once completed, documentation would be included in the resident's EHR. In an interview
on 11/19/2025 at 3:19 PM, Staff E, Licensed Practical Nurse, stated that documentation of completed 15-minute checks were documented on a form with initials of the staff performing the safety check along with the time and date. Staff E further stated, I have not seen that form for a while now.In an interview and joint record review on 11/24/2025 at 12:52 PM, Staff C stated Resident 1 was identified to be at risk for falls and that 15-minute checks were initiated for safety. Staff C stated that 15-minute checks were documented using a form at the nurses' station. A joint record review of Resident 1's EHR did not show documentation of 15-minute interval checks completed for Resident 1. Staff C stated, documentation should be in Resident 1's EHR and that I don't [do not] see it here. A joint record review and interview on 11/24/2025 at 1:24 PM with Staff B, showed a physician's order dated 10/29/2025 for Check every 15 minutes every [work] shift, and that they expected completed 15-minute checks would be documented in Resident 1's EHR.
Reference: (WAC) 388-97-1060 (1)(3).
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If continuation sheet
Edmonds Post Acute in EDMONDS, 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 EDMONDS, 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 Edmonds Post Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.