Edmonds Post Acute
Edmonds Post Acute in EDMONDS, WA — inspection on November 24, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.