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Complaint Investigation

Edmonds Post Acute

November 24, 2025 · Edmonds, WA · 21400 72nd Avenue West
Citations 1
CMS Rating 1/5
Beds 128
Provider ID 505236
Healthcare Facility
Edmonds Post Acute
Edmonds, WA  ·  View full profile →
Inspection Summary

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.

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Inspection Findings

FF0684
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

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).

Facility ID:

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.


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