Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Edmonds Post Acute

EDMONDS, WA · 128 certified beds · Last Life Safety survey March 4, 2026

CMS Certification Number 505236 · first certified August 1977

Ownership

Operated by KALESTA HEALTHCARE GROUP · For profit - Limited Liability company

New ownershipOwnership changed June 1, 2025 (change of ownership)from ALDERCREST HEALTH - EDMONDS, LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within WA

65 citations — more than 95% of the 193 certified nursing homes in WA. Compared within WA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 28 citations; the earlier surveys in the window averaged 18.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens February 2027 — about 5 months from now. This facility’s last Life Safety survey was March 2026. Facilities in WA are typically surveyed 12–15 months after the last one (median 13), measured over 320 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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8 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

23 of the 65 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

16 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 65 Life Safety citations above. The Physical Environment Index

F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.
F-0908 Keep all essential equipment working safely.
F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

How that compares

Citations on file over three years

Compared with the median facility in WA, and nationally. Surveyors differ markedly between states, so the WA figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	65
Median facility in WA	31
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
August 30, 2023	26
November 26, 2024	11
March 4, 2026	28

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2026-03-04
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	3	2026-03-04
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	3	2026-03-04
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	2	2026-03-04
E-0036	Establish emergency prep training and testing.	2	2026-03-04
E-0009	Include a process for Emergency Preparedness collaboration.	2	2026-03-04
K-0511	Have properly installed electrical wiring and gas equipment.	2	2024-11-26
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	2	2026-03-04

What the citations cover

Citations by CMS category

Emergency Preparedness Deficiencies 23
Smoke Deficiencies 17
Gas, Vacuum, and Electrical Systems Deficiencies 12
Miscellaneous Deficiencies 5
Other 8

Citations by CMS category
Category	Citations
Emergency Preparedness Deficiencies	23
Smoke Deficiencies	17
Gas, Vacuum, and Electrical Systems Deficiencies	12
Miscellaneous Deficiencies	5
Services Deficiencies	4
Egress Deficiencies	3
Construction Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

March 4, 2026 — 28 citations

Citations issued on March 4, 2026
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (March 31, 2026)
E-0009	Include a process for Emergency Preparedness collaboration.	Deficient, Provider has date of correction (March 31, 2026)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (March 31, 2026)
E-0018	Establish procedures for tracking staff and patients during an emergency.	Deficient, Provider has date of correction (March 31, 2026)
E-0020	Establish policies and procedures including evacuation.	Deficient, Provider has date of correction (March 31, 2026)
E-0023	Establish policies and procedures for medical documentation.	Deficient, Provider has date of correction (March 31, 2026)
E-0030	List the names and contact information of those in the facility.	Deficient, Provider has date of correction (March 31, 2026)
E-0034	Provide a means of sharing information on occupancy/needs.	Deficient, Provider has date of correction (March 31, 2026)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (March 31, 2026)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (March 31, 2026)
K-0100	Meet other general requirements.	Deficient, Provider has date of correction (April 23, 2026)
K-0232	Have corridors or aisles that are unobstructed and are at least 8 feet in width.	Deficient, Provider has date of correction (April 23, 2026)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (March 31, 2026)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (March 31, 2026)
K-0346	Follow proper procedures when the fire alarm was out of service for more than 4 hours.	Deficient, Provider has date of correction (March 31, 2026)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (April 23, 2026)
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	Deficient, Provider has date of correction (March 31, 2026)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (March 31, 2026)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (March 31, 2026)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (March 31, 2026)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (March 31, 2026)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (March 31, 2026)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (March 31, 2026)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (March 31, 2026)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (March 31, 2026)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (March 31, 2026)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (April 23, 2026)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (March 31, 2026)

November 26, 2024 — 11 citations

Citations issued on November 26, 2024
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (December 20, 2024)
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (December 20, 2024)
E-0031	Provide emergency officials' contact information.	Deficient, Provider has date of correction (December 20, 2024)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (December 20, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (December 20, 2024)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (December 20, 2024)
K-0522	Have an externally vented heating system.	Deficient, Provider has date of correction (December 20, 2024)
K-0915	Have proper power supply for life support equipment.	Deficient, Provider has date of correction (December 20, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (December 20, 2024)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (December 20, 2024)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (December 20, 2024)

August 30, 2023 — 26 citations

Citations issued on August 30, 2023
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (October 4, 2023)
E-0009	Include a process for Emergency Preparedness collaboration.	Deficient, Provider has date of correction (October 4, 2023)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (October 4, 2023)
E-0018	Establish procedures for tracking staff and patients during an emergency.	Deficient, Provider has date of correction (October 4, 2023)
E-0023	Establish policies and procedures for medical documentation.	Deficient, Provider has date of correction (October 4, 2023)
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (October 4, 2023)
E-0034	Provide a means of sharing information on occupancy/needs.	Deficient, Provider has date of correction (October 4, 2023)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (October 4, 2023)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (October 4, 2023)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (October 4, 2023)
K-0271	Have exits that are accessible at all times.	Deficient, Provider has date of correction (October 4, 2023)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (October 4, 2023)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (October 4, 2023)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (October 4, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Waiver has been granted (October 4, 2023)
K-0354	Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.	Deficient, Provider has date of correction (October 4, 2023)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (October 4, 2023)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (October 4, 2023)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (October 4, 2023)
K-0523	Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly.	Deficient, Provider has date of correction (October 4, 2023)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (October 4, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (October 4, 2023)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (October 4, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Waiver has been granted (October 4, 2023)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (October 4, 2023)
K-0926	Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	Deficient, Provider has date of correction (October 4, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.