Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Alderwood Post Acute & Rehabilitation
LYNNWOOD, WA · 113 certified beds · Last Life Safety survey August 20, 2025
CMS Certification Number 505319 · first certified May 1988
Ownership
Operated by HILL VALLEY HEALTHCARE · For profit - Corporation
- Ownership changed April 1, 2023 (change of ownership)from MANOR CARE OF LYNNWOOD WA, ASSOCIATION
56
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
12
Tags cited more than once
Across separate surveys
19
Inspection & testing records
Of the citations on file
Position within WA
56 citations — more than 91% 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
Improvingfewer citations at the latest survey than at its earlier surveys in the window.
The latest survey found 12 citations; the earlier surveys in the window averaged 22. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: August 2026 to November 2026. This facility’s last Life Safety survey was August 2025. 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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5 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
21 of the 56 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)
8 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 56 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- 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-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
How that compares
Compared with the median facility in WA, and nationally. Surveyors differ markedly between states, so the WA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 56 |
| Median facility in WA | 31 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 14, 2023 | 33 |
| November 15, 2024 | 11 |
| August 20, 2025 | 12 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2025-08-20 |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 3 | 2025-08-20 |
| K-0324 | Provide properly protected cooking facilities. | 3 | 2025-08-20 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-08-20 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2025-08-20 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2025-08-20 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2025-08-20 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 2 | 2024-11-15 |
What the citations cover
- Emergency Preparedness Deficiencies 21
- Smoke Deficiencies 15
- Egress Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Other 5
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 21 |
| Smoke Deficiencies | 15 |
| Egress Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Services Deficiencies | 2 |
| Miscellaneous Deficiencies | 2 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 20, 2025 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (September 16, 2025) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (September 16, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (September 16, 2025) |
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (September 16, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (September 16, 2025) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (September 16, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 16, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 16, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 16, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (September 16, 2025) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (September 16, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 10, 2025) |
November 15, 2024 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (December 10, 2024) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (December 10, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (December 10, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 10, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 10, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 10, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (December 10, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (December 10, 2024) |
| 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 (December 10, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 10, 2024) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (December 10, 2024) |
December 14, 2023 — 33 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (January 11, 2024) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (January 11, 2024) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (January 11, 2024) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (January 11, 2024) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (January 11, 2024) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (January 11, 2024) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (January 11, 2024) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (January 11, 2024) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (January 11, 2024) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (January 11, 2024) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (January 11, 2024) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (December 22, 2023) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (January 11, 2024) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (January 11, 2024) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (January 11, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (January 11, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 5, 2024) |
| K-0371 | Have properly sized and located compartments to protect residents from smoke. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (January 11, 2024) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (January 11, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.