Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Three Creeks Post Acute
PULLMAN, WA · 48 certified beds · Last Life Safety survey March 3, 2026
CMS Certification Number 505246 · first certified September 1979
Ownership
Operated by KALESTA HEALTHCARE GROUP · For profit - Limited Liability company
- New ownershipOwnership changed June 1, 2025 (change of ownership)from PULLMAN NURSING & REHAB LLC
Position within WA
34 citations — more than 57% 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
The latest survey found 10 citations; the earlier surveys in the window averaged 8. With 4 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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4 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
13 of the 34 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)
6 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 34 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-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0880 Provide and implement an infection prevention and control program.
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 | 34 |
| Median facility in WA | 31 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 19, 2023 | 14 |
| November 17, 2024 | 8 |
| December 23, 2025 | 2 |
| March 3, 2026 | 10 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2026-03-03 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-03-03 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2026-03-03 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 2 | 2026-03-03 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2026-03-03 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2024-11-17 |
| K-0923 | Have proper medical gas storage and administration areas. | 2 | 2026-03-03 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2023-08-19 |
What the citations cover
- Emergency Preparedness Deficiencies 13
- Gas, Vacuum, and Electrical Systems Deficiencies 9
- Smoke Deficiencies 8
- Miscellaneous Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 13 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 9 |
| Smoke Deficiencies | 8 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 3, 2026 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (April 2, 2026) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (April 2, 2026) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (April 2, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 2, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 2, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 2, 2026) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 2, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 2, 2026) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (April 2, 2026) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (April 2, 2026) |
December 23, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (January 28, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 28, 2026) |
November 17, 2024 — 8 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 16, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (December 16, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 16, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 16, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (December 16, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 16, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (December 16, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 16, 2024) |
August 19, 2023 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (September 20, 2023) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (September 20, 2023) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (September 20, 2023) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (September 20, 2023) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (September 20, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (September 20, 2023) |
| E-0042 | Meet the requirements of an integrated health system. | Deficient, Provider has date of correction (September 20, 2023) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (September 20, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (September 20, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 20, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 20, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 20, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (September 20, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (September 20, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.