Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
ELISEO
TACOMA, WA · 187 certified beds · Last Life Safety survey May 9, 2025
CMS Certification Number 505435 · first certified January 1992
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
72
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
22
Tags cited more than once
Across separate surveys
24
Inspection & testing records
Of the citations on file
Position within WA
72 citations — more than 98% 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 33 citations; the earlier surveys in the window averaged 19.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (April 2026 to July 2026), and past the point by which nine in ten WA facilities have been surveyed. This facility’s last Life Safety survey was May 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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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
24 of the 72 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 72 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0908 Keep all essential equipment working safely.
- F-0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
- 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.
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 | 72 |
| Median facility in WA | 31 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 17, 2023 | 19 |
| June 5, 2024 | 20 |
| May 9, 2025 | 33 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2025-05-09 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-05-09 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2025-05-09 |
| E-0037 | Establish staff and initial training requirements. | 3 | 2025-05-09 |
| E-0039 | Conduct testing and exercise requirements. | 3 | 2025-05-09 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 3 | 2025-05-09 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 2 | 2025-05-09 |
| E-0026 | Establish roles under a Waiver declared by secretary. | 2 | 2024-06-05 |
What the citations cover
- Emergency Preparedness Deficiencies 24
- Smoke Deficiencies 21
- Gas, Vacuum, and Electrical Systems Deficiencies 11
- Egress Deficiencies 6
- Other 10
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 24 |
| Smoke Deficiencies | 21 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 11 |
| Egress Deficiencies | 6 |
| Services Deficiencies | 5 |
| Miscellaneous Deficiencies | 4 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 9, 2025 — 33 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (August 8, 2025) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (August 1, 2025) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (August 8, 2025) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (August 8, 2025) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (August 8, 2025) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (August 4, 2025) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (August 8, 2025) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (August 8, 2025) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (August 4, 2025) |
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (August 8, 2025) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (August 8, 2025) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (August 8, 2025) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (August 8, 2025) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (August 8, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 4, 2025) |
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (June 12, 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 (June 12, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (June 12, 2025) |
| 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 (June 12, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 8, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 1, 2025) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (June 12, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 1, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (June 12, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 12, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (June 12, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 12, 2025) |
| K-0525 | Enure that solid fuel-burning fireplaces are not in patient sleeping areas. | Deficient, Provider has date of correction (June 12, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (August 1, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 1, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 12, 2025) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (August 1, 2025) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (June 12, 2025) |
June 5, 2024 — 20 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (July 10, 2024) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (August 9, 2024) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (July 10, 2024) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (July 10, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (July 10, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 9, 2024) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (July 10, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (July 10, 2024) |
| 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 (July 10, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 9, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 9, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 10, 2024) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (July 10, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 10, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 10, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 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 (July 10, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 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 (July 10, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 10, 2024) |
August 17, 2023 — 19 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (September 19, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (September 19, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (October 16, 2023) |
| K-0231 | Provide large enough exits. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (September 19, 2023) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 16, 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 12, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 19, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (September 19, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 19, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (October 12, 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 12, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 19, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (October 16, 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 (September 19, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.