Edmonds Post Acute
21400 72ND AVENUE WEST
EDMONDS, WA, 98026
4257751961
CCN: 505236
2
Overall2
Health4
Staffing4
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
| Name | Role | % |
|---|---|---|
| KALESTA HEALTHCARE GROUP, LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| CLAWSON, SCOTT | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 44% |
| WILLIAMS, RYAN | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 44% |
| CLAWSON, SCOTT | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| FRYLING, ALARIK | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| REEDY-MATRONE, BRANDON | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| WILLIAMS, RYAN | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
Penalties (1)
| Date | Type | Amount |
|---|---|---|
| 2023-04-13 | Fine | $27K |
Health Deficiencies (95)
2025-11-24 · Health
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2025-11-17 · Health
D
F585 · Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
2025-04-21 · Health
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2025-03-14 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
2025-02-10 · Health
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
2024-11-26 · Health
D
F887 · Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
D
F883 · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F
F882 · Infection Control Deficiencies
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
C
F838 · Administration Deficiencies
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
D
F758 · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
D
F757 · Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
E
F732 · Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
D
F727 · Nursing and Physician Services Deficiencies
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
E
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F645 · Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
D
F644 · Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
E
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F637 · Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
D
F625 · Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
D
F623 · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
D
F585 · Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
E
F584 · Resident Rights Deficiencies
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.
D
F578 · Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
D
F554 · Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
D
F552 · Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
D
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2024-09-26 · Health
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
2024-06-05 · Health
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2024-05-28 · Health
D
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2024-04-08 · Health
D
F921 · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
2023-11-30 · Health
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2023-08-30 · Health
D
F947 · Nursing and Physician Services Deficiencies
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
E
F908 · Environmental Deficiencies
Keep all essential equipment working safely.
E
F883 · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F803 · Nutrition and Dietary Deficiencies
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
E
F802 · Nutrition and Dietary Deficiencies
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
E
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F661 · Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
D
F625 · Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
D
F623 · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2023-08-21 · Health
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2023-04-13 · Health
G
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F623 · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
D
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2023-03-02 · Health
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2022-05-27 · Health
D
F919 · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
D
F883 · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
D
F881 · Infection Control Deficiencies
Implement a program that monitors antibiotic use.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F868 · Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F791 · Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
F
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
E
F758 · Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
D
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
D
F725 · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
D
F688 · Quality of Life and Care Deficiencies
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
D
F679 · Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
E
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
D
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
E
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
D
F625 · Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
D
F623 · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
D
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
E
F584 · Resident Rights Deficiencies
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.
D
F578 · Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
D
F565 · Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
D
F552 · Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
E
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
4.14
RN Hrs/Resident/Day0.54
0.79
LPN Hrs/Resident/Day0.81
0.93
CNA Hrs/Resident/Day2.33
2.42
PT Hrs/Resident/Day0.12
0.06
Data as of 2026-03-01