Deficiency Records for Alderwood Post Acute and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Alderwood Post Acute and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-01-04 | 2024-02-06 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-01-04 | 2024-02-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-14 | 2024-02-06 | N |
| 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. | Health | 2023-12-14 | 2024-02-06 | N |
| 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. | Health | 2023-12-14 | 2024-02-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-14 | 2024-02-06 | N |
| Respond appropriately to all alleged violations. | Health | 2023-12-14 | 2024-02-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-14 | 2024-02-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-12-14 | 2024-02-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-12-14 | 2024-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-14 | 2024-02-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-14 | 2024-02-06 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-12-14 | 2024-02-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-14 | 2024-02-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-14 | 2024-02-06 | N |
| 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. | Health | 2023-12-14 | 2024-02-06 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-12-14 | 2024-02-06 | N |
| Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. | Health | 2023-12-14 | 2024-02-06 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-12-14 | 2024-02-06 | N |
| Post nurse staffing information every day. | Health | 2023-12-14 | 2024-02-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-14 | 2024-02-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-14 | 2024-02-06 | N |
| 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. | Health | 2023-12-14 | 2024-02-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-14 | 2024-02-06 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-12-14 | 2024-02-06 | N |
| 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. | Health | 2023-12-14 | 2024-02-06 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-12-14 | 2024-02-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-14 | 2024-02-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-14 | 2024-02-06 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-12-14 | 2024-02-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-12-14 | 2024-02-06 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-14 | 2024-02-06 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-14 | 2024-02-06 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-14 | 2024-02-06 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Develop a communication plan. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| 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. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-12-07 | 2024-01-11 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-12-07 | 2023-12-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-03 | 2023-11-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-03 | 2023-11-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-23 | 2023-07-20 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-11 | 2023-06-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-11 | 2023-06-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-11 | 2023-06-15 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-05-11 | 2023-06-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-23 | 2023-02-01 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-12-23 | 2023-02-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-12-23 | 2023-02-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-23 | 2023-02-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-23 | 2023-02-01 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-23 | 2023-02-01 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-12-23 | 2023-02-01 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-12-23 | 2023-02-01 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-12-23 | 2023-02-01 | Y |
| Keep all essential equipment working safely. | Health | 2022-12-23 | 2023-02-01 | Y |
| 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. | Health | 2022-06-10 | 2022-07-15 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-10 | 2022-07-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-10 | 2022-07-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-10 | 2022-07-15 | N |
| 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. | Health | 2022-06-10 | 2022-07-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-06-10 | 2022-07-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-10 | 2022-07-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-06-10 | 2022-07-15 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-06-08 | 2022-07-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-08 | 2022-07-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-08 | 2022-07-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-08 | 2022-07-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-08 | 2022-07-11 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-06-08 | 2022-07-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-08 | 2022-07-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-06-08 | 2022-07-11 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-04-29 | 2022-05-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-23 | 2021-12-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-11-23 | 2021-12-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-08 | 2021-10-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-20 | 2019-11-22 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-10-20 | 2019-11-22 | N |
| 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. | Health | 2019-10-20 | 2019-11-22 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-10-20 | 2019-11-22 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-20 | 2019-11-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-20 | 2019-11-22 | N |
| 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. | Health | 2019-10-20 | 2019-11-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-20 | 2019-11-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-20 | 2019-11-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-20 | 2019-11-22 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-20 | 2019-11-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-20 | 2019-11-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-20 | 2019-11-22 | N |
| 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. | Health | 2019-10-20 | 2019-11-22 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-10-20 | 2019-11-22 | N |
| Post nurse staffing information every day. | Health | 2019-10-20 | 2019-11-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-20 | 2019-11-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-20 | 2019-11-22 | N |
| 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. | Health | 2019-10-20 | 2019-11-22 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-10-20 | 2019-11-22 | N |
| 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. | Health | 2019-10-20 | 2019-11-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-10-20 | 2019-11-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-20 | 2019-11-22 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-10-20 | 2019-11-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-20 | 2019-11-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-20 | 2019-11-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-14 | 2019-11-14 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-10-14 | 2019-11-14 | N |
