Alderwood Manor

In the surveyor’s words

From the most serious findings on record at Alderwood Manor, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 26, 2024

  Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents (Resident 1), reviewed for accidents, was transferredas directed by the careplan. Resident 1 experienced harm when they were found to have a fractured arm and clavicle the next shift after being assisted to the floor when the wrong transfer method was used. This failure placed the residents at risk for falls and serious injury. Findings included . Review of the facility assessment, dated 05/02/2024, showed Resident 1 had diagnoses to include a stroke which affected their right side, and had difficulty with speech. The resident was alert and oriented. Resident 1 required substantial/maximal assist with transfers. […]

• Actual harm, isolatedF686Jul 7, 2023

  Based on observation, interview, and record review, the facility failed to recognize pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin), accurately and thoroughly assess skin integrity: which potentially delayed the initiation and treatment and thoroughly document or measure wounds for 1 of 2 sampled residents (Resident 202), reviewed for pressure ulcers. These failures resulted in actual harm to Resident 202, who developed additional pressure ulcers to the right medial ankle, left heel and great toe after being admitted to the facility, and placed other residents at risk for untreated skin issues, pressure ulcers, and a decreased quality of life Findings included . […]

• Actual harm, isolatedF689Jul 7, 2023

  Based on observation, interview, and record review, the facility failed to ensure a resident who experienced multiple accidents that resulted in injury was evaluated for the need for increased supervision, and resident-specific fall preventative measures were added timely to care plans for 2 of 3 sampled residents (Residents 31, 11), reviewed for falls. Resident 31 experienced harm when they had multiple falls resulting in a fractured arm, abrasions to the chin and elbow, and a fractured hip, and this failure placed other residents at risk for falls with injury. […]

• Actual harm, isolatedF689Feb 17, 2021

  Based on interview and record review, the facility failed to ensure falls were thoroughly investigated, and fall prevention interventions specific to resident needs were identified and implemented for one of four sample residents (#2), reviewed for accidents. Failure to evaluate possible root causes, and revise and implement fall prevention interventions, resulted in actual harm for Resident #2 who suffered a fall with a fracture. Findings included . According to a 10/22/2020 admission assessment, Resident #2 was cognitively intact and required assistance of one person with most activities of daily living, including toileting. […]

• No harm, potential for more than minimal, widespreadF880Feb 13, 2026

  Based on observation, interview and record review, the facility failed to ensure hand hygiene was completed when indicated for 2 of 4 staff (Staff members W and R) observed during medication administration and failed to ensure enhanced barrier precautions (EBP, the use of gowns and gloves during high-contact care activities for residents infected or colonized with multi-drug-resistant organisms, or those with chronic wounds or indwelling medical devices) were implemented when indicated for 2 of 6 sampled residents (Resident 61 and 48) reviewed. […]