Alderwood Post Acute & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Alderwood Post Acute & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF755Dec 23, 2022

  Based on observation, interview and record review, the facility failed to ensure there was a system that provided pharmaceutical services (including procedures that effectively dealt with serious prescription discrepancies) that assured the accurate administration of all drugs and biologicals for four of five residents (4, 14, 1, 5) reviewed for safe and accurate medication practices. Resident 4 was harmed when they were administered 20x the intended dose of Oxycodone (a strong pain medication that affects mood/behavior and can be lethal in high doses) and had to be hospitalized . Several licensed nurses (LN), to include the only nurse manager, failed to verify the correct dose of the medication. […]

• Immediate jeopardy, patternF835Dec 23, 2022

  Based on interview and record review, the facility failed to ensure the facility was administered in a manner that used its resources effectively and efficiently so residents could attain or maintain their highest practicable physical, mental and psychosocial well-being and to ensure the facility maintained substantial compliance with state and federal regulations. The Administration failed to ensure there was active and engaged oversight and monitoring of systems related to Abuse/Neglect, Pressure Ulcers, Pharmacy Services, Hospice Services and Resident Records. These failures caused residents to have unmet care needs and caused harm to residents. […]

• Actual harm, isolatedF698Dec 3, 2025

  Based on interview and record review, the facility failed to ensure residents received scheduled hemodialysis (HD- a form of dialysis - an artificial filtration of waste products and excess fluid of the body from the blood using a machine with a special filter) treatment as ordered for 1 of 2 residents (Resident 1) reviewed for HD. Resident 1 experienced harm when they had volume overload (a condition where the body holds too much fluid) requiring hospitalization to intensive care unit due to missed HD treatments. […]

• Actual harm, isolatedF688Aug 20, 2025

  Based on observation, interview and record review, the facility failed to provide appropriate treatment, services and interventions to prevent an avoidable reduction of range of motion (ROM) for 1 of 4 sampled residents (Resident 4) reviewed for ROM. Resident 4 experienced harm as evidenced by moderate pain and decreased functional ability due to the formation of a hand contracture (joint becomes fixed in place) which was not present on admit. The failure to not provide appropriate services/interventions for ROM placed other residents at risk of developing new contractures and/or worsening of existing contractures. […]

• Actual harm, isolatedF689Jun 7, 2024

  Based on observation, interview and record review, the facility failed to provide adequate supervision and/or failed to follow the resident's care plan to prevent accidents/falls for 2 of 3 residents (Resident 1 and 2) reviewed for injuries and accident hazards. Resident 1 experience harm when they received care while in bed without two staff assistance which resulted in a fall and the resident sustained a pelvic fracture, and Resident 2 experienced harm when they exited the facility unsupervised, was subsequently found by an Emergency Medical Technician (EMT) lying on the sidewalk next to the road and sustained a significant injury requiring a hospital admission. This failed practice placed residents at risk for elopement, falls, and injury. […]