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Deficiency Records for Alderwood Manor
A list of the most recent deficiencies for Alderwood Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Alderwood Manor. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-07-26 | 2024-07-26 | Y |
| 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 | 2024-06-12 | 2024-07-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-06-12 | 2024-07-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-06 | 2024-03-06 | 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 | 2023-11-16 | 2023-12-22 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2023-09-18 | 2023-10-13 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-07-07 | 2023-08-18 | N |
| 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. | Health | 2023-07-07 | 2023-08-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-07 | 2023-08-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-07 | 2023-08-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-07 | 2023-08-18 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-07-07 | 2023-08-18 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-07-07 | 2023-08-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-07 | 2023-08-18 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-07-07 | 2023-08-18 | 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 | 2023-07-07 | 2023-08-18 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-07-07 | 2023-08-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-07 | 2023-08-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-07 | 2023-08-18 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-07 | 2023-08-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-07 | 2023-08-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-07 | 2023-08-18 | 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 | 2023-07-07 | 2023-08-18 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-07-07 | 2023-08-18 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Meet other general requirements. | Fire Safety | 2023-06-23 | 2023-07-28 | 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 | 2023-06-23 | 2023-07-28 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-06-23 | 2023-07-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-13 | 2023-07-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-18 | 2023-06-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-22 | 2023-01-27 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-12-12 | 2023-01-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-12 | 2023-01-27 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-12 | 2023-01-27 | Y |
| 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 | 2022-06-23 | 2022-07-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-15 | 2022-04-13 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-03-15 | 2022-04-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-29 | 2019-12-12 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-10-29 | 2019-12-12 | N |
| Honor the resident's right to choose his or her attending physician. | Health | 2019-10-29 | 2019-12-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-29 | 2019-12-12 | 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 | 2019-10-29 | 2019-12-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-29 | 2019-12-12 | N |
| Respond appropriately to all alleged violations. | Health | 2019-10-29 | 2019-12-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-29 | 2019-12-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-29 | 2019-12-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-10-29 | 2019-12-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-29 | 2019-12-12 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-29 | 2019-12-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-10-29 | 2019-12-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-29 | 2019-12-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-10-29 | 2019-12-12 | 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 | 2019-10-29 | 2019-12-12 | 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 | 2019-10-29 | 2019-12-12 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-10-29 | 2019-12-12 | N |
| Post nurse staffing information every day. | Health | 2019-10-29 | 2019-12-12 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-10-29 | 2019-12-12 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-10-29 | 2019-12-12 | 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 | 2019-10-29 | 2019-12-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-29 | 2019-12-12 | 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 | 2019-10-29 | 2019-12-12 | N |
| Provide or obtain dental services for each resident. | Health | 2019-10-29 | 2019-12-12 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-10-29 | 2019-12-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-29 | 2019-12-12 | 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 | 2019-10-29 | 2019-12-12 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-10-29 | 2019-12-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-29 | 2019-12-12 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-10-29 | 2019-12-12 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2019-10-29 | 2019-12-12 | 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 | 2019-10-29 | 2019-12-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-29 | 2019-12-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-29 | 2019-12-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-10-29 | 2019-12-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-29 | 2019-12-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-29 | 2019-12-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-29 | 2019-12-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-10-29 | 2019-12-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-29 | 2019-12-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-29 | 2019-12-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-29 | 2019-12-03 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-10-29 | 2019-12-03 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2018-08-10 | 2018-09-13 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2018-08-10 | 2018-09-13 | 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 | 2018-08-10 | 2018-09-13 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-08-10 | 2018-09-13 | N |
| Respond appropriately to all alleged violations. | Health | 2018-08-10 | 2018-09-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-08-10 | 2018-09-13 | N |
| Assess the resident when there is a significant change in condition | Health | 2018-08-10 | 2018-09-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-08-10 | 2018-09-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-08-10 | 2018-09-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-10 | 2018-09-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-08-10 | 2018-09-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-08-10 | 2018-09-13 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-08-10 | 2018-09-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-10 | 2018-09-13 | 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 | 2018-08-10 | 2018-09-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-10 | 2018-09-13 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-08-10 | 2018-09-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-08-10 | 2018-09-13 | 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 | 2018-08-10 | 2018-09-13 | 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 | 2018-08-10 | 2018-09-13 | N |
| Provide or obtain dental services for each resident. | Health | 2018-08-10 | 2018-09-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-08-10 | 2018-09-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-08-10 | 2018-09-13 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-08-06 | 2018-09-10 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-08-06 | 2018-09-10 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-08-06 | 2018-09-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-08-06 | 2018-09-10 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-08-06 | 2018-09-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-08-06 | 2018-09-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-08-06 | 2018-09-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-06 | 2018-09-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-08-06 | 2018-09-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-08-06 | 2018-09-10 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-08-06 | 2018-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-06 | 2018-08-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-06 | 2018-08-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-06 | 2018-08-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-08-06 | 2018-08-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-08-06 | 2018-08-09 | N |
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