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Deficiency Records for Alderwood Post Acute and Rehabilitation

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.

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?
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-08-07 2024-08-28 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-06-07 2024-07-09 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-06-07 2024-07-09 Y
Install corridor and hallway doors that block smoke. Fire Safety 2023-12-07 2024-03-05 N
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
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
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

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