Alderwood Post Acute: Sexual Assault Injury Unreported - WA
Staff at Alderwood Post Acute & Rehabilitation found the injury on August 23 around a resident's left labia, according to a nursing progress note reviewed by state inspectors. The facility's former director of nursing said the injury "absolutely should have been reported and investigated," particularly given the resident's recent sexual assault allegation made on August 18.
Nobody reported it.
The resident, identified only as Resident 1 in inspection records, was admitted to the facility with sepsis, anxiety disorder, depression, and paralysis affecting her left side. A June assessment indicated she had moderate cognitive impairment and required substantial to maximum assistance from staff with toileting.
The nursing progress note documenting the genital injury was written at 10:35 PM on August 23. State inspectors found no further documentation about the injury in subsequent progress notes.
Staff B, the former director of nursing, told inspectors in a phone interview on August 26 that their last day working at the facility was August 21 — two days before the injury was documented. They said they were unaware staff had found the skin tear on the resident's labia.
"This absolutely should have been reported and investigated, especially considering the residents recent allegation of sexual assault made on 08/18/2025," Staff B told inspectors.
The current nurse manager, Staff D, a licensed practical nurse, told inspectors on September 3 that they were notified on August 23 about the skin tear but had never actually seen the injury themselves.
Staff D acknowledged the location of the injury was concerning, particularly combined with the resident's recent sexual assault allegation. "This should have been reported and investigated," Staff D told inspectors, "but they had not reported or investigated this."
The facility's administrator, Staff A, told inspectors on September 3 at 2:00 PM that this was the first time they were reading the progress note documenting the genital injury. The administrator agreed it should have been reported and investigated but provided no further information.
When inspectors asked for documentation of any investigation into the allegation, the administrator was unable to provide one. The facility had not reported the injury to the state survey agency, as required by federal regulations.
Federal nursing home regulations require facilities to immediately report suspected abuse, neglect, or theft to the administrator and other officials, including the state survey agency. Facilities must also report the results of their investigation to proper authorities.
The failure to report injuries of unknown origin in vulnerable areas places residents at risk of undiscovered and continued abuse, according to the inspection report.
Resident 1's case highlights the particular vulnerability of nursing home residents with cognitive impairment and physical disabilities. Her moderate cognitive impairment combined with her need for maximum assistance with toileting created a situation where she depended entirely on staff for basic care and protection.
The timing sequence reveals a troubling pattern. The resident made a sexual assault allegation on August 18. Five days later, staff documented a skin tear around her genitals. The director of nursing left the facility on August 21, between the allegation and the discovery of the injury.
Despite multiple staff members acknowledging the injury should have been reported and investigated, no one took action. The nurse manager who was notified about the injury on the day it was discovered admitted to inspectors they had done nothing. The administrator claimed ignorance of the documented injury until inspectors showed them the progress note.
The inspection was conducted as a complaint investigation on September 3, 2025. State inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
However, the facility's failure to follow mandatory reporting requirements meant that whatever caused the resident's genital injury went uninvestigated. The resident, already vulnerable due to her cognitive impairment and physical disabilities, remained in an environment where staff documented concerning injuries but took no protective action.
The inspection report references related violations under F-600 and F-610, suggesting additional deficiencies were found during the investigation. Washington state nursing home regulations require facilities to report and investigate allegations of abuse, particularly when they involve residents in vulnerable populations.
For Resident 1, the failure meant that an injury in an intimate area discovered days after she reported sexual assault received no investigation, no follow-up documentation, and no report to authorities responsible for resident protection. The resident remained in the facility with the injury documented but unexplained, and with staff who acknowledged their obligations but failed to act on them.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alderwood Post Acute & Rehabilitation from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ALDERWOOD POST ACUTE & REHABILITATION in LYNNWOOD, WA was cited for violations during a health inspection on September 3, 2025.
A June assessment indicated she had moderate cognitive impairment and required substantial to maximum assistance from staff with toileting.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.