Alderwood Manor: Surgical Wound Monitoring Failures - WA
The inspection, completed September 12, 2025, followed a complaint. What inspectors found was not a single catastrophic failure but something more routine and in some ways more troubling: a facility where nobody had been watching.
The resident, identified only as Resident 1 in the inspection report, had undergone an initial surgery and then, at some point after, an amputation of their hand. The inspection report does not specify the original procedure or the exact timeline between surgery and amputation. What it does document is what happened, and what didn't happen, in between.
The Director of Nursing, identified as Staff C, told inspectors that when Resident 1 had their initial surgery and subsequent amputation, she was still being trained in that role. She said the facility did not use wound observation forms for surgical incisions. The surgeons, she explained, would be the ones to monitor and follow up. She acknowledged the policy had since changed.
That explanation, offered in a 1:50 p.m. interview on September 4, placed the responsibility for watching a surgical wound on doctors who were not present in the building, while the nurses who were present kept no formal records of what they saw.
Staff D, a registered nurse, told inspectors she had just started at the facility when Resident 1 had their hand surgery. She remembered being alerted to the wound when she came in for a shift but could not recall what the wound looked like. She said she did perform wound care and that if she had noticed anything abnormal, she would have documented it in the progress notes. Whether she did or did not find anything abnormal, she could not say.
Staff E, a licensed nurse, described doing wound care for the resident when it had not been completed on the day shift. She remembered that the resident was particular about dressing changes before surgeon follow-up visits, preferring to have the surgeon handle it rather than the floor nurses. Staff E said she did not recall the resident having a blister on their hand. She could not recall how the wound appeared.
The wound nurse, inspectors noted, was not available during the inspection. Staff F, another staff member, told inspectors they had not personally observed the resident's wound but knew the resident had developed an infection. Staff F said the protocol when there was a concern with a surgical wound was to contact the surgeon.
Taken together, the accounts form a picture of a wound that moved from surgery to infection to amputation while the nurses responsible for daily care kept no observation records, could not recall its appearance, and understood their role to be limited to alerting someone else if something seemed wrong.
The infection is not disputed in the report. What is absent is any documented evidence that the wound was being watched closely enough for staff to know when it crossed from healing to infected.
The Director of Nursing's acknowledgment that the facility's policy has since changed does not appear in the report as a formal corrective action plan. It is a statement made to an inspector, in an interview, after the amputation had already occurred.
Resident 1's preference to have the surgeon change their dressing before follow-up visits is the one detail in the report that belongs entirely to the resident, a person trying to maintain some control over what was happening to their own body. The nurses remembered that. They did not remember what the wound looked like.
The inspection cited the facility under Washington Administrative Code 388-97-1060(1) and tagged the deficiency as F0684, reflecting care that failed to meet professional standards. The level of harm was assessed as minimal harm or potential for actual harm, a regulatory classification that applies when the outcome has not been fully quantified. The resident's hand was gone before the inspector arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alderwood Manor from 2025-09-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
ALDERWOOD MANOR in SPOKANE, WA was cited for violations during a health inspection on September 12, 2025.
The inspection, completed September 12, 2025, followed a complaint.
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.