Alderwood Post Acute: Care Plan Failures Across Residents - WA
That gap, confirmed by staff during a March 30 inspection, was one of several care planning failures inspectors documented at the 3701 188th Street Southwest facility. Across multiple residents, orders and precautions that existed in one part of the medical record had never been carried over into the care plans and Kardex guides that nursing assistants rely on when they show up for a shift.
The nursing assistant assigned to Resident 2, identified in inspection records only by that designation, pulled up the Kardex before starting work, as staff are expected to do. There was nothing in it about mobility. Staff H, a nursing assistant certified, confirmed to inspectors that the care instruction for getting the resident out of bed was absent. Staff I, a licensed practical nurse and unit manager, confirmed the same thing and acknowledged the care plan could be updated.
That conversation happened on March 30. The Kardex reviewed by inspectors was dated March 25. How long the gap existed before that is not documented in the inspection report.
The mobility instruction wasn't the only thing missing from Resident 2's record.
A progress note from March 10 documented that Resident 2 had been placed on contact precautions, a protocol used when a resident carries an infection or organism that can spread through direct touch or contaminated surfaces. Inspectors observed contact precaution signage posted outside the resident's door on both March 24 and March 30. The care plan, which had been initiated in January 2025, listed a requirement for Enhanced Barrier precautions. The Kardex, as of March 25, contained no mention of contact precautions at all.
Staff I confirmed during the March 30 interview that the care plan had not been updated to reflect the contact precaution status. Staff J, a licensed practical nurse who also serves as the facility's infection preventionist, said the care plan and Kardex should have been updated. Neither offered an explanation for why they hadn't been.
The infection preventionist's role at a nursing facility is specifically to monitor and coordinate the response to infections and transmission risks. The person holding that role confirmed, in an interview with inspectors, that a resident under active contact precautions had no corresponding entry in the document nursing assistants consult before touching that resident.
A third resident, identified as Resident 3, had been admitted to the facility and discharged on March 2, 2026. Before discharge, a pressure ulcer had developed. A physician order initiated February 19 required staff to reposition the resident every two hours to relieve pressure on the coccyx area. A progress note from February 23 documented the ulcer and noted repositioning as tolerated. A care plan initiated that same day identified moisture-associated skin damage at the coccyx as a focus area.
The repositioning order was not in the care plan.
Staff J confirmed this during the March 30 interview, stating there was an order for repositioning every two hours that had not been updated in the care plan or Kardex. The order existed in the medication and treatment administration record. It existed as a physician directive. It did not exist in the document that would have told a nursing assistant, arriving for a shift, that this resident needed to be turned every two hours to keep a wound from getting worse.
Resident 3 was discharged before inspectors arrived. Whether the repositioning happened consistently, and whether the pressure ulcer worsened during the stay, is not addressed in the inspection report.
In a joint interview at 4:10 PM on March 30, the facility's interim administrator, Staff A, and director of nursing, Staff B, told inspectors that the expectation was for the interdisciplinary team to update care plans in a timely way so that all residents' needs and physician orders were accurately reflected.
That is what the expectation was. The inspection documents what the record showed instead.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting some residents. Inspectors cited the finding under Washington state regulation WAC 388-97-1020.
For Resident 3, who had an open wound and a repositioning order that never reached the people doing the repositioning, the gap between what was ordered and what nursing assistants were told to do closed only when the resident left the building.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alderwood Post Acute & Rehabilitation from 2026-03-30 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 18, 2026 · Our methodology
ALDERWOOD POST ACUTE & REHABILITATION in LYNNWOOD, WA was cited for violations during a health inspection on March 30, 2026.
There was nothing in it about mobility.
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.