Alderwood Post Acute & Rehabilitation

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

completed the form himself on 08/18/2025 so that the employee could get paid for their time off while suspended. Staff E's statement was included in the investigation and dated 08/22/2025, four days after the report of the allegation.Review of Staff E's timecard dated 08/18/2025 documented that they worked a full shift from 10:10 PM to 6:20 AM on 08/19/2025, when they should have been suspended. Staff A stated that

the prior DNS should have suspended the staff member but did not.Review of a nursing progress note dated 08/23/2025 at 10:35 PM, documented patient having a new skin tear around her left labia. Further

review of progress notes showed no further documentation regarding this injury of unknown origin. There was no documentation that a thorough skin check had been completed at the time of this discovery. Review of Resident 1's Treatment Administration Record (TAR) showed that treatment was initiated for the skin tear to the resident's labia on 08/23/2025. Further review showed that male staff documented this treatment as being completed by them on 08/23/2025, 08/25/2025, 08/26/2025 and 08/27/2025, when the Resident was care planned for female care only. In an interview on 09/03/2025 at 12:30 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager stated that they were notified on 08/23/2025 that Resident 1 was found to have a skin tear on their labia, I haven't actually seen this skin tear myself. Staff D stated that this resident has a lot of skin issues in other places, so they felt it was because they have really fragile skin. Staff D stated that due to the fact this skin issue was in a concerning place and the resident's recent allegation of sexual assault this concern should have been reported and investigated but they had not reported or investigated this. Staff D stated that the interventions placed following the initial allegation of sexual assault include female care only and care in pairs. Staff D stated that meant that male staff should not go into Resident 1's room even to answer a call light. When asked about the treatments signed for as being completed by male staff, Staff D was unable to provide further information. In an interview/record review on 09/03/2025 at 1:40 PM, Staff A stated that the prior DNS was the person responsible for investigating the initial report of sexual assault by Resident 1 on 08/18/2025. Staff A stated that part of the investigation process would include suspending the alleged staff member pending investigation as applicable, assessing

the resident for injuries, document the findings, place the resident on alert to monitor for psychosocial effects, and obtain statements from staff that worked with the resident in the past 48 hours prior to allegation. Staff reviewed the progress note dated 08/23/2025 that showed the resident was found with a skin tear to their labia and stated that it was the first time they had heard of this and that this should have been reported to the state and investigated. Refer F-F609 and F610Reference WAC 388-97-0640 (1)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Alderwood Post Acute & Rehabilitation

3701 188th Street Southwest Lynnwood, WA 98037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to report to the state survey agency allegations of injury of unknown origin in a vulnerable area for 1 of 1 sampled resident (Resident 1) reviewed for abuse. This failure placed residents at risk of undiscovered and potential, continued abuse.Findings include .Resident 1 was admitted to the facility on [DATE REDACTED] with diagnoses to include sepsis (infection in the blood), anxiety disorder, depression, hemiplegia (paralysis to one side of the body) and hemiparesis (a condition that causes weakness or partial paralysis on one side of the body) affecting their left side. According to the admission Minimum Data Set (MDS-an assessment tool) assessment, dated 06/05/2025, indicated the resident had moderate cognitive impairment and required substantial to maximum assistance from staff with toileting.

Review of a nursing progress note dated 08/23/2025 at 10:35 PM, documented patient having a new skin tear around her left labia. Further review of progress notes showed no further documentation regarding this injury of unknown origin. In a phone interview on 08/26/2025 at 1:35 PM Staff B, Former Director of Nursing (DNS) stated that there last day working at the facility was 08/21/2025, they were unaware staff had documented that Resident 1 had a skin tear to their labia and stated this absolutely should have been reported and investigated, especially considering the residents recent allegation of sexual assault made on 08/18/2025. In a interview on 09/03/2025 at 12:30 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager stated that they were notified on 08/23/2025 that Resident 1 was found to have a skin tear on their labia, I haven't actually seen this skin tear myself. Staff D stated that due to the fact that this skin issue was

in a concerning place and the resident's recent allegation of sexual assault, this should have been reported and investigated but they had not reported or investigated this. On 09/03/2025 at 2:00 PM, Staff A, Administrator, stated this was the first they were reading this progress note and stated that it should have been reported and investigated. No further information was provided. Staff A was unable to provide an investigation for this allegation, and the allegation was not reported to the state survey agency. Refer to F-600 and F610Reference WAC 388-97-0180-0640 (6)(c)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Alderwood Post Acute & Rehabilitation

3701 188th Street Southwest Lynnwood, WA 98037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

showed no documentation that the resident was placed on alert monitoring to assess for psychosocial harm, and that the resident's power of attorney or physician had been notified of the allegation reported on 08/18/2025.Review of Resident 1's skin assessment documentation for 08/18/2025 showed no thorough skin check had been completed following the resident's reported allegation of sexual assault. Review of a nursing progress note dated 08/23/2025 at 10:35 PM, documented patient having a new skin tear around her left labia. Further review of progress notes showed no further documentation regarding this injury of unknown origin. There was no documentation that a thorough skin check had been completed. In an

interview on 08/26/2025 at 4:08 PM, Staff E stated that they were unaware of the allegation made by Resident 1 on 08/18/2025. Staff E stated that they worked the night shift on 08/18/2025 and were told by Staff A to just not work with Resident 1, so they didn't. Staff E stated no one told them that they were suspended, no one asked for a statement from them regarding the allegation. Staff E stated the following three days 08/19/2025, 08/20/2025 and 08/21/2025 were their normal scheduled days off and they returned to work on 08/22/2025, and that was when Staff A gave them a copy of the suspension pending investigation form. Staff E stated that it was their first time seeing that form and was unsure why on the employee signature line had writing that said, over phone, when no one had talked to them regarding this form. In an interview on 09/03/2025 at 12:30 PM, Staff D, Licensed Practical Nurse (LPN)/Nurse Manager stated that they were notified on 08/23/2025 that Resident 1 was found to have a skin tear on their labia, I haven't actually seen this skin tear myself. Staff D stated that this resident has a lot of skin issues in other places, so they felt it was because they had fragile skin. Staff D stated that due to the fact that this skin issue was in a concerning place and the resident's recent allegation of sexual assault, this concern should have been reported and investigated but they had not reported or investigated this.In an interview/record

review on 09/03/2025 at 1:40 PM, Staff A stated that the prior DNS was the person responsible for investigating the initial report of sexual assault by Resident 1 on 08/18/2025. Staff A stated that part of the investigation process would include suspending the alleged staff member pending investigation as applicable, assessing the resident for injuries, document the findings, place the resident on alert to monitor for psychosocial effects, and obtain statements from staff that worked with the resident in the past 48 hours prior to allegation. Staff A reviewed the progress note dated 08/23/2025, that showed the resident was found with a skin tear to their labia and stated that it was the first time they had heard of this and that this should have been reported to the state and investigated. Refer to F-F600 and F609Reference WAC 388-97-0640 (6)(a)(b)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/03/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Alderwood Post Acute & Rehabilitation

3701 188th Street Southwest Lynnwood, WA 98037

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on interview and record review, the facility failed to designate and ensure a full-time Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis. This failure could negatively impact the care and services to the residents that could result in potential harm and unmet care needs.

Findings included .On 08/25/2025 at 11:35 AM, upon entry into the facility, approached the front desk. Staff C, Receptionist greeted this investigator. Staff C stated that the Administrator had just stepped out of the facility, so they were asked to get the DON. Staff C stated that there was not a current DON as of last week.

A review of the facility's list of Key personnel on 08/27/2025 documented that the facility currently did not have a full time DON.On 08/25/2025 at 1:20 PM, Staff A, Administrator stated the facility currently did not have a designated full-time RN to serve as the DON. Staff A stated that the previous DON, Staff B, was termed last week. Staff A stated that there was a corporate nurse covering the DON position as needed until the position is filled. In a follow-up interview on 09/03/2025 at 2:00 PM, Staff A confirmed again that there was not currently a full-time DON at the facility. Staff A stated that they had just interviewed and made

an offer to a potential new DON, but the corporate nurse was still covering, however they are not full-time.

Reference WAC 388- 97-1080(2)(a)

Event ID:

Facility ID:

If continuation sheet