Alderwood Post Acute & Rehabilitation
Alderwood Post Acute & Rehabilitation in LYNNWOOD, WA — inspection on September 3, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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 F610
Reference WAC 388-97-0640 (1)
505319 09/03/2025
Alderwood Post Acute & Rehabilitation 3701 188th Street Southwest Lynnwood, WA 98037
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 F610
Reference WAC 388-97-0180-0640 (6)(c)
505319 09/03/2025
Alderwood Post Acute & Rehabilitation 3701 188th Street Southwest Lynnwood, WA 98037
Review of a nursing progress note dated
There was no documentation that a thorough skin check had been completed. In an interview on
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 F609
Reference WAC 388-97-0640 (6)(a)(b)
505319 09/03/2025
Alderwood Post Acute & Rehabilitation 3701 188th Street Southwest Lynnwood, WA 98037
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)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.