Deficiency Records for Fernwood Supportive Living at Madrona Grove
Updated as of March 01, 2024
A list of the most recent deficiencies for Fernwood Supportive Living at Madrona Grove. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-06-09 | 2023-07-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-09 | 2023-07-29 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-13 | 2023-03-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-13 | 2023-03-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-13 | 2023-03-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-13 | 2023-03-07 | Y |
| 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. | Health | 2023-02-13 | 2023-03-07 | Y |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2023-02-13 | 2023-03-07 | Y |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-02-13 | 2023-03-07 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-13 | 2023-03-07 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-08 | 2023-03-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-08-20 | 2018-08-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-08-20 | 2018-08-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-08-20 | 2018-08-31 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-08-20 | 2018-08-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-20 | 2018-08-31 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-08-16 | 2018-08-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-08-16 | 2018-08-31 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-08-16 | 2018-08-31 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-08-16 | 2018-08-31 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-08-16 | 2018-08-31 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-08-16 | 2018-08-31 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-08-16 | 2018-08-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-08-16 | 2018-08-31 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-08-16 | 2018-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-16 | 2018-08-31 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-09-21 | 2017-09-25 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-09-21 | 2017-09-25 | N |
