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Deficiency Records for Fernwood Supportive Living at Madrona Grove

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.

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?
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2024-04-19 2024-06-08 N
Implement a program that monitors antibiotic use. Health 2024-04-19 2024-06-08 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-04-18 2024-06-08 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-04-18 2024-05-01 N
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

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