Fernwood Supportive Living at Madrona Grove

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Emergency Preparedness Deficiencies

Develop Emergency Preparedness policies and procedures.

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

Emergency Preparedness Deficiencies

Establish procedures for tracking staff and patients during an emergency.

Emergency Preparedness Deficiencies

Establish policies and procedures for sheltering.

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

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.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Nursing and Physician Services Deficiencies

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.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Administration Deficiencies

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.

Administration Deficiencies

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.