Fernwood Supportive Living at Madrona Grove

In the surveyor’s words

From the most serious findings on record at Fernwood Supportive Living at Madrona Grove, in the surveyor’s own words.

• Immediate jeopardy, patternF867Feb 13, 2023

  Based on interview and record review it was determined the facility failed to have an effective QAPI program which reviewed incidents of physical and sexual abuse for tracking and corrective action. This failure was determined to be an immediate jeopardy situation and continued to place residents at risk for abuse and resulted in two incidents of sexual abuse by Resident 67 against Resident 68. Findings include: The facility's Freedom from Abuse, Neglect and Exploitation revised 2/21 revealed the following: Any Alleged or identified abuse, neglect, exploitation, mistreatment, including injuries or unknown source and misappropriation of resident property is reported, tracked, monitored for trends, patterns, etc. […]

• Immediate jeopardy, isolatedF600Feb 13, 2023

  Based on interview and record review it was determined the facility failed to ensure residents were free from physical or sexual abuse for 4 of 5 sampled residents (#s 8, 68, 118 and 119) reviewed for abuse. This failure was determined to be an immediate jeopardy situation. This failure resulted in Resident 68 being sexually abused by Resident 67 and placed residents at risk for physical and sexual abuse. Findings include: The facility's Freedom from Abuse, Neglect and Exploitation Policy and Procedure revised 2/21 revealed Each resident has the right to be free from abuse, neglect, and exploitation. […]

• No harm, potential for more than minimal, widespreadF868Jun 4, 2026

  Based on interview and record review it was determined the facility failed to have the Infection Preventionist attend the quality assessment and assurance (QAA) committee meetings for 3 of 3 months reviewed for QAA. This placed residents at risk for unidentified and unmet needs. Findings include: Documentation of QAA/QAPI meeting minutes were requested from 3/2026 through 5/2026 which revealed a qualified Infection Preventionist did not attend any of the QAA/QAPI meetings.On 6/4/26 at 3:32 PM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged a qualified Infection Preventionist did not attend the QAA/QAPI meetings.

• No harm, potential for more than minimal, widespreadF882Jun 4, 2026

  Based on interview and record review it was determined the facility failed to have a qualified and trained Infection Preventionist in place for 1 of 1 facility reviewed for infection prevention and control. This placed residents at risk for inadequate infection control. Findings include: A Staff List provided on 6/1/26 did not identify an Infection Preventionist.On 6/2/26 at 9:30 AM, Staff 1 (Administrator) stated Staff 12 (RNCM) was the facility's designated Infection Preventionist.Staff 12 was out of the facility and unable to be interviewed.A review of documents provided by Staff 1 (Administrator) revealed Staff 12 completed 11 of 24 modules of training from CDC Train's program and no indication the modules were completed and no evidence of a completed certification.Additional… […]

• No harm, potential for more than minimal, widespreadF880Aug 7, 2025

  Based on interview and record review it was determined the facility failed to ensure to review the infection control policies annually and failed to transport clean laundry in a manner to prevent cross contamination for 1 of 1 facility. This placed residents at risk for ineffective infection control program and cross contamination of laundry. Findings include: 1. Review of the facility Policy and Procedure Manual revealed:-Influenza and Pneumococcal Immunizations policy was last reviewed on 1/2020. Information in the policy did not include the latest CDC guidelines on pneumococcal vaccines (Pneumococcal conjugate vaccines 15, 20, and 21). […]