Fernwood Supportive Living At Madrona Grove

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Staffing

How full it usually is: this home is certified for 16 beds and averages 15.4 residents a day — about 96% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.29 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.87 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 5.59 hrs/resident/day on weekends vs 6.57 on weekdays — 15% thinner on weekends. RN hours go from 1.95 to 1.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.

• Potential for harm · F2026-06-04 · tag F0868 — widespread
  Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
  What the surveyor found here — the official record, unedited, may be distressing

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-06-04 · tag F0882 — widespread
  Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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 information regarding completion of the training and certification was requested from Staff 1 (Administrator) and no additional information was provided.On 6/4/26 at 12:43 PM, Staff 1 confirmed there was no documentation verifying Staff 12 completed the appropriate certification to serve as the designated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-04 · tag F0578 — failed to honor advance directives / code status — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review it was determined the facility failed to have a process in place to ensure resident rights to execute an advance directive, obtain copies for the medical record and periodically follow up on preferences for 2 of 3 sampled residents (#s 1 and 14) reviewed for advance directives. Findings include: The facility's advance care planning and end of life policy and procedure manual dated 12/2025 included the following: - The Licensed Social Worker will determine or review the POLST and advance directive choices of each resident on admission, quarterly, and with each change of status.- If resident chooses not to execute an advance directive, the Licensed Social Worker will document accordingly.1. Resident 1 was admitted to facility in 1/2024 with a diagnosis of alcohol dependence. Resident 1's 1/30/26 Annual MDS revealed the resident was cognitively intact.A review of Resident 1's progress notes revealed advance directives were discussed on 5/29/24, 8/22/24, and 9/4/24 with Resident 1 and she/he declined each time.On 6/2/26 at 2:38 PM, Resident 1 stated…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-04 · tag F0756 — failed to review each resident's drug regimen — isolated
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review it was determined the facility failed to act upon and implement pharmacy recommendations for 1 of 5 sampled residents (#12) reviewed for medications. This placed residents at risk for unnecessary medications. Findings include: The facility's 11/2025 Pharmacy Recommendations and Medication Regimen Review Policy & Procedure Manual specified pharmacy recommendations are reviewed within five business days, follow up actions and implementation dates should be documented, and the MAR should be updated. Resident 12 was admitted to the facility in 5/2023 with diagnoses including dementia with behavioral disturbances. Resident 12's 3/2026 Physician Orders included diclofenac arthritis pain external gel 1% (pain relief gel) topical, apply to knees topically in the morning for pain. Resident 12's 3/17/26 Pharmacist's Recommendation to Prescriber specified to update the 3/2026 diclofenac order to include the missing dosage in grams as follows: diclofenac arthritis pain external gel 1%, apply 4 grams to knees topically in the morning for pain. There was no…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-06-04 · tag F0880 — failed to prevent and control infections — isolated
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview it was determined the facility failed to ensure staff wore Personal Protective Equipment for 1 of 1 sampled residents (#2) reviewed for Transmission Based Precautions. This placed resident at risk for infections. Findings include: Resident 2 was admitted to facility in 12/2024 with a diagnosis of parkinsonism (an umbrella term for a group of conditions that cause movement problems, such as tremors, slowness, stiffness, and balance issues).Resident 14's 3/5/26 Quarterly MDS revealed the resident was cognitively intact.On 6/1/26 at 10:46 AM, Resident 2's door was observed to have a contact precaution sign with a storage container of PPE outside the door. The signage did not include information regarding what to put on before entering the room and where to doff PPE prior to exiting the room. Instructions on the sequence of donning and doffing PPE were inside of the drawer of the PPE bin. On 6/1/26 at 10:46 AM, Staff 10 (LPN) stated Resident 2 was on contact precautions due to vomiting, loose stools and stomach cramps and everyone was required to don…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-08-07 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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). -Antibiotic Stewardship policy was last reviewed on 5/2024.-Infection Prevention and Control Program policy was last reviewed on 10/2023. On 8/5/25 at 9:34 AM Staff 2 (DNS) stated the infection control policies were not reviewed yearly and Staff 10 (Assistant Director of Health Services) might have additional information. On 8/7/25 at 10:51 AM Staff 10 stated the DNS was to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-07 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation interview and record review it was determined the facility failed to maintain a homelike environment for 1 of 1 facility and 4 of 4 sampled residents (#s 1, 3, 7, and 8) reviewed for environment. This placed residents at risk for an unhomelike environment. Findings include:1. On 8/6/25 at 8:11 AM the following observations were made of the facility handrails: -Near the corner where two rails meet by room [ROOM NUMBER] there was missing wood creating a rough area which was approximately one inch by one half inch.-Near the corner where two handrails meet across from room [ROOM NUMBER] there was missing wood creating a rough area which was approximately one inch by one half inch.-Across the hall from room [ROOM NUMBER] there was a deep one inch by one half inch gouge. -By room [ROOM NUMBER] there was missing wood creating a rough area which was approximately one inch by one half inch.-By room [ROOM NUMBER] near the corner where two handrails meet there was missing wood creating a rough area…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-07 · tag F0585 — failed to handle grievances — pattern
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview and record review it was determined the facility failed to ensure a system was in place to resolve resident grievances including a lack of an identified Grievance Official and a lack of information available to residents on how to file a grievance for 1 of 1 facility reviewed for Resident Council. This placed residents at risk for unresolved grievances. Findings include:The facility's Resident Grievance Policy & Procedure, dated 1/2024, included the following:-A resident and/or her/his legal representative may voice a grievance to any staff in person, by telephone, email, or in writing.-Complete details of the grievance are documented so the grievance can be resolved within thirty (30) calendar days.-All information related to the resident's grievance would be held in strict confidence and not be disclosed to staff or contract providers, except when appropriate to process the grievance.The policy did not specify how long the facility was required to retain grievance forms.On 8/6/25 at 3:15 PM Staff 2 (DNS) stated the facility did not have a process…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-07 · tag F0887 — pattern
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review it was determined the facility failed to maintain records of consent for covid vaccines for 5 of 5 sampled residents (#s 5, 6, 7, 12, and 15) reviewed for immunizations. This placed residents at risk for uniformed decisions. Findings include: 1. Resident 5 was admitted to the facility in 1/2023 with a diagnosis of a fracture. Resident 5's 8/2024 Quarterly MDS revealed she/he was cognitively intact. Resident 5's 9/30/24 Covid -19 vaccination form revealed no education was provided prior to administration.On 8/6/25 at 5:05 PM Resident 5 stated she/he did not recall if staff provided education regarding the risk and benefits of the vaccine prior to administration. Resident 5 stated she/he wanted the vaccine and just remembered staff came around, she/he said yep, and did not remember signing any documents. On 8/5/25 at 10:51 AM Staff 2 (DNS) stated a local pharmacy had come to the facility to administer the flu vaccines. Staff 2 also stated the facility did not make any copies of the paperwork for the residents' clinical records, and the pharmacy was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-07 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review it was determined the facility failed to ensure psychotropic medications were not increased without indication and failed to perform a GDR (gradual dose reduction) for 1 of 5 sampled residents (#10) reviewed for unnecessary medications. This placed residents at risk for sedation. Findings include:Resident 10 was admitted to the facility in 3/2023 with a diagnosis Lewy body dementia (progressive decline in cognition with symptoms including hallucinations which can occur throughout the disease's progression.)Resident 10's 4/11/25 Annual MDS revealed she/he had Lewy body dementia with significant cognitive impairment, experienced hallucinations, and was administered antipsychotic and antidepressant medications. a. Resident 10's 5/2025 MAR revealed she/he was administered Seroquel (antipsychotic) 50 mg in the morning, 100 mg midday and 150 mg at bedtime. Progress Notes Revealed the following:-5/20/25 An order was received to discontinue Resident 10's AM dose of Seroquel. -5/21/25 and 5/22/23 Resident 10 did not exhibit behaviors.-5/23/25 Resident 10…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in OR