Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fernhill Rehabilitation And Care during CMS and state inspections, most recent first.
The facility did not provide written or verbal responses to concerns raised by resident council members during two meetings, despite policy requiring tracking and resolution of such issues. Concerns included care, staff performance, cleanliness, and food services. Staff and residents confirmed that concerns were documented and shared, but no feedback was given to the council.
A resident with depression and anxiety, who was cognitively intact, reported missing personal property and submitted multiple grievances. The facility did not document resolutions, obtain signatures, or notify the resident of investigation outcomes, as required by policy. Both the Social Services Director and Administrator confirmed the grievance process was not properly followed.
Surveyors found that kitchen food prep areas were not kept clean or sanitary, with hundreds of small bugs present on surfaces and in traps, missing and uncleanable caulking, and a persistent rancid odor under the food prep sink. Staff confirmed ongoing issues with bugs swarming, migrating to food prep areas, and biting staff, as well as a longstanding foul smell that had not been resolved.
A resident who was cognitively intact and used a power wheelchair was discharged from the facility, but staff failed to return the resident's wheelchair. Instead, the wheelchair was stored for several months and then disposed of without any attempt to deliver it back to the resident.
Surveyors found that the facility did not provide a homelike environment in two of three hallways reviewed. A resident's personal fan was observed with a thick layer of dust and grime, and the resident reported waiting for staff to clean it. Multiple rooms had walls with scrapes, holes, and uncleanable surfaces, as well as dust build-up, sticky furniture, and other cleanliness issues. Residents and staff confirmed the need for cleaning and repairs.
A resident with a history of stroke and significant dental issues, including missing upper teeth and broken tooth fragments, was observed to have difficulty chewing certain foods. Despite these findings, the resident's MDS assessments inaccurately documented no difficulty chewing and no dental problems. The DNS confirmed the assessments did not accurately reflect the resident's dental condition.
A resident with chronic kidney disease and dementia, identified as being at increased risk for falls, did not have their call light consistently within reach as required by their care plan. Multiple observations found the call light out of reach, and staff confirmed both the resident's fall history and the expectation to keep the call light accessible, but acknowledged this was not always done.
A resident with anxiety and depression, who was cognitively intact and had specific leisure interests, was not provided with meaningful or preferred activities. Despite documented preferences for outdoor time and music, the resident reported frequent boredom and had minimal participation in activities, with limited documentation of engagement. The care plan included activities not aligned with the resident's stated interests, and staff acknowledged challenges in meeting individual preferences and documenting participation.
A resident with a history of stroke and diabetes, who reported worsening vision, was referred by the facility optometrist to a retina specialist, but no appointment was scheduled and the resident was not seen by a specialist. Despite repeated requests to staff over several months, the resident did not receive the necessary vision care, and staff confirmed that no appointment had been arranged.
A resident with a history of stroke and diabetes, who was missing most of their teeth and required dental care, repeatedly requested assistance from the Social Service Director to schedule an outside dental appointment for tooth fragment removal and denture fitting. Despite these requests and staff awareness, no dental appointment was scheduled, and the resident's medical record showed no evidence of dental services being provided.
A resident with depression and scoliosis was physically abused by another resident with a history of stroke, who entered the resident's room, pushed them onto the bed, and held the door shut from the outside. The incident was confirmed by the facility administrator following the resident's report to staff and law enforcement.
A resident was physically pushed onto a bed by another resident, who then held the door shut to prevent exit. Although staff were aware of the incident, the administrator was not informed until several hours later, resulting in a late submission of the required abuse report to the state agency.
The facility did not ensure that daily nurse staffing postings were accurate and complete, with multiple days showing missing or incomplete information such as nurse and CNA hours, census data, dates, and required signatures. These deficiencies were confirmed by the staffing coordinator during a review.
A resident with a mental health diagnosis and history of exit-seeking behavior eloped from the facility after being left unsupervised at the front door when a CNA briefly left to notify a nurse. The resident, who was cognitively impaired and refused medications, was later found by police several blocks away. Staff interviews confirmed that 1:1 supervision was required but not maintained at the time of the incident.
A resident with diabetes and end stage renal disease, identified as a fall risk, was left unattended for an extended period after using the call light to request transfer assistance. Due to lack of staff response, the resident attempted to self-transfer from a bedside commode, resulting in a fall and a fractured femur. Staff interviews confirmed that the assigned CNA was absent from the unit, and other staff were either unaware or occupied with other duties, leading to inadequate supervision and delayed assistance.
A resident with a history of aggressive behavior and alcohol dependence physically assaulted another resident following a verbal altercation, despite existing behavioral care plans instructing staff to intervene. Staff and clinical documentation confirmed the aggressor had been drinking and that the altercation escalated to physical abuse, with no injuries reported.
A resident with atrial fibrillation did not receive prescribed apixaban for several days after returning from a hospital stay, due to the admitting nurse failing to input the medication order. The medication was marked as on hold in the MAR without explanation, and staff confirmed there was no physician order to hold the drug. The error was recognized as a significant medication error by facility staff.
A resident with severe cognitive impairment and a high risk of elopement was not provided with the necessary interventions outlined in their care plan. Despite being observed near the facility's entrance, staff failed to engage or redirect the resident as required, until the Activities Director intervened. The facility administrator was informed of these findings.
A resident with severe cognitive impairment and a history of elopement risk managed to leave the facility undetected and was found at a bus stop several blocks away. Staff interviews revealed inconsistencies in supervision and redirection strategies, and the facility's investigation lacked thoroughness, failing to address the root cause of the security lapse. No management staff were present post-incident, and key staff involved in the search were not interviewed.
Failure to Respond to Resident Council Concerns
Penalty
Summary
The facility failed to provide written or verbal responses to concerns raised by resident council members during two of four reviewed meetings. According to facility policy, a Resident Council Response Form should be used to track issues and their resolution, with the relevant department responsible for addressing concerns. However, review of meeting records from two specific dates showed that concerns such as lack of toenail care, staff performance, facility cleanliness, care conferences, snack accessibility, outdoor access, food temperature, fresh fruit availability, community outings, lost clothing, unanswered call lights, and staff responses to concerns were documented but not addressed. No evidence was found of any responses being provided to the resident council regarding these issues. Interviews with staff and residents confirmed that concerns were recorded and shared with appropriate departments, but no follow-up or feedback was given to the resident council. The Activities Director stated she forwarded concerns to the relevant departments but did not receive any responses. Residents reported submitting concerns in writing but not receiving any feedback. Department heads, including the DNS, Dietary Manager, and Housekeeping Manager, indicated they either did not receive the concerns or were not instructed to provide written responses. The Administrator confirmed that while concerns were discussed among staff, no direct communication was provided to the resident council for the meetings in question.
Failure to Communicate Grievance Resolutions to Resident
Penalty
Summary
The facility failed to provide a written grievance resolution or communicate the outcome of a grievance to a resident or the resident's representative regarding missing personal property. According to the facility's policy, grievances are to be documented and resolved within five working days, with outcomes communicated to the resident. Record review showed that a resident with diagnoses of depression and anxiety, who was cognitively intact, reported multiple missing items and stated that staff were aware of the concerns but did not inform the resident about any investigation or resolution. A review of the grievance binder revealed four grievances submitted by the resident, none of which included documented resolutions, signatures, or evidence that the resident was notified of the investigation results. The Social Services Director confirmed responsibility for grievance follow-up but acknowledged the forms were incomplete and could not provide evidence of resident notification. The Administrator also confirmed that the grievance process was not followed, and forms were not completed as required.
Failure to Maintain Sanitary Kitchen Conditions Due to Pest Infestation and Odor
Penalty
Summary
Surveyors observed that the facility failed to maintain the kitchen food preparation areas in a clean and sanitary condition. During multiple kitchen inspections, hundreds of small bugs with wings were seen on the windowsill above the food prep sink, in the food prep sink, and on the steel counter where food was prepared. Additionally, a bug trap on the windowsill contained hundreds of bugs, and bugs were observed flying near the clean food prep area and inside the sanitary cleaning bucket used for wiping down food prep surfaces. The caulking along the windowsill above the food prep sink was missing and uncleanable, and a rancid odor was noted coming from under the food prep sink. Staff interviews confirmed that the issue with the bugs had been ongoing, with the bugs swarming the window and windowsill, migrating to the food prep sink and counters, and even biting kitchen staff. Staff also confirmed that the rancid smell under the food prep sink had persisted for some time, despite attempts to identify and treat the source, and described the odor as resembling that of a dead animal. These conditions were directly observed and confirmed by staff, indicating a failure to control pests and maintain sanitary food preparation areas as required by professional standards and the FDA Food Code.
Failure to Return Resident's Power Wheelchair After Discharge
Penalty
Summary
A resident with congestive heart failure, who was cognitively intact as indicated by a BIMS score of 15, was admitted to the facility in March 2024 and utilized a personal power wheelchair. Upon transfer to a hospital and subsequent discharge to another facility in May 2024, no attempt was made by the facility to return the resident's power wheelchair. Interviews with the Social Service Director and Maintenance Director revealed that the wheelchair was stored in a shed for six months after the resident's discharge and was ultimately disposed of during a storage area cleanup in October 2024. The Administrator confirmed that the wheelchair, found to be non-operational, was not returned to the resident.
Failure to Maintain a Homelike and Clean Environment in Resident Rooms
Penalty
Summary
Surveyors identified that the facility failed to maintain a homelike environment in two of three hallways reviewed. In one instance, a resident with congestive heart failure and a BIMS score indicating cognitive intactness had a personal fan on the bedside table that was coated with a thick, visible accumulation of dust, lint, and grime on the blades and protective grill. The resident reported wanting the fan cleaned and had been waiting for staff to do so. The Housekeeping Supervisor confirmed that housekeepers were responsible for cleaning personal fans, and the Administrator acknowledged the fan needed cleaning and expected all personal fans to be clean. Additional observations between multiple dates revealed several resident rooms with environmental deficiencies, including walls with numerous scrapes, areas requiring painting, residual masking tape, missing and uncleanable wood on closet drawers, holes in walls, patched areas needing paint, and deep scrapes. Other issues included multiple screws and nails in walls, splashes and streaks of unknown substances, dust build-up on ceiling vents, sticky bedside tables, and malfunctioning table wheels. Residents in these rooms stated their rooms required cleaning and repairs and were not homelike. The Maintenance Director and Administrator both confirmed that the identified rooms required repairs, painting, and updating to meet homelike standards.
Inaccurate MDS Assessment of Dental Status
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments were completed for a resident with a history of stroke who was admitted in April 2020. Observations on two separate occasions revealed the resident had no upper teeth, missing lower molars, and experienced difficulty chewing certain food textures such as cucumbers and large pieces of lettuce. The resident reported missing upper teeth with three broken tooth fragments and missing teeth on both sides of the lower mouth, as well as difficulty chewing hard food items. However, the resident's quarterly and annual MDS assessments indicated no cognitive impairment, no difficulty chewing food, and no natural teeth or tooth fragments, with no obvious or likely broken natural teeth. The Director of Nursing Services confirmed that the MDS assessments were inaccurate and did not reflect the resident's actual dental status.
Failure to Ensure Call Light Accessibility for Resident at Risk for Falls
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with chronic kidney disease and dementia who was at increased risk for falls. Despite the care plan specifying that the resident's call light should be kept within reach and that the resident should be encouraged to use it for assistance, multiple observations on different occasions showed the call light was out of reach. Staff interviews confirmed that the resident had experienced recent falls and was capable of using the call light, and staff were expected to ensure the call light was accessible during every room entry. However, staff acknowledged that the call light was not always within the resident's reach, as required by the care plan.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
A resident with diagnoses of anxiety and major depression, assessed as cognitively intact, was admitted to the facility and identified specific leisure interests as very important, including going outside for fresh air and engaging in favorite activities. The resident's activity assessments indicated independence in leisure pursuits and enjoyment of music, outdoor activities, television, socializing, and helping others. Despite these documented preferences, observations over several days revealed the resident was not engaged in meaningful or preferred activities, except for attending one Bingo group. The resident reported frequent boredom and a lack of interest in the group calendar activities, with limited access to music in their room. Review of activity participation records showed minimal involvement in both group and individual activities. The care plan included religious activities, despite the resident indicating religion was not important, and there was a lack of documentation regarding activity participation. The Activity Director acknowledged the difficulty in planning activities to meet all residents' interests and confirmed the lack of documentation for this resident. The Administrator also recognized the need for improvement in providing personalized activities and ensuring documentation of resident participation.
Failure to Arrange Vision Services for Resident with Declining Vision
Penalty
Summary
The facility failed to obtain necessary vision services for a resident with a history of stroke and diabetes, who was experiencing a continual decline in vision. According to the facility's policy, staff are responsible for assisting residents in locating resources, scheduling appointments, and arranging transportation for vision care. Documentation showed that the facility optometrist referred the resident to a retina specialist, but there was no evidence in the electronic health record that an appointment was scheduled or that the resident was seen by the specialist. The resident's care plan also indicated that staff would arrange a consultation with an eye care practitioner as required, but this was not carried out. The resident reported repeatedly asking the Social Service Director over a four-month period to schedule an appointment with an eye doctor due to worsening vision, but no appointment was made. The resident was observed wearing non-prescription reading glasses and stated they did not have prescription glasses. Both the Social Service Director and the Director of Nursing confirmed that no appointment had been scheduled for the resident to see an eye doctor, despite being aware of the resident's requests and ongoing vision concerns.
Failure to Obtain Dental Services for Resident
Penalty
Summary
The facility failed to obtain necessary dental services for a resident who had been admitted with a history of stroke and diabetes. The resident's care plan indicated significant dental needs, including missing upper teeth and most lower teeth, with interventions specifying coordination of dental care and transportation. Despite these documented needs, there was no evidence in the resident's medical record that a dental appointment had been scheduled or completed. Observations confirmed the resident was missing upper teeth and had chipped and worn lower teeth. The resident reported repeatedly requesting assistance from the Social Service Director over a four-month period to schedule an appointment with an outside dental provider for removal of tooth fragments and remaining lower teeth, in order to be fitted for dentures. Both the Social Service Director and the LPN-Care Manager acknowledged awareness of the resident's requests but confirmed that no appointment had been scheduled. The Director of Nursing Services also confirmed that the dental appointment had not yet been arranged and stated that it should have been scheduled more promptly.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of depression and scoliosis was physically abused by another resident who had a history of stroke. According to the facility's investigation, the incident took place when the resident awoke early in the morning to find the other resident in their room. Upon attempting to stand, the resident was pushed back onto the bed by the other resident, who then held the door shut from the outside. The affected resident subsequently called the police and informed staff of the incident. The facility administrator confirmed that physical abuse had occurred during this event.
Failure to Timely Report Alleged Physical Abuse Incident
Penalty
Summary
The facility failed to report an allegation of physical abuse within the mandated timeframe for one resident. According to the facility's policy, staff are required to report allegations of abuse promptly. On the date in question, a resident entered another resident's room, pushed the resident onto the bed, and then held the door shut from the outside, preventing the resident from leaving. Staff were aware of the incident at 4:00 AM, but the administrator was not informed until approximately 9:30 AM during a morning meeting. The Facility Reported Incident (FRI) was subsequently submitted late to the state agency, as confirmed by the administrator. This delay in reporting did not comply with the facility's abuse prevention policy.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the Direct Care Staff Daily Report (DCSDR) postings for 15 out of 45 days reviewed. Specific issues identified included missing or incomplete licensed nurse staff hours, absence of CNA hours, missing census data, incorrect dates, and missing signatures on the DCSDRs. These deficiencies were confirmed during a review of the reports by the Human Resources/Staffing Coordinator, who verified the inaccuracies and incomplete information on the specified dates. This failure resulted in the posting of inaccurate staffing information, as evidenced by the review of records and staff interviews.
Resident Elopement Due to Lapse in 1:1 Supervision
Penalty
Summary
A resident with a long history of mental health issues and houselessness was admitted to the facility and assessed as being at risk for elopement. The resident's care plan included interventions such as regular monitoring, redirection, offering food and fluids, providing activities during wandering or exit-seeking episodes, and 1:1 supervision until exit-seeking behavior resolved. The resident was noted to be cognitively impaired, with poor decision-making skills, and was able to ambulate independently without an assistive device. The resident also refused medications, resulting in hallucinations and an inability to ask for assistance. On the night of the incident, the resident was observed by the front door, with a CNA assigned to monitor them. The CNA was not positioned closely due to the resident's preference for personal space. At some point, the CNA left the resident unattended for a brief period to notify the nurse that the resident was attempting to leave. During this time, the resident exited the facility without staff knowledge. Staff searched the facility and surrounding neighborhood but were unable to locate the resident, and the police were notified. The resident was later found by police several blocks away, sitting on a private residence's porch. Facility staff attempted to persuade the resident to return, but the resident refused and expressed a desire not to return. Interviews with staff confirmed that 1:1 supervision was expected when the resident exhibited exit-seeking behavior, and that the resident was left unsupervised at the door, which allowed the elopement to occur.
Failure to Provide Timely Transfer Assistance Results in Resident Fall and Fracture
Penalty
Summary
A resident with diabetes and end stage renal disease, identified as a fall risk due to medical conditions, lack of safety awareness, and poor impulse control, was not timely assisted with a transfer. The resident's care plan included interventions such as keeping the call light within reach and anticipating needs. On the evening of the incident, the resident used the call light and requested assistance from the night nurse, who was occupied with wound care. After waiting for approximately 45 minutes without staff response, the resident attempted to self-transfer from the bedside commode to the bed, resulting in a fall. Staff interviews revealed that the assigned CNA did not respond to the call light because he had left the facility to search for an eloped resident, and was unaware of the resident's need for assistance. Other staff members were either not aware of the situation or were engaged in other tasks. The resident was found on the floor after the fall, subsequently hospitalized, and diagnosed with a fractured femur. The facility's failure to provide timely assistance and adequate supervision directly contributed to the resident's accident and injury.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident, with a known history of aggressive behaviors and alcohol dependence, physically assaulted another resident. The aggressor had a behavioral care plan in place instructing staff to remove other residents or the aggressor from the area if aggressive or verbally inappropriate behaviors occurred. On the day of the incident, the aggressor had been drinking and engaged in a verbal altercation with another resident near the smoking area, which escalated to the aggressor punching the other resident in the face. Staff and clinical notes confirmed that the aggressor had been drinking and that the altercation resulted in a physical assault, though no injuries were noted. The resident who was assaulted had a behavioral care plan addressing high anxiety due to a history of homelessness and medical conditions, with staff directed to provide mental health support. Despite these care plans, staff did not prevent the altercation, and the resident was struck in the face after requesting the aggressor to pick up cigarette butts. Multiple staff interviews confirmed the sequence of events, the aggressor's history of aggressive behavior, and the failure to prevent the physical abuse.
Failure to Administer Anticoagulant Following Hospital Readmission
Penalty
Summary
A resident with a diagnosis of atrial fibrillation was admitted to the facility with physician orders to receive 5 mg of apixaban twice daily. Following a hospitalization for pneumonia, the resident was readmitted to the facility with discharge orders to continue apixaban. However, the medication was not administered from the date of readmission through several days afterward, as documented in the Medication Administration Record (MAR), which showed the medication was on hold without any nursing notes explaining the reason. The admitting nurse did not input the apixaban order upon the resident's return, and there was no physician order to hold the medication. The resident reported to a complainant that they had not received their blood thinner since returning from the hospital and expressed concern about being taken off the medication. Facility staff confirmed that the apixaban was not administered until several days after readmission, and the medication could have been accessed from the emergency medication kit if not available. The physician verified that the medication was not supposed to be held, and the error was acknowledged by facility staff as a serious medication error.
Failure to Implement Elopement Risk Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident identified as a high elopement risk. The resident, who was admitted in May 2024 with diagnoses of schizophrenia and dementia, had a BIMS score of 0, indicating severe cognitive impairment. An elopement risk evaluation conducted in August 2024 confirmed the resident's high risk of elopement, as they frequently stood by the entrance door expressing a desire to leave. The care plan, dated October 2024, included interventions such as distracting the resident with diversions, activities, food, conversation, television, or a book. However, during the survey, staff members were observed failing to implement these interventions, as the resident was seen seated by the front door without any staff attempting to distract or provide a diversion. Multiple staff members, including CNAs and a Physical Therapist, were present in the area but did not engage with the resident as per the care plan. The resident was observed writing in a notebook and watching staff enter and exit the facility, but no attempts were made to redirect or engage the resident until the Activities Director offered a drink, which the resident accepted. The facility administrator was informed of these findings, but no additional information was provided to address the lack of implementation of the care plan interventions.
Inadequate Supervision and Investigation of Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and thoroughly evaluate an elopement incident involving a resident with severe cognitive impairment. The resident, diagnosed with schizophrenia and dementia, was identified as a high elopement risk and had a history of attempting to leave the facility. Despite this, the resident managed to elope from the facility and was found at a bus stop several blocks away, indicating a lapse in supervision and security measures. Interviews with staff revealed inconsistencies in the understanding and implementation of interventions to prevent the resident from eloping. Some staff members were aware of the resident's exit-seeking behavior but were unable to effectively redirect the resident. The facility's investigation into the incident was inadequate, lacking detailed documentation, including who conducted the investigation, when it was initiated, and whether key staff members involved in the search were interviewed. The facility's investigation report did not address the root cause of the security failure that allowed the resident to leave undetected. Additionally, no management staff were present at the facility following the elopement, and the investigation did not include interviews with the CNA staff who found the resident. This lack of thorough investigation and analysis of the incident placed residents at risk for future unsafe elopements.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Porthaven Post Acute | 1.1 mi | ★★★★★ | 9 | 0 |
| Marquis Piedmont Post Acute Rehab | 1.7 mi | ★★★★★ | 13 | 0 |
| Holladay Park Plaza | 2.4 mi | ★★★★★ | 4 | 0 |
| Providence Child Center | 2.6 mi | ★★★★★ | 2 | 0 |
| Evergreen Post Acute | 3.1 mi | ★★★★★ | 3 | 0 |
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