Fernwood Supportive Living at Madrona Grove
13505 Se River Road · Portland, OR · 97222 · 5036543171
16 certified beds Non profit - Corporation Part of a CCRC
Why this verdict
- Inspection results are getting worse cycle over cycle, not better.
- No federal fines or payment denials in CMS’s 3-year window.
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Red flags
2 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 4 of 5 Inspections: 3 of 5 Staffing: not rated Quality measures: 5 of 5
| Total nurse hours / resident-day | — | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | — | 0.55–0.75 |
| Weekend hours / resident-day | — | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | none |
Inspection citations (24 in the current record)
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Potential for harm · E August 7, 2025
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.
Corrected September 22, 2025 · Resident Rights
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Potential for harm · E August 7, 2025
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.
Corrected September 22, 2025 · Resident Rights
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Potential for harm · D August 7, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected September 22, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 7, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected September 22, 2025 · Quality of Life and Care
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Potential for harm · D August 7, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 22, 2025 · Quality of Life and Care
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Potential for harm · D August 7, 2025
Provide care or services that was trauma informed and/or culturally competent.
Corrected September 22, 2025 · Quality of Life and Care
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Potential for harm · D August 7, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected September 22, 2025 · Pharmacy Service
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Potential for harm · F August 7, 2025
Provide and implement an infection prevention and control program.
Corrected September 22, 2025 · Infection Control
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Potential for harm · D August 7, 2025
Implement a program that monitors antibiotic use.
Corrected September 22, 2025 · Infection Control
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Potential for harm · D August 7, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected September 22, 2025 · Infection Control
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Potential for harm · E August 7, 2025
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.
Corrected September 22, 2025 · Infection Control
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Potential for harm · D August 6, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected May 6, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 19, 2024
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.
Corrected June 8, 2024 · Resident Rights
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Potential for harm · D April 19, 2024
Implement a program that monitors antibiotic use.
Corrected June 8, 2024 · Infection Control
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Potential for harm · D June 9, 2023 · found via complaint
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected July 29, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 9, 2023 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected July 29, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · J February 13, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected March 7, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · K February 13, 2023
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected March 7, 2023 · Administration
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Potential for harm · D February 13, 2023
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected March 7, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 13, 2023
Respond appropriately to all alleged violations.
Corrected March 7, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 13, 2023
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.
Corrected March 7, 2023 · Nursing and Physician Services
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Potential for harm · D February 13, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 7, 2023 · Nutrition and Dietary
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Potential for harm · D February 13, 2023
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.
Corrected March 7, 2023 · Administration
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Potential for harm · D February 13, 2023
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected March 7, 2023 · Administration
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 38A031 · certified since December 31, 2012. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.