Fernwood Supportive Living at Madrona Grove
13505 Se River Road, Portland, OR 97222 · Clackamas County · (503) 654-3171
16 certified beds, about 15 residents a day · Non profit - Corporation · Medicaid since 2012
CMS Care Compare ratings, data as of September 1, 2026 · CCN 38A031 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on June 4, 2026, inspectors cited 5 health deficiencies (the Oregon average is 9.2, the national average 9.2).
None of its 19 health citations since April 2024 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 6.29 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 1.76 of those hours.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 19 health citations on file.
June 4, 2026Standard inspection · 5 citations
- F Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Inspectors wroteBased 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.
- F Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased 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.
- D 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.
Inspectors wroteBased 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.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased 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.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased 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.
August 7, 2025Standard inspection · 11 citations
- F Provide and implement an infection prevention and control program.
Inspectors wroteBased 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.
- E 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.
Inspectors wroteBased 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.
- E 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.
Inspectors wroteBased 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.
- E 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.
Inspectors wroteBased 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.
- D Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased 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.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to monitor a resident for a change of condition for 1 of 1 sampled resident (#13) reviewed for change of condition. This placed residents at risk for delayed care.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure residents were free from accidents for 2 of 5 sampled residents reviewed for accidents (#s 7 and 14). This placed residents at risk for adverse medication reactions.
- D Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents received trauma informed care for 1 of 1 sampled resident (#5) reviewed for behavioral-emotional care and abuse. This placed residents at risk for re-traumatization.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a pharmacy recommendation was acted upon timely for 1 of 5 sampled residents (#10) reviewed for unnecessary medications. This placed residents at risk for inaccurate diagnoses.
- D Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review it was determined the facility failed follow antibiotic stewardship for 1 of 1 sampled resident (#13) reviewed for antibiotics. This placed residents at risk for drug resistant organisms.
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review it was determined the facility failed to maintain records of consent for vaccinations for 2 of 5 sampled residents (#s 5 and 7). This placed residents at risk for uninformed decisions.
August 6, 2024Complaint inspection · 1 citation
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to protect the resident's right to be free from verbal abuse from a staff member for 1 of 1 sampled resident (#1) reviewed for abuse. This placed residents at risk for abuse.
April 19, 2024Standard inspection · 2 citations
- D 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure current copies of residents' advance directives were obtained and accessible in the health record for 1 of 7 sampled residents (#16) reviewed for medications and advance directives. This placed residents at risk for receiving medical treatments and life sustaining interventions against their wishes.
- D Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review it was determined the facility failed to implement antibiotic stewardship practices for 1 of 5 sampled residents (#16) reviewed for medications. This placed residents at risk for adverse medication effects, inappropriate antibiotic use and potential for development of antibiotic resistance.
Fire safety inspections
13 fire safety citations on file: 5 on June 4, 2026, 6 on August 7, 2025, 2 on April 19, 2024.
Every fire safety citation13 citations
- F Establish an Emergency Preparedness Program (EP).
- F Conduct risk assessment and an All-Hazards approach.
- F Develop Emergency Preparedness policies and procedures.
- F Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- F Have proper medical gas storage and administration areas.
- F Develop Emergency Preparedness policies and procedures.
- F Address subsistence needs for staff and patients.
- F Establish procedures for tracking staff and patients during an emergency.
- F Establish policies and procedures for sheltering.
- F Implement emergency and standby power systems.
- D Meet requirements for the installation and maintenance of electrical systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have generator or other power source capable of supplying service within 10 seconds.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 6.29 | 5.03 | 3.86 |
| Registered nurses | 1.76 | 0.72 | 0.69 |
| All nursing staff on weekends | 5.59 | 4.51 | 3.42 |
| Nurse aides | 3.87 | ||
| Licensed practical nurses | 0.66 | ||
| Nursing staff turnover (share who left in a year) | not reported | 47.4% | 45.8% |
| Registered nurse turnover | not reported | 51.6% | 42.9% |
| Administrators who left | not reported |
CMS expects 2.83 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 6.57 on weekdays and 5.59 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 1.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.78 in April to June 2025 to 6.29 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 6.29 | 1.76 | 6.57 | 5.59 | 1.0% | 0 of 90 | 15 |
| Apr to Jun 2025 | 5.78 | 1.77 | 6.34 | 4.39 | 0.3% | 0 of 91 | 16 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
Staff pay at this home
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
Official wage estimates for Oregon
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Oregon, all employers | |||
| CNAs (nursing assistants) | $23.96 | $22.83 to $28.40 | 14,800 |
| LPNs and LVNs | $38.69 | $35.11 to $43.60 | 4,260 |
| Registered nurses | $62.02 | $51.55 to $64.63 | 39,730 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 6.3 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.6 | 2.4 | 3.2 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 0.0 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 0.0 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 19.2 | 13.9 | 15.4 |
Short-term rehab results
For a stay to recover after a hospital visit, these are the results CMS publishes for Fernwood Supportive Living at Madrona Grove's Medicare short-stay residents. How to read these, and what Medicare pays for.
CMS reports none of these results for this home: This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Owners and operators
Legal business name: Legal Business Name Not Available.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ownership data not available |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 7 problems in this area, most recently on June 4, 2026: "Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 4 problems in this area, most recently on June 4, 2026: "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."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 3 problems in this area, most recently on August 7, 2025: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 2 problems in this area, most recently on June 4, 2026: "Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures."
Other nursing homes nearby
- Willamette View Health Center Milwaukie, 0.2 mi · 5 of 5 stars · 5 citations
- Stanley Post Acute Milwaukie, 2.5 mi · 3 of 5 stars · 32 citations
- The Pearl at Kruse Way Lake Oswego, 3.4 mi · 4 of 5 stars · 22 citations
- Avamere Rehabilitation of Clackamas Gladstone, 4.1 mi · 4 of 5 stars · 16 citations
- Avamere Crestview of Portland Portland, 4.6 mi · 4 of 5 stars · 57 citations
- The Creston Health & Rehabilitation Portland, 4.6 mi · 1 of 5 stars · 62 citations
- Reedwood Post Acute Portland, 4.9 mi · 5 of 5 stars · 11 citations
- Rose Linn Care Center West Linn, 5 mi · 3 of 5 stars · 14 citations
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is Fernwood Supportive Living at Madrona Grove's Medicare star rating?
- CMS rates Fernwood Supportive Living at Madrona Grove 4 out of 5 stars overall, with 3 for health inspections, 4 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Fernwood Supportive Living at Madrona Grove get at its last inspection?
- 5 health deficiencies at the standard inspection on June 4, 2026. The Oregon average is 9.2.
- Has Fernwood Supportive Living at Madrona Grove been fined?
- CMS lists no fines in the last three years.
- Does Fernwood Supportive Living at Madrona Grove accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Fernwood Supportive Living at Madrona Grove?
- CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.