Fernwood Supportive Living at Madrona Grove

Name: Fernwood Supportive Living at Madrona Grove
Address: 13505 SE RIVER ROAD, Portland, OR, 97222, US
Telephone: 5036543171

13505 SE River Road, Portland, OR 97222 · Clackamas County · 16 certified beds · avg 15 residents/day · certified since Dec 31, 2012

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

8.53

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (19)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jun 4, 2026	F · Potential for harm, facility-wide	The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months.
Jun 4, 2026	F · Potential for harm, facility-wide	The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program.
Jun 4, 2026	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Jun 4, 2026	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Jun 4, 2026	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Aug 7, 2025	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Aug 7, 2025	E · Potential for harm, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Aug 7, 2025	E · Potential for harm, repeated	The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Aug 7, 2025	E · Potential for harm, repeated	The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Aug 7, 2025	D · Potential for harm, one-off	The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
Aug 7, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Aug 7, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Aug 7, 2025	D · Potential for harm, one-off	The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from.
Aug 7, 2025	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Aug 7, 2025	D · Potential for harm, one-off	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Aug 7, 2025	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Aug 6, 2024	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Apr 19, 2024	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Apr 19, 2024	D · Potential for harm, one-off	The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (11 → 5).

Year	Citations	Worst severity that year
2024	3	D
2025	11	F
2026	5	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Oregon avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	8.53	5.42	3.95	top 2% in Oregon; top 1% in the U.S.
Registered Nurse hours	2.38	0.78	0.69	top 2% in Oregon; top 1% in the U.S.
Weekend total nurse staffing	7.58	4.85	3.50	top 2% in Oregon; top 1% in the U.S.
Weekend RN hours (not acuity-adjusted)	1.28	0.48	0.48	top 3% in Oregon; top 3% in the U.S.
Total nursing staff turnover (%)	0.0	47.4	45.8	—
RN turnover (%)	0.0	51.6	42.9	—

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 6.29, RN 1.76, weekend 5.59. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5

Who owns this facility

Non profit - Corporation

Owner / manager	Type	Role	Stake	Since
		Ownership Data Not Available

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How does your quality committee work, and can you share an example of a problem it identified and fixed?"
"Who is your infection preventionist, and what training do they have?"
"How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
"Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
"Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
"How do you handle COVID-19 vaccination for residents and staff, and what happens during an outbreak?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Willamette View Health Center	0.1 mi	Milwaukie, OR	★★★★★	5/5
Stanley Post Acute	2.5 mi	Milwaukie, OR	★★★☆☆	3/5
The Pearl at Kruse Way	3.4 mi	Lake Oswego, OR	★★★★☆	4/5
Avamere Rehabilitation of Clackamas	4.1 mi	Gladstone, OR	★★★★☆	3/5
Avamere Crestview of Portland	4.6 mi	Portland, OR	★★★★☆	3/5
The Creston Health & Rehabilitation	4.6 mi	Portland, OR	★☆☆☆☆	1/5
Reedwood Post Acute	4.9 mi	Portland, OR	★★★★★	5/5
Rose Linn Care Center	5.0 mi	West Linn, OR	★★★☆☆	4/5
Mirabella Portland	5.1 mi	Portland, OR	★★★★★	5/5
West Hills Health & Rehabilitation	5.2 mi	Portland, OR	★★★★☆	3/5
Avamere Rehabilitation of Oregon City	5.7 mi	Oregon City, OR	★★☆☆☆	2/5
Marquis Vermont Hills	5.8 mi	Portland, OR	★★★★★	5/5

Compare this facility with the 3 closest →

All facilities in Portland →

Facility data as of CMS processing date 2026-08-01. CCN 38A031.

The Care File

Visit checklist — Fernwood Supportive Living at Madrona Grove

13505 SE River Road, Portland, OR 97222 · 5036543171

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $0

Questions for the administrator:

☐ "How does your quality committee work, and can you share an example of a problem it identified and fixed?"
☐ "Who is your infection preventionist, and what training do they have?"
☐ "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
☐ "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
☐ "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
☐ "How do you handle COVID-19 vaccination for residents and staff, and what happens during an outbreak?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 38A031 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)