Portland, OR

Fernwood Supportive Living At Madrona Grove

3-star overall rating with 3-star inspections with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

13505 Se River Road, Portland, OR

(503) 654-3171

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2012-12-31

CMS approved date

Coverage

Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.00

Registered nurse staffing

LPN hours / resident day

0.00

Licensed practical nurse staffing

Aide hours / resident day

0.00

Nurse aide staffing

Total nurse hours

0.00

All reported nurse hours

Licensed hours

0.00

RN + LPN hours

Weekend hours

0.00

Weekend nurse staffing

Weekend RN hours

0.00

Weekend registered nurse coverage

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.00

CMS adjusted RN staffing hours

Adjusted total hours

0.00

CMS adjusted total nurse staffing hours

Case-mix index

0.00

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

Annual nurse turnover

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Medicare spending per beneficiary	Not Available	1.02	This provider is not required to submit SNF QRP data.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Staff COVID-19 vaccination coverage	Not Available	8.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.2%	95.5% 0.3 pts worse	93.4% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 95.2%
Percentage of long-stay residents experiencing one or more falls with major injury	0.0%	2.4% 2.4 pts better	3.3% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.7%	4.7% 3 pts better	11.4% 9.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7%
Percentage of long-stay residents who lose too much weight	8.8%	5.0% 3.8 pts worse	5.4% 3.4 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 8.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	3.5%	12.5% 9 pts better	19.6% 16.1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 3.5%
Percentage of long-stay residents who received an antipsychotic medication	13.7%	14.7% 1 pts better	16.7% 3 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 13.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	3.7%	24.1% 20.4 pts better	16.3% 12.6 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 3.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.0%	15.8% 9.8 pts better	14.9% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 6.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	1.7% 1.7 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	2.0% 2 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	13.1%	22.2% 9.1 pts better	19.8% 6.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 13.1%
Percentage of long-stay residents with pressure ulcers	1.7%	6.5% 4.8 pts better	5.1% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 1.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-08-07 · Fire 2025-08-07

11 health deficiencies

Top issue: Infection Control (4 deficiencies)

6 fire-safety deficiencies

Top issue: Emergency Preparedness (5 deficiencies)

Cycle 2 Health 2024-04-19 · Fire 2024-04-19

3 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2023-02-13 · Fire 2023-02-13

10 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)

1 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-08-07

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2025-09-22

F · Potential for more than minimal harm 2025-08-07

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2025-09-22

F · Potential for more than minimal harm 2025-08-07

E18 · Emergency Preparedness Deficiencies

Fire Safety

Establish procedures for tracking staff and patients during an emergency.

Corrected 2025-09-22

F · Potential for more than minimal harm 2025-08-07

E22 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for sheltering.

Corrected 2025-09-22

F · Potential for more than minimal harm 2025-08-07

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2025-09-22

D · Potential for more than minimal harm 2025-08-07

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2025-09-22

F · Potential for more than minimal harm 2024-04-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-05-01

F · Potential for more than minimal harm 2024-04-19

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-06-08

F · Potential for more than minimal harm 2023-02-13

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-03-07

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-08-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-22

E · Potential for more than minimal harm 2025-08-07

F584 · Resident Rights Deficiencies

Health

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 2025-09-22

E · Potential for more than minimal harm 2025-08-07

F585 · Resident Rights Deficiencies

Health

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 2025-09-22

E · Potential for more than minimal harm 2025-08-07

F887 · Infection Control Deficiencies

Health

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 2025-09-22

D · Potential for more than minimal harm 2025-08-07

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2025-09-22

D · Potential for more than minimal harm 2025-08-07

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-09-22

D · Potential for more than minimal harm 2025-08-07

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-09-22

D · Potential for more than minimal harm 2025-08-07

F699 · Quality of Life and Care Deficiencies

Health

Provide care or services that was trauma informed and/or culturally competent.

Corrected 2025-09-22

D · Potential for more than minimal harm 2025-08-07

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-09-22

D · Potential for more than minimal harm 2025-08-07

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2025-09-22

D · Potential for more than minimal harm 2025-08-07

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-09-22

D · Potential for more than minimal harm 2024-08-06

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-05-06

D · Potential for more than minimal harm 2024-04-19

F578 · Resident Rights Deficiencies

Health

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 2024-06-08

D · Potential for more than minimal harm 2024-04-19

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-06-08

D · Potential for more than minimal harm 2023-06-09

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2023-07-29

D · Potential for more than minimal harm 2023-06-09

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-07-29

K · Immediate jeopardy 2023-02-13

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2023-03-07

J · Immediate jeopardy 2023-02-13

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-03-07

D · Potential for more than minimal harm 2023-02-13

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-03-07

D · Potential for more than minimal harm 2023-02-13

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-03-07

D · Potential for more than minimal harm 2023-02-13

F727 · Nursing and Physician Services Deficiencies

Health

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 2023-03-07

D · Potential for more than minimal harm 2023-02-13

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-03-07

D · Potential for more than minimal harm 2023-02-13

F843 · Administration Deficiencies

Health

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 2023-03-07

D · Potential for more than minimal harm 2023-02-13