Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fernwood Supportive Living At Madrona Grove during CMS and state inspections, most recent first.
A resident with alcohol dependence and Parkinsonism, who had moderate cognitive impairment, was verbally abused by an agency RN. The resident was intoxicated and repeatedly pressing the call light when the RN spoke harshly to them, causing the resident to cry and seek comfort from CNAs. Witnesses reported the resident was upset, while the RN did not recall the harsh interaction.
The facility failed to ensure that a resident's advance directive was obtained and accessible in the health record. The resident, admitted with Alzheimer's disease, did not have their do not resuscitate status documented in the current health record, leading staff to consider the resident as full code in the event of a medical emergency.
The facility failed to implement antibiotic stewardship practices for a resident who was prescribed antibiotics without the necessary UA with C&S tests. Despite the resident's persistent urinary tract infection symptoms, the required tests were not conducted, placing residents at risk for adverse medication effects and inappropriate antibiotic use.
Verbal Abuse Incident Involving Intoxicated Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member. The incident involved a resident who was admitted with diagnoses including alcohol dependence and Parkinsonism. The resident had a moderate cognitive impairment as indicated by a BIMS score of 12. On the night of the incident, the resident was intoxicated and repeatedly pressing the call light. Staff 8, an agency RN, entered the resident's room and spoke harshly to the resident about their intoxicated state and behavior, which resulted in the resident crying and seeking comfort from CNA staff. Staff members who witnessed the incident reported that the resident was upset and tearful after the encounter with Staff 8. Staff 5, a CNA, noted that the resident was redirectable and understanding of the staff's duties, while Staff 7, another CNA, heard Staff 8 yelling harsh words at the resident. Staff 8, however, did not recall speaking harshly but was sent home early from the shift. The Interim DNS stated that it was expected for all staff to treat residents with dignity and respect, ensuring they are free from any form of abuse.
Failure to Ensure Advance Directives Are Accessible in Health Records
Penalty
Summary
The facility failed to ensure that current copies of residents' advance directives were obtained and accessible in the health record for one of the seven sampled residents reviewed for medications and advance directives. Resident 16, who was admitted with Alzheimer's disease, did not have an advance directive or instructions regarding medical treatments and life-sustaining interventions in their health record. The face sheet for Resident 16 was blank in the section titled 'Code Status,' and staff members confirmed that without specific instructions, the resident was considered full code, meaning all resuscitation procedures would be provided in the event of a medical emergency. Interviews with staff revealed that the Director of Social Services was responsible for obtaining and storing advance directives in the residents' health records upon admission. However, Resident 16's advance directive was found in a different electronic health record system that was not accessible to the facility's clinical staff. This advance directive indicated that Resident 16 was designated as do not resuscitate, but this information was not available in the current health record, leading to the risk of not honoring the resident's life-sustaining medical intervention preferences in an emergency.
Failure to Implement Antibiotic Stewardship Practices
Penalty
Summary
The facility failed to implement antibiotic stewardship practices for a resident who was prescribed antibiotics without the necessary laboratory tests to confirm the appropriate treatment. The resident, admitted in May 2023 with a diagnosis of irregular heartbeat, received two separate courses of the antibiotic nitrofurantoin monohydrate. The first course was prescribed on April 9, 2024, for one week, and the second course was prescribed on April 15, 2024, for 14 administrations. However, no urinalysis (UA) with culture and sensitivity (C&S) tests were completed before, during, or after the antibiotic courses, as required by the facility's Antibiotic Stewardship Policy & Procedure. Staff interviews confirmed that the necessary UA with C&S tests were not conducted. On April 17, 2024, an LPN noted that the resident's urinary tract infection symptoms persisted, leading to an extension of the antibiotic course. On April 18, 2024, the Director of Nursing Services (DNS) and a Registered Nurse Case Manager (RNCM) reviewed the resident's health record and acknowledged the absence of the required UA with C&S tests. This failure to follow the facility's policy placed residents at risk for adverse medication effects, inappropriate antibiotic use, and potential development of antibiotic resistance.
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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.
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Nursing homes near Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willamette View Health Center | 0.2 mi | — | 0 | 0 |
| Stanley Post Acute | 2.5 mi | — | 3 | 0 |
| Pearl At Kruse Way, The | 3.4 mi | — | 3 | 0 |
| Avamere Rehabilitation Of Clackamas | 4.1 mi | — | 6 | 0 |
| Avamere Crestview Of Portland | 4.6 mi | — | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.