Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 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.
Infection control policies were not reviewed annually, and one policy on influenza and pneumococcal immunizations was outdated and did not include the latest CDC pneumococcal vaccine guidance. Staff also transported clean laundry on an uncovered rack through common areas, despite the laundry safety sheet requiring plastic coverings to prevent dust and contamination. The DNS acknowledged the uncovered transport exposed clean laundry to dust and cross contamination.
Damaged and Soiled Resident Areas and Hallway Surfaces: Surveyors observed multiple gouged handrails in hallways and several residents with damaged or soiled room surfaces, including stained carpet and wall damage behind beds and chairs. Staff, including the Maintenance Preventative Lead and DNS, were unaware of several of the concerns, and one resident's spouse had already requested carpet replacement and wall repair without a clear plan in place.
A facility failed to maintain a formal grievance system, including no identified Grievance Official, no grievance forms for residents or reps, and no clear process for tracking or resolving concerns. Residents reported they did not know how to file a grievance, and multiple staff members, including the DNS, CNAs, ADHS, and Administrator, were unaware of the grievance form, tracking process, follow-up process, or required record retention.
Missing COVID-19 Vaccine Consent Documentation: The facility failed to keep consent records for COVID-19 vaccines for multiple residents. A pharmacy came to the facility to administer vaccines, but the DON stated copies of the paperwork were not kept in the residents’ charts and the pharmacy could not provide the consents. Several residents, including some cognitively intact and some cognitively impaired, had vaccine forms or recollections that did not confirm documented education or signed consent.
Unnecessary Psychotropic Medication Use and Lack of GDR: A resident with Lewy body dementia, significant cognitive impairment, and hallucinations received Seroquel and fluoxetine. The record showed Seroquel was reduced, then restarted after behaviors such as hallucinations, yelling, and combativeness, and later increased even though the clinical record did not support the increase. The resident’s fluoxetine remained at the same dose since admission, with no documented GDR or evidence that it was the lowest effective dose.
A resident with dementia and a history of allergies reported possible pneumonia and was observed by an RN to have an unstoppable cough and runny nose. The resident was given tea, honey, and PRN allergy medication, but the chart did not show follow-up respiratory assessments or monitoring of temp, cough, or O2 sat over the next several days, despite staff noting the symptoms could have been allergies or an illness.
Staff left antifungal powder in the bathrooms of two residents instead of administering it directly. One resident had Huntington’s disease and required extensive ADL assistance, while the other had heart disease and needed ADL and incontinence care. A CNA applied the powder after it was found in each room, and the DNS stated medications should not be left in residents’ bathrooms to avoid adverse medication reactions.
Failure to Provide Trauma-Informed Care: A resident with alcohol dependence and PTSD was not screened for trauma at admission, and no trauma assessment or care plan addressing trauma triggers was found in the record. The resident stated staff never discussed the cause of the PTSD or potential triggers, while the CNA was unaware of the diagnosis, the RN knew of past trauma but not triggers, the SW confirmed no admission trauma screening or trauma-related care plan, and the DNS acknowledged nothing had been implemented related to trauma triggers.
A resident admitted with dementia had a pharmacy MRR that found fluoxetine was being used for an inappropriate diagnosis of neurocognitive disorder with Lewy bodies. A request was sent to the Geriatric Psychiatrist to address the concern, but the physician did not respond and the DNS did not involve the MD to intervene; the MAR later still listed the same indication.
Failure to follow antibiotic stewardship for a resident with urinary retention and intermittent catheterization. The resident had a UA with only a trace leukocyte esterase, was started on cephalexin after a pharmacy fax, and the record did not include the UA or culture results or documentation showing the physician’s office was contacted to confirm the antibiotic was indicated. The McGeer surveillance checklist showed UTI criteria were not met.
Missing vaccine consent and offer documentation. Two residents had flu vaccines documented without evidence of education or signed consent in the chart, and one resident with Huntington’s disease also had no documentation that an additional pneumonia vaccine was offered. Staff said the pharmacy administered the flu vaccines, but the facility did not keep copies of the consent paperwork.
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.
Infection Control Policies Not Reviewed Annually and Clean Laundry Transported Uncovered
Penalty
Summary
The facility failed to ensure infection control policies were reviewed annually. Review of the Policy and Procedure Manual showed the Influenza and Pneumococcal Immunizations policy had last been reviewed on 1/2020 and did not include the latest CDC guidelines on pneumococcal vaccines, including pneumococcal conjugate vaccines 15, 20, and 21. The Antibiotic Stewardship policy was last reviewed on 5/2024, and the Infection Prevention and Control Program policy was last reviewed on 10/2023. The DNS stated on interview that the infection control policies were not reviewed yearly, and the Assistant Director of Health Services stated the DNS was responsible for reviewing and updating all policies as needed. The facility also failed to transport clean laundry in a manner to prevent cross contamination. The Laundry Safety Sheet stated staff were to use plastic coverings on carts when transporting clean laundry to prevent dust and contamination, but a CNA was observed wheeling an uncovered laundry rack with hanging dress shirts, folded shirts, and socks through the living room and dining room adjacent to the kitchen to a room. The CNA stated this was the only cart staff used to deliver clean laundry and she was unaware of a covered laundry cart. The Laundry Manager stated residents' laundry was often washed and dried in the laundry room on the main floor by the shared living room and that staff used uncovered laundry racks to collect and deliver residents' clean laundry to their rooms. The DNS acknowledged staff delivered clean laundry using uncovered racks and stated this exposed clean laundry to dust and cross contamination.
Damaged and Soiled Resident Areas and Hallway Surfaces
Penalty
Summary
The facility failed to maintain a homelike environment for 1 of 1 facility and 4 of 4 sampled residents reviewed for environment. Survey observations on 8/6/25 identified multiple damaged handrails throughout the hallways, including missing wood, rough areas, and gouges near several room locations. Staff 16, the Maintenance Preventative Lead, stated he was not aware of the handrail gouges and said he could not fix damage unless he was notified. Staff 2, the DNS, stated she was not aware of concerns related to the facility handrails. Resident 1, admitted in 11/2019 with chronic lung disease and cognitively intact per the 6/27/25 MDS, had a soiled carpet area about three feet in diameter and a bathroom wall that needed repair and paint. The resident's spouse had requested carpet replacement at the 7/16/25 care conference review, and a work order was noted as in progress, but staff stated no concrete decisions had been made and the bathroom wall work order was not submitted until 8/6/25. Resident 3, admitted in 11/2017 with dementia and cognitively impaired per the 6/19/25 quarterly MDS, had nine gouges in the wall behind the bed and damage to the lower wall by the bathroom sink. Resident 7, admitted in 6/2016 with Huntington's disease, had a carpet stain about three feet in diameter that staff said had been present for at least six months. Resident 8, admitted in 5/2018 with diabetes and forgetful but able to converse per the 11/13/24 annual MDS, was observed with significant gouges in the wall behind the recliner where the chair headrest corners hit the wall.
Lack of grievance process and designated grievance official
Penalty
Summary
The facility failed to ensure a system was in place to resolve resident grievances, including having no identified Grievance Official and no information available to residents on how to file a grievance. The facility's Resident Grievance Policy & Procedure, dated 1/2024, stated that a resident or legal representative could voice a grievance in person, by telephone, email, or in writing, and that grievance details would be documented so the grievance could be resolved within 30 calendar days. The policy did not specify how long grievance forms were to be retained. During interview, Staff 2 (DNS) stated the facility did not have a process for providing residents or representatives grievance forms and was unaware of how grievances were tracked, who the grievance official was, how grievances were followed up on, or how long forms were kept. Resident 5 and Resident 8 stated they attended Resident Council occasionally and were unaware of how to file a grievance. Staff 7 and Staff 8, both CNAs, reported they were not aware of a grievance form, the formal process for submitting grievances, or the process for resolving resident concerns. Staff 10, the Assistant Director of Health Services, stated residents or representatives typically verbalized concerns or sent emails when expressing a grievance, that grievance documentation was kept in residents' charts, and that she was unaware of who was responsible for tracking and addressing grievances. Staff 1, the Administrator, acknowledged there was no specific form used to document grievances, no formal process for collecting, reviewing, or tracking grievances to ensure resolution, and no process for maintaining grievance records for the required three years.
Missing COVID-19 Vaccine Consent Documentation
Penalty
Summary
The facility failed to maintain records of consent for COVID-19 vaccines for 5 of 5 sampled residents reviewed for immunizations. Resident 5, admitted with a fracture and later documented as cognitively intact, had a COVID-19 vaccination form showing no education was provided before administration, and the resident later stated not recalling any education or signing documents. Resident 6, admitted with cancer and documented as cognitively intact, had a COVID-19 vaccine form showing education was provided, but the resident later did not remember whether the risks and benefits were reviewed or whether a consent was signed. Resident 7, admitted with Huntington's disease and documented as moderately cognitively impaired, received a COVID-19 vaccine with no education documented and no signed consent form in the clinical record; the resident later did not remember signing anything but thought risks and benefits may have been discussed. Resident 12, admitted with Parkinson's disease and documented as cognitively impaired, had a vaccine form showing education was provided, but no signed consent form was in the record. Resident 15, admitted with diabetes and documented as cognitively intact, had a vaccine form showing education was provided, but the clinical record did not contain a signed consent form, and the resident did not recall the paperwork details.
Unnecessary Psychotropic Medication Use and Lack of GDR
Penalty
Summary
The facility failed to ensure psychotropic medications were not increased without indication and failed to perform a gradual dose reduction for one resident reviewed for unnecessary medications. The resident had Lewy body dementia with significant cognitive impairment, hallucinations, and was receiving antipsychotic and antidepressant medications. The record showed the resident was administered Seroquel 50 mg in the morning, 100 mg midday, and 150 mg at bedtime, and the resident’s annual MDS documented hallucinations and significant cognitive impairment. After the morning Seroquel dose was discontinued, the resident had periods without behaviors, but later had episodes of hallucinations, yelling, screaming, combativeness during care, refusal of medications, and statements such as “Go away i [sic] will kill you.” Staff documented some behavioral episodes and interventions such as reapproaching the resident, providing 1:1 interventions, and music therapy. A request was then made to restart the morning Seroquel dose due to a failed dose reduction, and the dose was restarted. The record also showed that after the restart, behaviors were documented on only two days before the medication was later increased. The resident’s midday Seroquel dose was increased after staff reported continued hallucinations, but the clinical record did not support the increase in dosage. Staff stated the resident’s behavior varied and that when there was too much noise or stimulation the resident became agitated, hallucinated, and yelled. The resident was also prescribed fluoxetine, and a quarterly psychotropic review noted the resident had been on the same dose since admission with no gradual dose reduction. The record did not contain information showing that the fluoxetine dose was the lowest effective dose or that a failed gradual dose reduction had been attempted and failed.
Failure to Monitor Resident After Respiratory Change in Condition
Penalty
Summary
The facility failed to monitor a resident for a change in condition after the resident reported thinking he or she had pneumonia and was observed by an RN to have an unstoppable coughing fit and a runny nose. The resident, who had a diagnosis of dementia and a history of allergies, was assessed as having clear lungs and was given tea, honey, and PRN allergy medication, with a note that the resident would be monitored. The resident’s progress notes did not show any additional respiratory assessments after that encounter, and the clinical record did not indicate that temperatures, cough, or oxygen saturation levels were monitored over the following days. The RN stated the resident was thought to have allergies but might also have been ill, so monitoring for a few shifts was considered best, and the DNS stated the resident should have been monitored to determine whether the symptoms were related to allergies versus an illness.
Medication Left in Resident Bathrooms
Penalty
Summary
The facility failed to ensure residents were free from accidents when antifungal powder was left in residents’ bathrooms instead of being administered directly by staff. Resident 7 was admitted with Huntington’s disease and, according to the annual MDS, required extensive assistance with ADLs, was incontinent, and did not transfer. Resident 7’s MAR directed staff to administer an antifungal powder twice daily, but on observation a medicine cup with white powder was found on the bathroom sink counter in the resident’s room. A CNA stated the powder was an antifungal powder and that she applied it to the resident’s rash, while an RN stated she had placed the powder in the room and that CNA staff were to page her when the resident was in bed so it could be applied. A similar issue occurred for Resident 14, who was admitted with heart disease and whose annual MDS showed the resident required assistance with ADLs and incontinence care. Resident 14’s MAR also directed staff to administer an antifungal powder twice daily, and a medicine cup with white powder was observed on the bathroom sink in the resident’s room. A CNA stated the powder was for Resident 14’s rash and that she assisted the resident to apply it. The DNS stated staff should not leave medications in residents’ bathrooms to ensure adverse medication reactions did not occur.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure trauma informed care for one resident who was admitted with diagnoses including alcohol dependence and PTSD. The facility’s Trauma-Informed Care Policy & Procedure stated that each resident would receive a preliminary trauma screening upon admission and that the facility would account for residents’ experiences, preferences, and cultural differences to help mitigate triggers that could cause re-traumatization. In this case, no evidence was found in the resident’s clinical record showing that a trauma assessment was completed or that a care plan was developed to address potential trauma triggers. The resident’s 8/1/25 quarterly MDS indicated the resident was cognitively intact and able to make self understood and understand others without difficulty. During observations on 8/5/25 and 8/6/25, the resident was in bed facing the door with the lights off and stated that PTSD resulted from childhood trauma and that no one at the facility had discussed the cause of the PTSD or potential triggers for re-traumatization. Staff interviews showed the CNA was unaware of the PTSD and it was not listed on the Kardex, the RN knew the resident had past trauma but was unaware of triggers or the PTSD diagnosis, the SW stated trauma screenings were not completed at admission and no trauma-related care plan was developed, and the DNS acknowledged the trauma history but stated nothing had been implemented related to trauma triggers.
Delayed response to pharmacy review recommendation for antidepressant indication
Penalty
Summary
The facility failed to ensure a pharmacy recommendation was acted upon timely for one sampled resident who was reviewed for unnecessary medications. Resident 10 was admitted in 3/2025 with a diagnosis of dementia. A Medical Director Report Medication Regimen Review completed between 5/19/25 and 5/21/25 showed the resident was receiving fluoxetine with an indication listed as neurocognitive disorder with Lewy bodies, and the review stated that this was not an appropriate diagnosis for the use of fluoxetine. A handwritten note on the review form indicated that on 6/9/25 a request was made to the resident’s Geriatric Psychiatrist to address the concern. The resident’s 8/2025 MAR still listed fluoxetine with the indication of neurocognitive disorder with Lewy bodies. On 8/6/25, the DNS stated she expected physicians to respond to pharmacy recommendations within one to two weeks, but the physician did not respond to the request to change the diagnosis and the DNS did not involve the medical director to intervene.
Failure to Follow Antibiotic Stewardship for Suspected UTI
Penalty
Summary
The facility failed to follow antibiotic stewardship for 1 of 1 sampled resident reviewed for antibiotics. The resident was admitted with a diagnosis of bladder disorder and, according to the 6/27/25 Annual MDS, had urinary retention and required staff assistance with intermittent catheterization. The resident’s 10/27/24 UA dipstick showed only a trace of leukocyte esterase. Progress notes documented that on 10/27/24 the resident reported not feeling well and required multiple catheterizations, and the spouse requested a UA, which was collected and sent to the lab. On 10/28/24, the pharmacy faxed orders for cephalexin for 14 days, and the resident received cephalexin from 10/28/24 through 11/10/24. The clinical record did not contain the 10/27/24 UA or culture results or progress notes showing communication with the physician’s office to obtain the culture and confirm the antibiotic was indicated. The resident’s 10/31/24 McGeer Criteria for Infection Surveillance Checklist showed UTI criteria were not met, and Staff 2 stated on 8/7/25 that the McGeer surveillance form indicated the resident did not meet UTI criteria and that the facility did not receive the culture to ensure the antibiotics were appropriate.
Missing Vaccine Consent and Offer Documentation
Penalty
Summary
The facility failed to maintain records of consent for flu vaccinations for 2 of 5 sampled residents. One resident, admitted in 1/2023 with a fracture diagnosis and documented as cognitively intact on the 8/2025 quarterly MDS, received a flu vaccine on 9/30/24, but the clinical record did not show that education was provided and did not contain a signed consent form. Staff stated that a local pharmacy came to the facility to administer the flu vaccines, but the facility did not make copies of the paperwork for the residents’ clinical records and the pharmacy was unable to provide copies of the consents. The resident stated she/he wanted the vaccine, recalled staff coming around, and did not remember signing any documents. The second resident, admitted in 6/2016 with Huntington’s disease and documented as moderately cognitively impaired on the 5/23/25 quarterly MDS, also received a flu vaccine on 9/30/24. The clinical record did not show that education was provided and did not contain a signed consent form. The resident stated she/he did not remember whether anything was signed, but thought the risks and benefits form had been provided. In addition, the resident’s record showed two pneumonia vaccines had been given, but the resident was eligible for another pneumonia vaccine and there was no documentation that an additional vaccine was offered. Staff stated the facility had just ordered the pneumonia vaccine and was not sure why the resident had not been offered the vaccine in prior years.
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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How nearby facilities compare on the same public inspection record.
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| Willamette View Health Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Stanley Post Acute | 2.5 mi | ★★★★★ | 12 | 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 July 2026) and official state health department websites.