Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
FERNWOOD SUPPORTIVE LIVING AT MADRONA GROVE
PORTLAND, OR · 16 certified beds · Last Life Safety survey June 4, 2026
CMS Certification Number 38A031 · first certified December 2012
Also on this campus
The same campus holds a state-licensed assisted living facility, with its own state record on the Assisted Living Index: Larkspur Supportive Living at Madrona Grove (13505 Se River Rd). Matched by the telephone number the two records share. The records are separate and are never added together.
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within OR
13 citations — more than 58% of the 128 certified nursing homes in OR. Compared within OR rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens September 2027 — about 11 months from now. This facility’s last Life Safety survey was June 2026. Facilities in OR are typically surveyed 15–17 months after the last one (median 16), measured over 188 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
8 of the 13 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 13 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in OR, and nationally. Surveyors differ markedly between states, so the OR figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 13 |
| Median facility in OR | 11 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 19, 2024 | 2 |
| August 7, 2025 | 6 |
| June 4, 2026 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | 2 | 2026-06-04 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-04-19 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2026-06-04 |
| E-0001 | Establish an Emergency Preparedness Program (EP). | 1 | 2026-06-04 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2026-06-04 |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | 1 | 2025-08-07 |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | 1 | 2025-08-07 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2025-08-07 |
What the citations cover
- Emergency Preparedness Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Smoke Deficiencies 2
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Smoke Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 4, 2026 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (July 24, 2026) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (July 24, 2026) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (July 24, 2026) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (July 24, 2026) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (July 24, 2026) |
August 7, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (September 22, 2025) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (September 22, 2025) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (September 22, 2025) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (September 22, 2025) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (September 22, 2025) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (September 22, 2025) |
April 19, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 1, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 8, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.