Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Rose City Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not maintain the required RN coverage for at least eight consecutive hours per day, seven days a week, as per their policy. Over a period of three months, there were 33 days without appropriate RN coverage, which was acknowledged by the facility's administrators.
The facility failed to properly label and store food and beverages in all kitchen and unit refrigerators, risking spoilage and cross-contamination. Observations revealed unlabeled and undated items, including cheese, butter, and beverages, contrary to the facility's policy and FDA guidelines. Staff confirmed the deficiency, highlighting ongoing non-compliance.
A facility failed to provide a person-centered activity program for three residents, leading to a decline in their psychosocial well-being. One resident, unable to participate in activities due to mobility issues, was isolated in their room. Another resident, interested in art and music, reported a lack of enrichment activities. A third resident expressed interest in group activities but was rarely invited. The Activity Director's dual responsibilities contributed to missed activities and inadequate documentation.
The facility was found deficient for not having a qualified professional to direct the activities program. The Activity Director/Social Services Director admitted to not having the necessary certification or training, which was confirmed by the Administrator. This deficiency posed a risk to residents' physical, mental, and psychosocial needs.
Expired medications were not properly disposed of in a facility, as observed in a resident medication storage refrigerator and a medication storage room. An LPN confirmed an expired multi-dose vial of Tuberculin, and an Administrator-In-Training verified expired bottles of lotion. The facility's policy did not adequately address the disposal of vials, leading to potential risks for residents.
A resident with congestive heart failure was not assessed for smoking safety upon admission, as required by the facility's policy. The resident was observed smoking independently without prior evaluation, and staff later acknowledged the oversight. The resident was not listed among those who smoke, despite having smoking supplies and smoking independently since admission.
A resident with end-stage renal disease did not receive consistent dialysis communication and monitoring from the facility. The facility failed to complete necessary Dialysis Communication Forms on multiple occasions and did not contact the dialysis center to obtain missing information. The resident reported inconsistent assessments upon returning from dialysis, and staff confirmed the lack of communication and documentation.
A facility failed to provide a transfer notice with appeal rights to a resident or their representative and did not notify the Office of the State Long-Term Care Ombudsman of the resident's hospitalization. The resident, admitted with hypothermia and sepsis, was transferred to the hospital without the required documentation. Staff confirmed the oversight and lack of awareness regarding the notification requirement.
The facility failed to post accurate and complete staffing information as required by their policy. A review of Direct Care Staff Daily Reports (DCSDRs) from January to February revealed inaccuracies on 11 days. The Administrator and Administrator-In-Training confirmed these deficiencies, acknowledging the reports did not meet expected standards.
Inadequate RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was available for at least eight consecutive hours per day, seven days a week, as required by their policy. This deficiency was identified through interviews and record reviews, which revealed that for 33 out of 61 days reviewed, there was a lack of appropriate RN coverage. Specifically, in July 2024, four days lacked RN coverage; in August 2024, twelve days were without coverage; and in September 2024, seventeen days were identified without the required RN presence. The facility's Staffing, Sufficient and Competent Nursing Policy, last revised in August 2022, mandates RN services for at least eight consecutive hours every 24 hours, seven days a week. The facility's administrators acknowledged the challenge in maintaining RN coverage during the reviewed period.
Improper Food Labeling and Storage in Facility Refrigerators
Penalty
Summary
The facility failed to ensure that food and beverages were labeled and stored properly to minimize spoilage and cross-contamination in all four kitchen refrigerators and the unit refrigerator reviewed. This deficiency was identified during a kitchen tour and subsequent observations, where numerous food items, including cheese slices, grated substances, pitchers of red liquid, butter cubes, and blocks of cheese, were found unlabeled and undated. Staff members, including a cook and the dietary manager, confirmed these items were not properly labeled or dated, which is against the facility's Food Receiving and Storage Policy and the US FDA 2022 Food Code. Additionally, the residents' refrigerator contained several unlabeled and undated food and beverage items, such as opened bottles of soda, cola, and tea, as well as a dirty cloth bag with various food items. Staff confirmed these items were improperly stored, raising concerns about cross-contamination. The dietary manager reiterated the expectation that all food and beverage items should be labeled and dated, yet the follow-up visit revealed continued non-compliance with labeling and dating requirements.
Failure to Provide Person-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing person-centered activity program for three residents, leading to a decline in their psychosocial well-being and quality of life. Resident 10, who was admitted with diagnoses including non-traumatic subarachnoid hemorrhage and mild cognitive impairment, was very social and enjoyed activities such as watching old TV shows and playing bingo. However, due to mobility issues, Resident 10 was unable to participate in activities held downstairs and was observed isolated in their room without access to preferred activities. Scheduled activities like bingo did not occur, and the resident expressed frustration over the lack of social interaction and activities. Resident 20, diagnosed with end-stage renal disease and major depressive disorder, also experienced a lack of engagement in activities. Despite having interests in music, nature, and art, Resident 20 reported being confined to their room with limited access to art supplies and enrichment activities. Observations confirmed the absence of scheduled activities, and the resident voiced concerns about the lack of opportunities to engage in preferred activities and socialize with others. Resident 5, with a diagnosis of heart failure, expressed interest in participating in group activities but was rarely invited or able to participate due to the infrequent occurrence of scheduled activities. The Activity Director, who was also responsible for social services and medical records, acknowledged the challenges in fulfilling their role, resulting in missed activities and inadequate documentation of resident participation. The facility's failure to provide adequate staffing and resources for the activities program contributed to the deficiency.
Unqualified Activity Director Puts Residents at Risk
Penalty
Summary
The facility failed to provide a qualified professional to direct the activities program, which was identified during a survey. Staff 11, who held the position of Activity Director/Social Services Director, stated that he was responsible for organizing and leading activities. However, he admitted that he was informed that a certification was not necessary for the role of Activity Director and confirmed that he had neither started nor completed the required training. This was corroborated by Staff 1, the Administrator, who confirmed that Staff 11 did not possess the necessary Activity Director certification. This deficiency placed residents at risk for unmet physical, mental, and psychosocial needs.
Expired Medications Not Properly Disposed
Penalty
Summary
The facility failed to properly dispose of expired medications, which was identified during an observation, interview, and record review. In the resident medication storage refrigerator, an open and used multi-dose vial of Tuberculin, with an open date of 1/22/25, was found on 2/24/25 at 11:33 AM. Staff 12, an LPN, confirmed the expiration and stated that the facility policy was to discard open vials after 30 days. Additionally, in the medication storage room, two bottles of lotion with expiration dates of 9/2022 and three bottles with expiration dates of 3/2023 were found. Staff 2, an Administrator-In-Training, verified these findings and stated that the facility policy was to dispose of expired medications and order replacements if necessary. These deficiencies placed residents at risk for lack of medication efficacy and adverse reactions from expired medications, as the facility's Storage of Medications policy did not adequately address the disposal of vials of medications, despite the manufacturer's instructions for Tuberculin vials.
Failure to Assess Resident for Smoking Safety
Penalty
Summary
The facility failed to assess the safety of a resident for smoking, which placed the resident at risk for unsafe smoking. According to the facility's Smoking Policy for Residents, a smoking assessment should be conducted upon admission, evaluating the resident's current level of tobacco consumption, method of tobacco consumption, desire to quit smoking, and ability to smoke safely with or without supervision. Resident 19, who was admitted in January 2025 with a diagnosis of congestive heart failure, did not have a smoking assessment completed, nor was it determined if the resident was an independent smoker. On February 23, 2025, a list of residents who smoke was provided by the Administrator, and Resident 19 was not included. However, on February 25, 2025, Resident 19 was observed independently entering the smoking area with smoking supplies. The Administrator later entered the smoking area and took Resident 19's cigarettes and lighter, stating an intention to conduct a smoking assessment. A CNA confirmed that Resident 19 had been keeping their own smoking supplies and smoking independently since admission. The DNS/RNCM acknowledged that Resident 19 should have been assessed for smoking safety prior to being allowed to smoke independently.
Failure in Dialysis Communication and Monitoring
Penalty
Summary
The facility failed to ensure proper dialysis services and communication for a resident with end-stage renal disease who was dependent on dialysis. The resident, admitted in August 2024, required dialysis three times a week. However, the facility did not consistently complete the necessary Dialysis Communication Forms on specific dates, namely 2/4/25, 2/6/25, and 2/15/25. This lack of documentation meant there was no pre-dialysis and post-dialysis information available for these dates, and there was no evidence that nursing staff contacted the dialysis center to obtain the required reports. The resident reported that the facility did not always assess them upon returning from dialysis, sometimes waiting several hours before doing so. Staff 3, identified as DNS/RNCM, confirmed the absence of the required communication forms and acknowledged that the facility did not contact the dialysis center to retrieve the missing information. The expectation was for the facility to maintain consistent communication with the dialysis center through the Dialysis Communication Form for each visit, which was not adhered to, leading to the deficiency.
Failure to Provide Transfer Notice and Notify Ombudsman
Penalty
Summary
The facility failed to provide a transfer notice with appeal rights in writing to a resident or their representative, and also failed to notify the Office of the State Long-Term Care Ombudsman of the resident's hospitalization. This deficiency was identified during a review of the health record of a resident who was admitted to the facility with diagnoses including hypothermia and sepsis. The resident, who was cognitively intact, was transferred to the hospital, but there was no evidence in the health record that a transfer notice with appeal rights was provided to the resident or their representative. Additionally, the facility did not notify the Office of the State Long-Term Care Ombudsman about the resident's hospitalization. During an interview, Staff 3, a DNS/RNCM, confirmed that a transfer notice was supposed to be sent with the resident at the time of transfer and that the RNCM was responsible for ensuring the notice was given. Staff 3 also admitted to being unaware of the requirement to notify the Ombudsman at the time of transfer, verifying that neither the transfer notice was given nor the Ombudsman was notified, contrary to the facility's bed hold policy.
Inaccurate and Incomplete Staffing Information
Penalty
Summary
The facility failed to post accurate and complete staffing information, as required by their Staffing, Sufficient and Competent Nursing Policy, which was last revised in August 2022. This policy mandates that direct care daily staffing numbers be posted for every shift. A review of the facility's Direct Care Staff Daily Reports (DCSDRs) from January 21, 2025, through February 22, 2025, revealed that on 11 out of 32 days, the reports were incomplete or inaccurate. The specific dates identified with deficiencies were January 23, 24, 29, 30, 31, and February 12, 13, 14, 20, 21, and 20. On February 25, 2025, at 4:01 PM, the Administrator and Administrator-In-Training confirmed the inaccuracies and incompleteness of the DCSDRs for the identified days, acknowledging that the reports did not meet the expected standards of accuracy and completeness.
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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) |
|---|---|---|---|---|
| Menlo Park Post Acute | 0.6 mi | ★★★★★ | 15 | 0 |
| Glisan Post Acute | 0.7 mi | ★★★★★ | 11 | 0 |
| Gateway Care And Retirement | 0.9 mi | ★★★★★ | 0 | 0 |
| Portland Health And Rehabilitation | 1.1 mi | ★★★★★ | 21 | 0 |
| Evergreen Post Acute | 1.5 mi | ★★★★★ | 3 | 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.