Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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 failed to post required contact information for State agencies and advocacy groups. During observations, no required complaint posting was found, and residents at a Resident Council meeting said they did not know how to contact the State Agency or APS or where to find the information. The Administrator stated the poster had not been posted since the facility opened.
Improper Food Labeling and Storage in Kitchen: Surveyors found multiple food items in the walk-in refrigerator, freezer, and dry storage that were unlabeled, undated, uncovered, or improperly stored, including opened dairy, sauces, frozen foods, and dry goods. Expired items were also observed in the refrigerator, and boxes of juice mix were stored directly on the floor. The Dietary Manager acknowledged the storage issues, and the Administrator stated that opened, expired, unlabeled, or undated items were expected to be discarded.
A resident with hemiplegia/hemiparesis after CVA and recurrent UTIs had a physician order for a UA with reflex C&S due to dysuria, suprapubic discomfort, and urgency, but the urine sample was not collected promptly and lab results and new medication were delayed. The physician said the order was entered into the EHR and the RCM was to follow up, while the RCM was unsure what happened to the order and said the system did not prompt staff to collect the sample.
A resident with PTSD and a history of trauma did not receive trauma-informed care. The resident’s assessment, PASARR II, and care plan identified anxiety, fear of touch, and other trauma-related triggers, but staff were unaware of key triggers and helpful interventions, and the social services director did not update the care plan with PASARR recommendations or contact family for additional trauma history. The resident and family reported preferences such as avoiding certain topics, keeping the door open, and using religion and reassurance for comfort, while the resident was heard objecting to being touched.
A facility failed to develop a system to notify the State LTC Ombudsman's office of resident transfers. A resident with thoracic spine fusion was transferred to the hospital for emergency spinal surgery, and staff interviews confirmed there was no established process for notifying the Ombudsman's office of transfers or discharges, despite the facility policy requiring notice when practicable.
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.
Missing State Agency Complaint Posting
Penalty
Summary
The facility failed to ensure that contact information for pertinent State agencies was posted and readily available to residents. Random observations from 6/22/26 through 6/24/26 from 8:00 AM to 5:00 PM found no required posting with State agency contact information for reporting complaints or other concerns. During a Resident Council meeting on 6/24/26 at 2:30 PM, 11 residents were present, and multiple residents stated they were not aware of how to contact the State Agency, Adult Protective Services, or where to locate that information in the facility. On 6/24/26 at 2:54 PM, the Administrator stated he was not aware the required posting was not in place and confirmed the poster had not been posted since the facility opened in 9/2025.
Improper Food Labeling and Storage in Kitchen
Penalty
Summary
The facility failed to ensure foods were properly labeled, dated, covered, and stored in accordance with safe food storage practices in the kitchen. During observation of the walk-in refrigerator, walk-in freezer, and dry storage room, surveyors found multiple food items that were not labeled or dated, including a glass of chocolate drink, opened strawberry yogurt, liquid whole eggs, beef base, beef-flavored stew base, salsa containers, barbeque chicken breast, cucumber salad, granola, pancake flour, chopped walnuts, and cornbread. Several items were also not covered or sealed, including the liquid whole eggs, cucumber salad, and some items in plastic bags or containers without lids. Surveyors also observed expired items in the walk-in refrigerator, including a container of wasabi horseradish with an expiration date of 4/2/26 and a container of horseradish with an expiration date of 2/15/26. In dry storage, two boxes of unopened juice mix were stored directly on the floor, and other dry goods were stored in plastic bags that were not sealed or dated. The Dietary Manager acknowledged the food items were not stored, labeled, dated, or covered in accordance with facility policy, and the Administrator stated the expectation was that all food items be properly labeled and dated upon opening or preparation and that expired, unlabeled, or undated items be discarded immediately.
Delayed Follow-Through on Urine Testing Order
Penalty
Summary
The facility failed to follow a physician order for a urinalysis with reflex culture for a resident admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction. The resident's 4/29/26 quarterly MDS showed the resident was cognitively intact. On 6/22/26, the resident stated having recurrent UTIs but could not recall details of any recent UTIs, and on 6/25/26 the resident stated that UTIs caused very uncomfortable feelings in the private areas. The physician ordered the urinalysis with reflex culture on 4/9/26 because the resident had painful urination, suprapubic discomfort, dysuria, and urgency for a week. The clinical record showed the urine sample was not collected until 4/19/26, lab results were returned on 4/21/26, and a new medication was prescribed on 4/23/26. The physician confirmed she entered the order into the facility electronic health system and expected the RCM to follow up, while the RCM stated she was unsure what happened to the order and that the system did not trigger staff to promptly collect a sample. The DNS stated she expected staff to confirm and follow physician orders to prevent delay in treatment.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that a resident with PTSD received trauma-informed care. The resident was admitted with diagnoses including PTSD, and the admission social service assessment noted the resident had experienced something bad in childhood but did not want to discuss the trauma, had a history of substance abuse and houselessness, and had family as a support system. The admission MDS identified the resident as cognitively intact with an active PTSD diagnosis, and the PASARR Level II identified a history of sexual trauma, significant anxiety, fear of being alone, touch, and falling, dislike of lights being turned off, and a need for constant care and verbal reassurance due to severe anxiety and pain. The PASARR also stated that staff were to provide care with a trauma-informed approach and recognize that any touch or request may trigger an anticipatory pain response. The behavior care plan identified behaviors including being accusatory, agitated, and frustrated, with triggers related to the resident’s medical condition, prior substance use, change in environment, and anxiety around life choices. Interventions in the care plan included calmly explaining care, reminding the resident to use the call light, setting boundaries, and calling the resident’s family. The social services director stated she did not reach out to the resident’s family about the trauma history because the resident did not want her to, and she had not updated the care plan to include the PASARR recommendations. The resident and family reported trauma-related preferences and triggers that were not reflected in staff knowledge. The family member stated the resident had experienced physical abuse as a child and additional trauma as an adult, and that religious television, talking about religion, and reassurance were helpful when upset. The resident stated they did not like to be touched, did not want to discuss previous relationships or children, preferred the door open because of claustrophobia, and wanted staff to contact family to discuss trauma history. Multiple CNAs and an LPN stated they were unaware of the resident’s trauma history, triggers, or helpful interventions, and the resident was heard yelling, "Don't touch me, I don't want her touching me. They just force themselves on you, and I don't want her touching me."
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to develop a system to notify the State Long-Term Care Ombudsman's office of residents' facility transfers for 1 of 1 sampled resident reviewed for hospitalization. The facility's Transfer or Discharge-Facility Initiated policy, dated 10/2022, stated that when a resident transferred to the hospital or was discharged from the facility, a copy of the notice of transfer was to be provided to the resident and representative and to the Long-Term Care Ombudsman's office when practicable in a monthly list of residents that included all notice content requirements. Resident 55 was admitted to the facility in 4/2026 with diagnoses including fusion of the spine at the thoracic region. Progress notes dated 5/4/26 indicated the resident was transferred to the hospital on 5/4/26 for emergency spinal surgery. During interviews on 6/24/26 and 6/25/26, Staff 3, Staff 2, Staff 1, and Staff 11 stated they were not responsible for notifying the Ombudsman's office or confirmed the facility had no system in place to do so, and that the facility had not been notifying the Ombudsman's office when a resident was transferred or discharged.
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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