Rose City Nursing and Rehabilitation
11325 Ne Weidler Street, Portland, OR 97220 · Multnomah County · (503) 231-0276
55 certified beds, about 51 residents a day · For profit - Limited Liability company · Medicaid since 1975
Certified for Medicaid
Overall
3 of 5
Health inspections
3 of 5
Staffing
4 of 5
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 38E157 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on June 26, 2026, inspectors cited 5 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 31 health citations since October 2023, 1 was rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 5.30 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.65 of those hours.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1510/23
203/24
902/25
506/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
17D
7E
3F
Potential for minimal harm
0A
2B
1C
June 26, 2026Standard inspection · 5 citations
- E Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure contact information for pertinent State agencies was posted and readily available to residents for 1 of 1 facility observed for required postings. This failure placed residents at risk for not having access to information necessary to file a complaint or contact appropriate oversight or protective agencies.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure foods were properly labeled, dated, and stored in accordance with safe food storage practices in 1 of 1 kitchen reviewed for food sanitation and storage. This placed residents at risk for foodborne illness.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for (1 of 5) sampled residents (#3) reviewed for unnecessary medications. This placed residents at risk for discomfort and delay in treatment.
- D Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents who were trauma survivors received trauma-informed care for 1 of 3 sampled residents (#43) reviewed for trauma-informed care. This placed residents at risk for re-traumatization and a decrease in their quality of life.
- C Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review it was determined 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 (#55) reviewed for hospitalization. This placed residents at risk for lack of advocacy from the ombudsman's office.
February 26, 2025Standard inspection · 9 citations
- F Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours per day, seven days per week for 33 of 61 days reviewed for staffing. This placed residents at risk for lack of timely RN assessments and care.
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure food and beverages were labeled and stored in a manner to minimize spoilage and cross contamination for 4 of 4 kitchen refrigerators and 1 of 1 unit refrigerator reviewed for sanitary conditions. This placed residents at risk for foodborne illness.
- E Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activity program for 3 of 3 sampled residents (#s 5,10 and 20) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life.
- E Ensure the activities program is directed by a qualified professional.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide a qualified professional to direct the activities program for 1 of 1 facility reviewed for activities. This placed residents at risk for unmet physical, mental and psychosocial needs.
- E Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to properly dispose of expired medications for 1 of 1 resident medication storage refrigerators and 1 of 1 medical storage rooms reviewed for medication storage. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and records review it was determined the facility failed to assess safety with smoking for 1 of 1 resident (#19) reviewed for smoking. This placed residents at risk for unsafe smoking.
- D Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure dialysis services were in place including monitoring and communication with the dialysis provider for 1 of 1 sampled resident (# 20) reviewed for dialysis. This placed residents at risk for dialysis complications and delayed treatment.
- B Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a transfer notice with appeal rights was provided in writing to the resident or their representative, and the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified of the resident's hospitalization for 1 of 1 sampled resident (#3) reviewed for hospitalizations. This placed residents at risk for lack of access to an advocate to inform them of their options and rights, and lack of information regarding discharge.
- B Post nurse staffing information every day.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents and the public at risk for incomplete and inaccurate staffing information.
March 8, 2024Complaint inspection · 2 citations
- G Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure bowel status was assessed and a bowel care medication regimen was administered as ordered for 1 of 3 sampled residents (#1) reviewed for bowel care. Resident 1 developed abdominal pain, was admitted to the hospital and required surgery to remove part of the large intestine due to impaction (hardened stool stuck in the rectum or lower colon due to chronic constipation-occurs when constipated for a long time) and a colostomy (surgical procedure used to bring the healthy end of the large intestine through the abdominal wall for feces to leave the body) was placed.
- D Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident representative was provided written notice of the facility bed hold policy for 1 of 3 sampled residents (#1) reviewed for bowel care. This placed residents and responsible parties at risk for lack of knowledge related to rights to return to the facility.
October 20, 2023Standard inspection, Complaint inspection · 15 citations
- F Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure an RN worked eight consecutive hours per day seven days per week for 46 of 97 days reviewed for RN coverage. This placed residents at risk for lack of RN oversight including resident assessment, care and services.
- E Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were free from medication error rates of five percent or greater for 4 of 6 sampled residents (#s 2, 4, 10 and 15) reviewed for medication administration. The facility's medication error rate was 18.5 percent. This placed residents at risk for adverse medication consequences.
- E Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 2 of 5 randomly selected staff members (#s 13 and 14) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to notify the physician of a worsening wound and weight loss for 2 of 2 sampled residents (#18 and #72) reviewed for wounds and nutrition. This placed residents at risk for inappropriate treatment, delayed healing and weight loss.
- D 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.
Inspectors wroteBased on observations and interviews it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment.
- D Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review it was determined the facility failed to comprehensively assess a resident for dementia for 1 of 1 sampled resident (#8) reviewed for dementia. This placed residents at risk for unmet care needs.
- D Assess the resident when there is a significant change in condition
Inspectors wroteBased on interview and record review it was determined the facility failed to timely assess a resident for a significant change in condition for 1 of 1 sampled resident (#8) reviewed for dementia, hospice and unnecessary medications. This placed residents at risk for unmet care needs.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review it was determined the facility failed to accurately assess a resident for behaviors for 1 of 1 sampled resident (#8) reviewed for dementia. This placed residents at risk for unmet care needs.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide wound care and obtain physician's orders for wound care for 1 of 1 sampled resident (#72) reviewed for wounds. This placed residents at risk for infection and delayed healing.
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assess and monitor weight loss for 1 of 1 sampled resident (#18) reviewed for nutrition. This placed residents at risk for unidentified weight changes.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure pharmacist recommendations were addressed for 2 of 5 sampled residents (#s 8 and 9) reviewed for unnecessary medications. This placed residents at risk for unnecessary medications.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review it was determined the facility failed to discontinue a medication per physician's order for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences.
- D Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure PRN psychotropic medications were ordered with duration of treatment and rationale for 2 of 5 sampled residents (#s 8 and 9) reviewed for unnecessary medications. This placed residents at risk for unnecessary psychotropic medications.
- D Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure records were accurate for 2 of 5 sampled residents (#s 3 and 8) reviewed for hospice and unnecessary medications. This placed resident at risk for inaccurate treatment.
Fire safety inspections
9 fire safety citations on file: 1 on June 26, 2026, 1 on March 9, 2026, 5 on February 26, 2025, 2 on October 20, 2023.
Every fire safety citation9 citations
- F Have generator or other power source capable of supplying service within 10 seconds.
- D Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- F Keep aisles, corridors, and exits free of obstruction in case of emergency.
- D Provide properly protected cooking facilities.
- D Properly select, install, inspect, or maintain portable fire extinguishes.
- D Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- D Ensure proper usage of power strips and extension cords.
- E Have properly installed hallway dispensers for alcohol-based hand rub.
- D Properly select, install, inspect, or maintain portable fire extinguishes.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 5.30 | 5.03 | 3.86 |
| Registered nurses | 0.65 | 0.72 | 0.69 |
| All nursing staff on weekends | 4.95 | 4.51 | 3.42 |
| Nurse aides | 3.79 | ||
| Licensed practical nurses | 0.86 | ||
| Nursing staff turnover (share who left in a year) | not reported | 47.4% | 45.8% |
| Registered nurse turnover | not reported | 51.6% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.22 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.45 on weekdays and 4.95 on weekends, 9% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 12.6% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.12 in April to June 2025 to 5.30 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 5.30 | 0.65 | 5.45 | 4.95 | 12.6% | 0 of 90 | 51 |
| Oct to Dec 2025 | 5.55 | 0.71 | 5.64 | 5.33 | 27.5% | 0 of 92 | 44 |
| Jul to Sep 2025 | 5.96 | 1.00 | 6.11 | 5.59 | 14.2% | 0 of 92 | 20 |
| Apr to Jun 2025 | 5.12 | 0.60 | 5.25 | 4.80 | 7.1% | 10 of 91 | 19 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 21.1 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.4 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.9 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 11.3 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.0 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 24.6 | 13.9 | 15.4 |
Owners and operators
Legal business name: Legal Business Name Not Available.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ownership data not available |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 9 problems in this area, most recently on June 26, 2026: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 6 problems in this area, most recently on June 26, 2026: "Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 6 problems in this area, most recently on February 26, 2025: "Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs."
- How many nurses and aides work each shift, nights and weekends included?Inspectors cited 4 problems in this area, most recently on February 26, 2025: "Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis."
- How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.
Other nursing homes nearby
- Menlo Park Post Acute Portland, 0.6 mi · 2 of 5 stars · 36 citations
- Glisan Post Acute Portland, 0.7 mi · 3 of 5 stars · 34 citations
- Gateway Care and Retirement Portland, 0.9 mi · 3 of 5 stars · 34 citations
- Portland Health and Rehabilitation Portland, 1.1 mi · 1 of 5 stars · 55 citations
- Evergreen Post Acute Portland, 1.5 mi · 2 of 5 stars · 41 citations
- Marquis Mill Park Portland, 1.5 mi · 3 of 5 stars · 17 citations
- Mt. Tabor Health & Rehabilitation Portland, 2.7 mi · 2 of 5 stars · 44 citations
- Avalon Care Center - Portland Portland, 2.9 mi · 3 of 5 stars · 32 citations
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is Rose City Nursing and Rehabilitation's Medicare star rating?
- CMS rates Rose City Nursing and Rehabilitation 3 out of 5 stars overall, with 3 for health inspections, 4 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Rose City Nursing and Rehabilitation get at its last inspection?
- 5 health deficiencies at the standard inspection on June 26, 2026. The Oregon average is 9.2.
- Has Rose City Nursing and Rehabilitation been fined?
- CMS lists no fines in the last three years.
- Does Rose City Nursing and Rehabilitation accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Rose City Nursing and Rehabilitation?
- CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.