Portland Health And Rehabilitation
PORTLAND HEALTH AND REHABILITATION in PORTLAND, OR — inspection on February 27, 2026.
Found 18 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
his or her rights.
interview and record review, it was determined that the facility failed to ensure care was provided in
residents at risk for undignified care.
Findings include:Resident 67 was admitted to the facility in 6/2024 with diagnoses including hemiplegia (loss of movement and/or sensation in half of the body), depression, and anxiety.An 8/14/25 Annual MDS assessment determined Resident 67 had normal cognitive function.An 8/6/25 facility investigation report included the following statements from Resident 39, Resident 67, Staff 12 (LPN), and Staff 22 (CNA):- Resident 39 was in a shared room with Resident 67 and witnessed the incident. Resident 39 stated Staff 22 entered and exited Resident 67's room loudly.
When confronted about slamming the door, Staff 22 and Resident 67 raised their voices at each other to which Resident 67 became upset.- Resident 67 stated Staff 22 was moving quickly around Resident 67's room and slammed the door upon exit. Resident 67 asked Staff 22 why he slammed the door to which Staff 22 responded and asked, What are you going to do about it?- Staff 12 stated he observed Staff 22 and Resident 67 cursing at each other inside Resident 67's room as well as at the nurse's station when Resident 67 was filling out a grievance form.- Staff 22 stated Resident 67 was talking to Staff 22 with attitude and cursing at him regarding closing the door loudly.
Staff 22 stated Resident 67 threatened to hit him to which Staff 22 asked Resident 67 what are you going to do? Resident 67 then stated she/he was going to file a complaint on Staff 22.
Staff 22 responded by saying, do what you want. I don't even care. I'm not working with disrespectful residents like [her/him] no more.An 8/11/25 Incident Report concluded the incident between Resident 67 and Staff 22 was a verbal dispute provoked by both Resident 67 and Staff 22.On 2/24/26 at 12:09 PM Resident 67 stated Staff 22 was moving quickly and slamming doors on 8/4/25. Resident 67 stated he told Staff 22 to leave the room. Resident 67 stated Staff 22 said something like, what are you going to do about it. Resident 67 stated her/his [NAME] was hurt more than anything after how Staff 22 interacted with her/him.On 2/24/26 at 12:24 PM Resident 39 stated after Staff 22 had slammed the door, Resident 67 was upset. Resident 39 stated she/he recalled Staff 22 talking back to Resident 67 disrespectfully.On 2/24/26 at 12:37 PM Staff 12 (LPN) stated he witnessed the incident between Resident 67 and Staff 22.
Staff 12 stated he overheard two people shouting at each other and he had to intervene.
Staff 12 stated Staff 22 was very rude towards Resident 67 who was initially upset but did not appear bothered the following day.On 2/24/26 and 2/25/26 attempts to communicate with Staff 22 were made but were unsuccessful. On 2/27/26 at 11:21 AM Staff 5 (Business Office Manager/Human Resources) stated Resident 67 tended to be explosive and confrontational, but Staff 22 should not have matched Resident 67 behavior and treated Resident 67 disrespectfully.
Staff 5 stated Staff 22's behavior was unprofessional.On 2/27/26 at 11:48 AM Staff 2 (DNS) confirmed the incident which occurred on 8/6/25 and Staff 22's behavior with slamming the door and yelling back at Resident 67 was unprofessional and undignified.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
385228 02/27/2026
Portland Health and Rehabilitation 12441 SE Stark Street Portland, OR 97233
Federal health inspectors cited PORTLAND HEALTH & REHABILITATION CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0565 during a standard health inspection conducted on 2026-02-27.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to organize and participate in resident/family groups in the facility.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of PORTLAND HEALTH & REHABILITATION CENTER.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-15.
Federal health inspectors cited PORTLAND HEALTH & REHABILITATION CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0576 during a standard health inspection conducted on 2026-02-27.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Ensure residents have reasonable access to and privacy in their use of communication methods.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of PORTLAND HEALTH & REHABILITATION CENTER.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-15.
Federal health inspectors cited PORTLAND HEALTH & REHABILITATION CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0578 during a standard health inspection conducted on 2026-02-27.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of PORTLAND HEALTH & REHABILITATION CENTER.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-15.
Staff 2 stated he expected all residents to be free from abuse.
- Resident 48 was admitted to the facility in 1/2025 with a diagnosis of pressure ulcer.
Resident 48's 10/14/25 quarterly MDS and 1/13/26 Annual MDS revealed Resident 48 was cognitively intact. Resident 68's 10/1/25 Montreal Cognitive Assessment revealed she/he had severe cognitive impairment.
The facility's 10/21/25 Allegation of Sexual Inappropriate Behavior investigation revealed on 10/21/25 Staff 27 (CNA) heard Resident 48 call out.
Staff 27 entered Resident 48's room and observed Resident 68 in her/his wheelchair. Resident 48 reported to Staff 27 Resident 68 touched her/his thigh inappropriately. Resident 68 denied the interaction. Resident 68 was removed from Resident 48's room and was placed on 1:1 supervision.
On 2/23/26 at 10:05 AM Resident 48 stated Resident 68 came in her/his room and Resident 68 rubbed her/his hands on Resident 48's legs. Resident 48 stated it upset her/him for about a month but was now over it.
On 2/24/26 at 1:46 PM Staff 3 (RNCM) stated prior to Resident 68 entering Resident 48's room, Resident 68 was usually at the nurse's station and not going into other resident rooms.
On 2/24/26 at 6:15 PM and 2/26/26 at 3:31 PM telephone messages were left for Staff 27. A return call was not received.
On 2/26/26 at 4:07 PM Staff 2 (DNS) stated Resident 68 touched Resident 48 in a nonconsensual manner.
385228 02/27/2026
Portland Health and Rehabilitation 12441 SE Stark Street Portland, OR 97233
Federal health inspectors cited PORTLAND HEALTH & REHABILITATION CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0604 during a standard health inspection conducted on 2026-02-27.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of PORTLAND HEALTH & REHABILITATION CENTER.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-15.
Federal health inspectors cited PORTLAND HEALTH & REHABILITATION CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0605 during a standard health inspection conducted on 2026-02-27.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of PORTLAND HEALTH & REHABILITATION CENTER.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-15.
authorities.
abuse within the mandated timeframe for 3 of 4 sampled residents (#s 6, 65 and 66) for 1 of 5 FRI
facility's revised 2022 Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property and Exploitation revealed it was expected for the facility to immediately report all suspected and/or allegations of abuse in accordance with state and federal law.
The policy defined immediately to mean as soon as possible but no later than two-hours after an allegation of abuse was made.On 9/26/25 at 11:09 AM, the state agency (SA) received a FRI for a 9/25/25 at 9:00 AM alleged abuse with Resident 6, Resident 65 and Resident 66.On 2/26/26 at12:28 PM Staff 2 (DNS) stated on 9/26/25 he completed the FRI and sent it to the SA and he was not aware of any other attempts to contact the SA within the required two-hour timeframe.On 2/26/26 at 12:41 PM, Staff 1 (Administrator) confirmed the 9/26/25 FRI for allegations of abuse was submitted to the SA late and he expected all allegations of abuse to be reported to the SA within the required two-hour reporting timeframe.
385228 02/27/2026
Portland Health and Rehabilitation 12441 SE Stark Street Portland, OR 97233
Federal health inspectors cited PORTLAND HEALTH & REHABILITATION CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0628 during a standard health inspection conducted on 2026-02-27.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of PORTLAND HEALTH & REHABILITATION CENTER.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-15.
Federal health inspectors cited PORTLAND HEALTH & REHABILITATION CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0636 during a standard health inspection conducted on 2026-02-27.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of PORTLAND HEALTH & REHABILITATION CENTER.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-15.
residents received required assistance with ADL care for 2 of 2 sampled residents (#s 12 and 32)
Resident 12 was admitted to the facility in 1/2021 with diagnoses of stroke and dementia.Resident 12's Annual MDS dated [DATE] indicated the resident was dependent on staff for personal hygiene and grooming.A review of Resident 12's care plan dated 1/19/26 revealed no interventions addressing facial hair removal or grooming preferences. Resident 12 was observed on 2/24/26 at 9:14 AM and on 2/25/26 at 8:55 AM with a significant amount of visible chin hair. On 2/24/26 at 9:16 AM, Resident 12 stated she/he did not want to have facial hair and would like staff to take care of her/his unwanted hair. On 2/25/26 at 10:13 AM, Staff 14 (CNA) observed Resident 12 's facial hair and stated her/his facial hair is really long. On 2/25/26 at 10:35 AM, Staff 18 (CNA) observed Resident 12's facial hair and stated her/his chin hair is long and needs to be shaved.On 2/25/26 at 3:09 PM, Staff 10 (RN) stated there were no care plan interventions addressing Resident 12's facial hair and acknowledged she had observed facial hair on Resident 12's chin. On 2/25/26 at 4:27 PM, Staff 2 (DNS) stated he was unaware Resident 12 had long chin hairs and acknowledged it was not proper ADL care.
Staff 2 stated the expectation was for residents to be offered grooming on shower days and as needed. 2. Resident 32 was admitted to the facility in 12/2024 with diagnoses of fracture and legal blindness. Resident 32's annual MDS dated [DATE] indicated Resident 32 was dependent on staff for ADL care related to toileting and hygiene. A review of Resident 32's care plan dated 12/18/25 indicated she/he was dependent on staff for toileting and required assistance with toilet transfers, including setup and clean-up. A 9/2/25 Facility Reported Incident revealed morning staff found Resident 32 on 8/31/25 soiled with a bowel movement.
The resident's brief and bed linens were saturated with fecal matter, and the floor surrounding the bed was also soiled.On 2/26/26 at 9:11 AM, Staff 12 (LPN) stated he worked the morning of 8/31/25 and observed Resident 32's bedding and the surrounding floor covered in feces.
Staff 12 stated he had never observed Resident 32 in that condition before. On 2/26/26 at 9:27 AM, Staff 13 (Medical Records/CNA) stated on the morning of 8/31/25, she observed Resident 32 with feces present on the bed, floor, sleepwear, and on one of the resident's legs.
Staff 13 stated it appeared the resident had been left soiled for an extended period of time. On 2/26/26 at 12:15 PM, Staff 15 (Former CNA) stated he worked the morning shift on 8/31/25.
Staff 15 reported when he checked on Resident 32, the resident's bed and surrounding floor were soiled.
Staff 15 stated the resident required a full bedding change and a head-to-toe shower. On 2/26/26 at 12:52 PM, Staff 2 (DNS) stated he was aware of the incident on the morning of 8/31/25.
Staff 2 acknowledged Resident 32 was found in a soiled condition, with feces on the bed, floor, and on her/his sleepwear, as documented in the Facility Reported Incident.
Staff 2 stated it was his expectation residents requiring ADL assistance, received care consistent with their individualized care plans. On 2/27/26 at 9:11 AM, Staff 19 (Former CNA) stated he worked the night shift beginning on 8/30/25.
Staff 19 stated he was unaware Resident 32 was incontinent and required assistance with toileting.
Staff 19 confirmed he did not provide incontinent care for Resident 32 during his shift or the morning of 8/31/25.
385228 02/27/2026
Portland Health and Rehabilitation 12441 SE Stark Street Portland, OR 97233
Federal health inspectors cited PORTLAND HEALTH & REHABILITATION CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0679 during a standard health inspection conducted on 2026-02-27.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide activities to meet all resident's needs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of PORTLAND HEALTH & REHABILITATION CENTER.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-15.
assistance. (There was no assessment related to the alleged allegation of abuse and Resident 37's
now over it. On 2/26/26 at 9:41 AM Staff 24 (RN) stated if a resident had a change of condition, or
completed each shift (every eight hours) and the note should address the area of concern being monitored.
The alert charting was to be done for at least 72 hours but longer if needed. On 2/24/26 at 1:46 PM and 2/26/26 at 4:06 PM Staff 2 (DNS) stated he completed the investigation related to this incident would expect staff would monitor and document on a resident every shift for at least 72 hours and it was to be specific to the concern identified. 3. Resident 55 was admitted to the facility in 9/2021 with a diagnosis of heart disease. Resident 55's 12/4/25 Order Details report revealed zinc oxide (treats skin irritations) was to be applied every two hours. Resident 55's 12/2025 TAR revealed zinc oxide was applied every two hours on most shifts. Resident 55's 1/2026 and 2/2026 TAR did not include staff were to apply zinc every two hours. On 2/26/26 at 11:19 AM Staff 17 (CNA) stated the CNAs applied barrier cream to Resident 55's skin every two hours.
The nurses had to apply the medicated cream. On 2/26/26 at 2:29 PM AM Staff 9 (RN) stated if a resident required zinc oxide cream to be applied it was documented on the TAR. On 2/26/26 at 4:21 PM Staff 2 (DNS) stated Zinc oxide was a medicated cream, and the licensed nurses were to administer the medication.
Staff 2 acknowledged the order was not on the current TARs and was not documented as administered. 4. Resident 62 was admitted to the facility in 1/2026 with a diagnosis of seizures. Resident 62's 1/26/26 Progress Note by Staff 3 (RNCM) revealed staff observed her/him at the nurse's station and she/he was shaking and was unresponsive.
The note indicated a CNA stated that [she/he] did this again yesterday . Resident 62's clinical record did not have an assessment of shaking or unresponsiveness on 1/25/26. On 2/27/26 at 11:11 AM Staff 3 stated she did not recall the CNA who reported Resident 62 had a shaking and unresponsive event on 1/25/26.
Staff 3 stated if a resident had a change in condition the CNA should report to the nurse and the nurse should document an assessment. On 2/27/26at 11:25 AM Staff 2 (DNS) stated if a resident had a change of condition the CNA was to report to the nurse, the physician was to be notified, and the resident was to be monitored. 5. Resident 63 was admitted to the facility in 12/2025 with diagnoses of kidney disease and heart failure. Resident 12/4/25 hospital Physician Discharge Orders included Resident 62 was to be weighed upon admission to the facility and daily.
Staff were to call the physician if Resident 63 gained three pounds in more than 24 hours or five pound in five days. Resident 62's weight log revealed the following: -12/625 202 pounds.-12/8/25 209.4 pounds.-12/925 209 pounds.-12/10/25 207 pounds.-12/1125 223 pounds.-12/15/25 200 pounds.-12/16/25 200.2 pounds.-12/17/25 200 pounds.-12/19/25 200.2 pounds.-12/20/25 209.2 pounds.-12/23/25 211.4 pounds. Resident 63's clinical record did not have documentation to indicate her/his physician was notified of weight gains per orders on 12/8/26, 12/11/25, and 12/20/25. On 2/26/26 at 4:26 PM Staff 2 (DNS) stated Resident 63 was on dialysis and weight fluctuations were expected.
Staff did not call the physician with weight gain per physician orders but should have clarified the order due to dialysis related weight fluctuations.
Federal health inspectors cited PORTLAND HEALTH & REHABILITATION CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2026-02-27.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of PORTLAND HEALTH & REHABILITATION CENTER.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-15.
Federal health inspectors cited PORTLAND HEALTH & REHABILITATION CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0698 during a standard health inspection conducted on 2026-02-27.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of PORTLAND HEALTH & REHABILITATION CENTER.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-15.
Federal health inspectors cited PORTLAND HEALTH & REHABILITATION CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2026-02-27.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: 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.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of PORTLAND HEALTH & REHABILITATION CENTER.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-15.
Federal health inspectors cited PORTLAND HEALTH & REHABILITATION CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0847 during a standard health inspection conducted on 2026-02-27.
Category: Administration Deficiencies
The facility was found deficient in the following area: Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of PORTLAND HEALTH & REHABILITATION CENTER.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-15.
Federal health inspectors cited PORTLAND HEALTH & REHABILITATION CENTER in PORTLAND, OR for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2026-02-27.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of PORTLAND HEALTH & REHABILITATION CENTER.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-04-15.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.