Cycle 1
Health 2024-10-29 · Fire 2024-10-29
17 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Portland, OR
Portland Health & Rehabilitation Center
2-star overall rating with 2-star inspections with $24,827 in total fines with 17 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
12441 Se Stark Street, Portland, OR
(503) 255-7040
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
105
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1992-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.82
Registered nurse staffing
LPN hours / resident day
0.85
Licensed practical nurse staffing
Aide hours / resident day
2.88
Nurse aide staffing
Weekend hours
3.90
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
47%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.5%
4.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.8% |
95.2%
5.4 pts worse
|
95.5%
5.7 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.5% |
2.4%
1.9 pts better
|
3.3%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
4.7%
1.4 pts worse
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.1% |
5.0%
3.9 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.4% |
12.5%
1.1 pts better
|
19.6%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 23.7% |
14.7%
9 pts worse
|
16.7%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.2% |
24.1%
0.9 pts better
|
16.3%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
15.8%
6.7 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
1.7%
0.9 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.0%
2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.9% |
22.2%
1.7 pts worse
|
19.8%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
6.5%
0.1 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
85.4%
6.3 pts better
|
81.7%
10 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.7%
1.7 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.7% |
81.2%
4.5 pts better
|
79.7%
6 pts better
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-17 · Fire 2023-07-17
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-06-21 · Fire 2022-06-21
6 health deficiencies
Top issue: Nursing and Physician Services (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-28
F · Potential for more than minimal harm
2023-07-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-16
F · Potential for more than minimal harm
2022-06-21
K255 · Egress Deficiencies
Fire Safety
Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.
Corrected 2022-07-12
F · Potential for more than minimal harm
2022-06-21
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-07-12
F · Potential for more than minimal harm
2022-06-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-12
F · Potential for more than minimal harm
2022-06-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-07-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-18
G · Actual harm
2024-10-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-28
G · Actual harm
2024-10-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-28
E · Potential for more than minimal harm
2024-10-29
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-11-28
E · Potential for more than minimal harm
2024-10-29
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-11-28
E · Potential for more than minimal harm
2024-10-29
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-11-28
E · Potential for more than minimal harm
2024-10-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-29
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-29
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-29
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-29
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-29
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-10-29
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-03-21
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-02-09
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-09
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-02-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-03-11
E · Potential for more than minimal harm
2023-07-17
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-08-16
E · Potential for more than minimal harm
2023-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-16
E · Potential for more than minimal harm
2022-06-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-12
Penalties and ownership
What sits behind the stars
$24,827
2024-10-29
Fine
Fine · fine $24,827
Fine
Ownership
Ch Pacific Northwest Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Witzcorp Global LLC
5% Or Greater Indirect Ownership Interest · Organization
Ceesay, Basiru
Operational/Managerial Control · Individual
Couve Financial Services LLC
Operational/Managerial Control · Organization
Couve Healthcare Consulting LLC
Operational/Managerial Control · Organization
Dezember, Duffy
Operational/Managerial Control · Individual
Morris, Christopher
Operational/Managerial Control · Individual
Odenthal, Jason
Operational/Managerial Control · Individual
Oregon SNF Consulting LLC (De)
Operational/Managerial Control · Organization
Pacific Northwest Opco Management LLC
Operational/Managerial Control · Organization
Perlman, Harold
Operational/Managerial Control · Individual
Portland SNF Operations LLC
Operational/Managerial Control · Organization
Spielman, Shimon
Operational/Managerial Control · Individual
Yenowitz, Yitzchok
Operational/Managerial Control · Individual
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#3
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