Portland Health and Rehabilitation

Name: Portland Health and Rehabilitation
Address: 12441 SE STARK STREET, Portland, OR, 97233, US
Telephone: 5032557040

12441 SE Stark Street, Portland, OR 97233 · Multnomah County · 105 certified beds · avg 55 residents/day · certified since Jan 1, 1992

Part of chain: EVERGREEN HEALTHCARE GROUP (44 facilities, chain avg rating 2.5★)

1/5

Health inspection rating (on-site)

Serious findings on record

$24,827

Fines, last 3 years

5.10

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Oct 29, 2024 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Nov 28, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Oct 29, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Nov 28, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (55)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Feb 27, 2026	E · Potential for harm, repeated	The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Feb 27, 2026	E · Potential for harm, repeated	The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately.
Feb 27, 2026	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Feb 27, 2026	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Feb 27, 2026	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Feb 27, 2026	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Feb 27, 2026	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Feb 27, 2026	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Feb 27, 2026	D · Potential for harm, one-off	The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Feb 27, 2026	D · Potential for harm, one-off	The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
Feb 27, 2026	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Feb 27, 2026	D · Potential for harm, one-off	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
Feb 27, 2026	D · Potential for harm, one-off	The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that.
Feb 27, 2026	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Feb 27, 2026	D · Potential for harm, one-off	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Feb 27, 2026	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Feb 27, 2026	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Feb 27, 2026	D · Potential for harm, one-off	The facility did not properly inform residents or their representatives about arbitration agreements — contracts that give up the right to sue in court — including their right to refuse to sign.
Jul 11, 2025	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jul 11, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Oct 29, 2024	▲ G · Actual harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Oct 29, 2024	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Oct 29, 2024	E · Potential for harm, repeated	The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Oct 29, 2024	E · Potential for harm, repeated	The facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials.
Oct 29, 2024	E · Potential for harm, repeated	The facility did not observe each nurse aide's job performance or provide regular training as required.
Oct 29, 2024	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Oct 29, 2024	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Oct 29, 2024	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Oct 29, 2024	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Oct 29, 2024	D · Potential for harm, one-off	The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
Oct 29, 2024	D · Potential for harm, one-off	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Oct 29, 2024	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it.
Oct 29, 2024	D · Potential for harm, one-off	The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
Oct 29, 2024	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Oct 29, 2024	D · Potential for harm, one-off	The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life.
Mar 21, 2024	D · Potential for harm, one-off	The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint
Feb 9, 2024	F · Potential for harm, facility-wide	The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint
Feb 9, 2024	E · Potential for harm, repeated	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Feb 9, 2024	E · Potential for harm, repeated	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint
Jul 17, 2023	E · Potential for harm, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jul 17, 2023	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 17, 2023	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Jul 17, 2023	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jul 17, 2023	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jul 17, 2023	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jul 17, 2023	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jul 17, 2023	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Jul 17, 2023	D · Potential for harm, one-off	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Jul 17, 2023	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jul 17, 2023	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Jul 17, 2023	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Jul 17, 2023	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Jul 17, 2023	D · Potential for harm, one-off	The facility did not provide routine dental care and 24-hour emergency dental care for residents.
Jul 17, 2023	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Jul 17, 2023	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (15 → 18).

Year	Citations	Serious (G–L)	Worst severity that year
2023	16	0	E
2024	19	2	G ▲
2025	2	0	E
2026	18	0	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $24,827.

Date	Type	Amount / length
Oct 29, 2024	Fine	$24,827

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Oregon avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	5.10	5.42	3.95	bottom 29% in Oregon; top 12% in the U.S.
Registered Nurse hours	0.96	0.78	0.69	top 20% in Oregon; top 18% in the U.S.
Weekend total nurse staffing	4.44	4.85	3.50	bottom 26% in Oregon; top 13% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.43	0.48	0.48	top 41% in Oregon; top 42% in the U.S.
Total nursing staff turnover (%)	50.0	47.4	45.8	bottom 39% in Oregon; bottom 38% in the U.S.
RN turnover (%)	53.3	51.6	42.9	top 50% in Oregon; bottom 31% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.68, RN 0.88, weekend 4.08. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
CH Pacific Northwest Holdings LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	08/31/2023
Herzka, Yisroel	Individual	Indirect Ownership Interest	NOT APPLICABLE	08/31/2023
Pacific Northwest SNF Operations Holdings (or) LLC	Organization	Direct Ownership Interest	NOT APPLICABLE	08/31/2023
Pacific Northwest SNF Operations Holdings LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	08/31/2023
Portland SNF Operations LLC	Organization	Direct Ownership Interest	NOT APPLICABLE	08/31/2023
Witzcorp Global LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	08/31/2023
Yenowitz, Yitzchok	Individual	Indirect Ownership Interest	NOT APPLICABLE	08/31/2023
Ceesay, Basiru	Individual	Operational/Managerial Control	NOT APPLICABLE	08/31/2023
Ceesay, Basiru	Individual	ADP of the SNF	NOT APPLICABLE	08/31/2023
Cepeda, Mylene	Individual	Managing Control - Governing Body	NOT APPLICABLE	08/31/2023
Cepeda, Mylene	Individual	ADP of the SNF	NOT APPLICABLE	08/31/2023
CH Pacific Northwest Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	08/31/2023
Couve Financial Services LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	08/31/2023
Couve Financial Services LLC	Organization	ADP of the SNF	NOT APPLICABLE	08/31/2023
Couve Healthcare Consulting LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	08/31/2023
Couve Healthcare Consulting LLC	Organization	ADP of the SNF	NOT APPLICABLE	03/31/2025
Dezember, Duffy	Individual	Operational/Managerial Control	NOT APPLICABLE	08/31/2023
Dezember, Duffy	Individual	ADP of the SNF	NOT APPLICABLE	08/31/2023
Herzka, Yisroel	Individual	ADP of the SNF	NOT APPLICABLE	08/31/2023
Morris, Christopher	Individual	Operational/Managerial Control	NOT APPLICABLE	08/31/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"Does your facility have an active resident council, and how does management respond to its concerns?"
"How can my family member make private phone or video calls, and can we see where?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Menlo Park Post Acute	0.6 mi	Portland, OR	★★☆☆☆	2/5
Gateway Care and Retirement	1.0 mi	Portland, OR	★★★☆☆	3/5
Marquis Mill Park	1.1 mi	Portland, OR	★★★☆☆	2/5
Glisan Post Acute	1.1 mi	Portland, OR	★★☆☆☆	2/5
Rose City Nursing and Rehabilitation	1.1 mi	Portland, OR	★★★☆☆	3/5
Avalon Care Center - Portland	1.8 mi	Portland, OR	★★★☆☆	2/5	abuse
Secora Rehabilitation of Cascadia	2.2 mi	Portland, OR	★★☆☆☆	2/5
Cascade Terrace Post Acute	2.5 mi	Portland, OR	★☆☆☆☆	1/5	SFF
Gracelen Care Center	2.5 mi	Portland, OR	★☆☆☆☆	1/5
Evergreen Post Acute	2.6 mi	Portland, OR	★★☆☆☆	2/5
Mt. Tabor Health & Rehabilitation	2.9 mi	Portland, OR	★★☆☆☆	2/5
Cedar Crossings	2.9 mi	Portland, OR	★★★☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Portland →

Facility data as of CMS processing date 2026-08-01. CCN 385228.

The Care File

Visit checklist — Portland Health and Rehabilitation

12441 SE Stark Street, Portland, OR 97233 · 5032557040

Health inspection rating 1/5 · CMS overall 1/5· Fines (3y): $24,827

Most serious findings on record:

▲ Oct 29, 2024 (F-0684, Actual harm, one-off): The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
▲ Oct 29, 2024 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "Does your facility have an active resident council, and how does management respond to its concerns?"
☐ "How can my family member make private phone or video calls, and can we see where?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 385228 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)