Cedar Crossings
6003 SE 136th Avenue, Portland, OR 97236 · Multnomah County · 89 certified beds · avg 79 residents/day · certified since Jul 1, 2021
Part of chain: SAPPHIRE HEALTH SERVICES (8 facilities, chain avg rating 1.9★)
2/5
Health inspection rating (on-site)
2
Serious findings on record
$32,383
Fines, last 3 years
6.43
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
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)
▲ Immediate jeopardy, one-off · Jun 17, 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 (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 10, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 9, 2023 · 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: Dec 7, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (57)
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 |
|---|---|---|
| May 22, 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. |
| May 22, 2026 | 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. |
| May 22, 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. |
| May 22, 2026 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| May 22, 2026 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| May 22, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| May 22, 2026 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| May 22, 2026 | 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. |
| Apr 3, 2026 | 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 |
| Jan 17, 2025 | 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. · from a complaint |
| Jan 17, 2025 | E · Potential for harm, repeated | 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 |
| Jan 17, 2025 | 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 |
| Jan 17, 2025 | E · Potential for harm, repeated | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint |
| Jan 17, 2025 | 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. · from a complaint |
| Jan 17, 2025 | 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. · from a complaint |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Jan 17, 2025 | 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. · from a complaint |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · from a complaint |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not dispose of garbage and refuse properly. · from a complaint |
| Jan 17, 2025 | D · Potential for harm, one-off | 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. · from a complaint |
| Jan 17, 2025 | D · Potential for harm, one-off | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · from a complaint |
| Jan 17, 2025 | B · Minimal risk, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint |
| Jan 17, 2025 | B · Minimal risk, repeated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · from a complaint |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed. · from a complaint |
| Oct 3, 2024 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint |
| Jul 17, 2024 | 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. · from a complaint |
| Jul 17, 2024 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. · from a complaint |
| Jun 17, 2024 | ▲ J · Immediate jeopardy, 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 |
| Jun 17, 2024 | F · Potential for harm, facility-wide | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. · from a complaint |
| Jun 17, 2024 | F · Potential for harm, facility-wide | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. · from a complaint |
| Mar 22, 2024 | D · Potential for harm, one-off | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint |
| Mar 22, 2024 | 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 |
| Nov 9, 2023 | ▲ 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 |
| Nov 9, 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. · from a complaint |
| Nov 9, 2023 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Aug 14, 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. |
| Aug 14, 2023 | 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. |
| Aug 14, 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. |
| Aug 14, 2023 | E · Potential for harm, repeated | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Aug 14, 2023 | 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 |
| Aug 14, 2023 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Aug 14, 2023 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Aug 14, 2023 | 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 |
| Aug 14, 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. |
| Aug 14, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Aug 14, 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. |
| Aug 14, 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. |
| Aug 14, 2023 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Aug 14, 2023 | 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. |
| Aug 14, 2023 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Aug 14, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Aug 14, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Aug 14, 2023 | D · Potential for harm, one-off | The facility did not provide routine dental care and 24-hour emergency dental care for residents. |
| Aug 14, 2023 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Aug 14, 2023 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (15 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 23 | 1 | G ▲ |
| 2024 | 10 | 1 | J ▲ |
| 2025 | 15 | 0 | E |
| 2026 | 9 | 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)
2 fines totaling $32,383.
| Date | Type | Amount / length |
|---|---|---|
| Jun 17, 2024 | Fine | $24,193 |
| Nov 9, 2023 | Fine | $8,190 |
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) | 6.43 | 5.42 | 3.95 | top 5% in Oregon; top 3% in the U.S. |
| Registered Nurse hours | 0.52 | 0.78 | 0.69 | bottom 23% in Oregon; bottom 41% in the U.S. |
| Weekend total nurse staffing | 5.75 | 4.85 | 3.50 | top 7% in Oregon; top 2% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.47 | 0.48 | 0.48 | top 34% in Oregon; top 37% in the U.S. |
| Total nursing staff turnover (%) | 64.5 | 47.4 | 45.8 | bottom 12% in Oregon; bottom 10% in the U.S. |
| RN turnover (%) | 71.4 | 51.6 | 42.9 | bottom 20% in Oregon; bottom 11% 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 5.24, RN 0.42, weekend 4.69. Staffing rating: 3/5.
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: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Becker, Andrew | Individual | 5% or Greater Direct Ownership Interest | 30% | 06/01/2020 |
| Hilty, Lisa | Individual | 5% or Greater Direct Ownership Interest | 25% | 06/01/2020 |
| Morris, Bryan | Individual | 5% or Greater Direct Ownership Interest | 5% | 06/01/2020 |
| Ricker, Kevin | Individual | 5% or Greater Direct Ownership Interest | 40% | 07/01/2020 |
| Ames, Deborah | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Ames, Deborah | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Becker, Andrew | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| Hilty, Lisa | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| Meeko, Mary | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/15/2024 |
| Meeko, Mary | Individual | ADP of the SNF | NOT APPLICABLE | 07/23/2024 |
| Morris, Bryan | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| Ricker, Kevin | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2024 |
| Sapphire Healthcare SRVS. | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/04/2021 |
| Sapphire Healthcare SRVS. | Organization | ADP of the SNF | NOT APPLICABLE | 04/16/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "How do you arrange eye and hearing care for residents, including appointments and equipment like glasses or hearing aids?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
- "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 |
|---|---|---|---|---|---|
| Cascade Terrace Post Acute | 1.0 mi | Portland, OR | ★☆☆☆☆ | 1/5 | SFF |
| Avalon Care Center - Portland | 1.2 mi | Portland, OR | ★★★☆☆ | 2/5 | abuse |
| Gracelen Care Center | 2.0 mi | Portland, OR | ★☆☆☆☆ | 1/5 | |
| Secora Rehabilitation of Cascadia | 2.1 mi | Portland, OR | ★★☆☆☆ | 2/5 | |
| Village Health Care | 2.2 mi | Gresham, OR | ★★☆☆☆ | 2/5 | |
| Portland Health and Rehabilitation | 2.9 mi | Portland, OR | ★☆☆☆☆ | 1/5 | |
| Marquis Mill Park | 3.0 mi | Portland, OR | ★★★☆☆ | 2/5 | |
| Menlo Park Post Acute | 3.5 mi | Portland, OR | ★★☆☆☆ | 2/5 | |
| Gateway Care and Retirement | 3.6 mi | Portland, OR | ★★★☆☆ | 3/5 | |
| Glisan Post Acute | 3.8 mi | Portland, OR | ★★☆☆☆ | 2/5 | |
| Marquis Centennial Post Acute Rehab | 4.0 mi | Portland, OR | ★★★★★ | 4/5 | |
| Rose City Nursing and Rehabilitation | 4.1 mi | Portland, OR | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 385284.