Gresham Post Acute Care and Rehabilitation
405 NE 5th Street, Gresham, OR 97030 · Multnomah County · 78 certified beds · avg 71 residents/day · certified since Feb 23, 1989
Part of chain: SAPPHIRE HEALTH SERVICES (8 facilities, chain avg rating 1.9★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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 · May 23, 2023 · F-0689
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: Jun 22, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · May 23, 2023 · F-0725
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.
Why it matters: Understaffing means longer waits for help, missed care, and higher risk of falls and other harm.
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: Jun 22, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 19, 2025 · F-0686
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.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
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: Jan 22, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 17, 2025 · 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: Jul 1, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Aug 30, 2024 · F-0686
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.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
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: Oct 14, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, facility-wide · May 23, 2023 · F-0865
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.
Why it matters: Without a real quality improvement process, the same care problems tend to repeat instead of getting fixed.
Severity (I): Residents were actually harmed and the failure existed throughout the facility. Rare and serious.
Corrected: Jun 22, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (51)
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 |
|---|---|---|
| Dec 19, 2025 | ▲ G · Actual 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. |
| Dec 19, 2025 | 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. |
| Dec 19, 2025 | 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. |
| Dec 19, 2025 | 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 |
| Dec 19, 2025 | 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. |
| Dec 19, 2025 | 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. |
| Dec 19, 2025 | 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. |
| Dec 19, 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 |
| Dec 19, 2025 | 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. |
| Dec 19, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Dec 19, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Dec 19, 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. |
| Dec 19, 2025 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Dec 19, 2025 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Dec 19, 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. |
| Dec 19, 2025 | 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. |
| Dec 19, 2025 | D · Potential for harm, one-off | 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. |
| Dec 19, 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. |
| Nov 24, 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 |
| Jun 17, 2025 | ▲ 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 |
| Aug 30, 2024 | ▲ G · Actual 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. |
| Aug 30, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 30, 2024 | E · Potential for harm, repeated | 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. |
| Aug 30, 2024 | 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 30, 2024 | D · Potential for harm, one-off | 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. |
| Aug 30, 2024 | D · Potential for harm, one-off | 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. |
| Aug 30, 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. |
| Aug 30, 2024 | 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 30, 2024 | 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. |
| Aug 30, 2024 | 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. |
| Aug 30, 2024 | 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. |
| Aug 30, 2024 | 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. |
| Oct 31, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| May 23, 2023 | ▲ 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. |
| May 23, 2023 | ▲ J · Immediate jeopardy, one-off | 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. |
| May 23, 2023 | ▲ I · Actual 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. |
| May 23, 2023 | E · Potential for harm, repeated | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| May 23, 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. |
| May 23, 2023 | 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. |
| May 23, 2023 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| May 23, 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. |
| May 23, 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. |
| May 23, 2023 | 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. |
| May 23, 2023 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| May 23, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| May 23, 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. |
| May 23, 2023 | D · Potential for harm, one-off | 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. |
| May 23, 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. |
| May 23, 2023 | D · Potential for harm, one-off | 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 23, 2023 | D · Potential for harm, one-off | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. |
| May 23, 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. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (12 → 18).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 19 | 3 | J ▲ |
| 2024 | 12 | 1 | G ▲ |
| 2025 | 20 | 2 | G ▲ |
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 $76,801.
| Date | Type | Amount / length |
|---|---|---|
| Jun 17, 2025 | Fine | $19,949 |
| Aug 30, 2024 | Fine | $56,852 |
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) | 4.37 | 5.42 | 3.95 | bottom 4% in Oregon; top 27% in the U.S. |
| Registered Nurse hours | 0.70 | 0.78 | 0.69 | top 47% in Oregon; top 36% in the U.S. |
| Weekend total nurse staffing | 3.98 | 4.85 | 3.50 | bottom 8% in Oregon; top 23% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.92 | 0.48 | 0.48 | top 7% in Oregon; top 8% in the U.S. |
| Total nursing staff turnover (%) | 66.2 | 47.4 | 45.8 | bottom 10% in Oregon; bottom 9% in the U.S. |
| RN turnover (%) | 73.7 | 51.6 | 42.9 | bottom 13% in Oregon; bottom 9% 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 6.25, RN 1.00, weekend 5.69. 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: 3/5 · long-stay residents: 3/5 · short-stay residents: 3/5
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% | 01/06/2020 |
| Hilty, Lisa | Individual | 5% or Greater Direct Ownership Interest | 25% | 01/06/2020 |
| Morris, Bryan | Individual | 5% or Greater Direct Ownership Interest | 5% | 01/06/2020 |
| Ricker, Kevin | Individual | 5% or Greater Direct Ownership Interest | 40% | 01/06/2020 |
| Ferdowsali, Kameron | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Ferdowsali, Kameron | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Sapphire Healthcare SRVS. | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2020 |
| Sapphire Healthcare SRVS. | Organization | ADP of the SNF | NOT APPLICABLE | 10/07/2025 |
| Welker, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/12/2024 |
| Welker, David | Individual | ADP of the SNF | NOT APPLICABLE | 08/12/2024 |
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?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How does your quality improvement program work, and can you share a recent example of a problem you found and fixed?"
- "How do you explain health changes and treatment options to residents and their families?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
- "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 |
|---|---|---|---|---|---|
| Fairlawn Health and Rehabilitation of Cascadia | 1.5 mi | Gresham, OR | ★★★★★ | 4/5 | |
| Marquis Centennial Post Acute Rehab | 1.9 mi | Portland, OR | ★★★★★ | 4/5 | |
| Village Health Care | 2.5 mi | Gresham, OR | ★★☆☆☆ | 2/5 | |
| Village Manor of Cascadia | 2.6 mi | Wood Village, OR | ★★★★☆ | 3/5 | |
| Regency Gresham Nursing & Rehabilitation Center | 3.0 mi | Gresham, OR | ★★★★★ | 4/5 | |
| Cedar Crossings | 4.6 mi | Portland, OR | ★★★☆☆ | 2/5 | |
| Avalon Care Center - Portland | 4.9 mi | Portland, OR | ★★★☆☆ | 2/5 | abuse |
| Portland Health and Rehabilitation | 5.5 mi | Portland, OR | ★☆☆☆☆ | 1/5 | |
| Cascade Terrace Post Acute | 5.5 mi | Portland, OR | ★☆☆☆☆ | 1/5 | SFF |
| Menlo Park Post Acute | 5.7 mi | Portland, OR | ★★☆☆☆ | 2/5 | |
| Lacamas Creek Post Acute | 6.1 mi | Camas, WA | ★★★★★ | 5/5 | |
| Rose City Nursing and Rehabilitation | 6.2 mi | Portland, OR | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 385190.