405 Ne 5th Street, Gresham, OR 97030 · Multnomah County · (503) 666-5600
78 certified beds, about 71 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1989
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385190 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on December 19, 2025, inspectors cited 18 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 51 health citations since May 2023, 6 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists 2 fines totaling $76,801 in the last three years; the largest was $56,852, and the latest is dated June 17, 2025.
Nurses and nurse aides worked 6.25 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 1.00 of those hours.
66.2% of nursing staff left within the year CMS measured (Oregon average 47.4%).
CMS links it to Sapphire Health Services, an affiliated group of 8 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 51 health citations on file.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assess, implement treatment and provide on-going monitoring to prevent pressure ulcers for 1 of 2 sampled residents (#30) reviewed for pressure ulcers. This failure resulted in Resident 30 developing a facility acquired Stage 2 pressure ulcer (a shallow wound involving partial skin loss).
Inspectors wroteBased on interview and record review it was determined the facility failed to provide the risk and benefits for the use of a psychotropic medication to a resident prior to administration for 1 of 5 sampled residents (#2) reviewed for medications. This placed residents at risk for lack of informed consent.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure call devices and overbed lights were accessible for 2 of 5 sampled residents (#s 5 and 30) reviewed for accommodation of needs. This placed residents at risk for delayed assistance and unmet needs.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure personal fans were clean for 2 of 2 sampled residents (#s 44 and 67) reviewed for personal fans and 1 of 1 sampled resident (#10) reviewed for privacy curtains. This placed residents at risk for not having a clean hygienic and comfortable homelike environment.
Inspectors wroteBased on interview and record review it was determined the facility failed to accurately reassess for ongoing restraint use for 1 of 1 sampled resident (#58) reviewed for restraints. This placed residents at risk for unnecessary restraint use and reduced communication.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accurately identify restraint use in the comprehensive assessment for 1 of 1 sampled resident (#58) reviewed for restraints. This placed residents at risk for injuries and unidentified care needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide the necessary care and assistance to maintain good grooming for 2 of 3 sampled residents (#s 5 and 58) reviewed for ADLs. This placed residents at risk for poor grooming.
Inspectors wroteBased on observations, interviews and record review it was determined the facility failed to reassess resident's ability to swallow medications for 1 of 6 sampled residents (#12) reviewed for medications, failed to complete neurological checks for 1 of 1 sampled resident (#6) reviewed for accidents and obtain a physician order for 1 of 1 sampled resident (#8) reviewed for suction devices. This placed residents at risk for side effects related to missed medications, unassessed injuries and medical complications.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow up on resident's request for new hearing aids for 1 of 2 sampled resident (#6) reviewed for hearing. This placed resident at risk for unmet needs.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to assess bowel and bladder continence for 1 of 1 sampled resident (#12) reviewed for bladder and bowel incontinence. This placed residents at risk for incontinence.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow the nutritional orders and care plan for 1 of 1 sampled resident (#58) reviewed for assisted nutrition and hydration. This placed residents at risk for inadequate nutrition and dehydration.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure resident respiratory equipment was maintained for 2 of 3 sampled residents (#s 10 and 68) reviewed for respiratory care. This placed residents at risk for increased respiratory concerns.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident received trauma informed care for 1 of 1 sampled residents (# 55) reviewed for behavioral and emotional care needs. This placed resident at risk for re-traumatization. Findings Include:The facility's undated Trauma Informed Care and Culturally Competent Care policy revealed the resident assessment process involved an in-depth evaluation of trauma-related symptoms and the identification of triggers. The policy revealed the facility's process involved the development of an individualized care plan to address past trauma, and to identify and decrease exposure to triggers that may re-traumatize the resident. Resident 55 was admitted to the facility on [DATE] with diagnoses including Post-Traumatic Stress Disorder (PTSD) and sleep terrors. [...]
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to conduct a safety assessment and obtain orders prior to initiating the use of bed rails for 1 of 2 sampled resident (#18) reviewed for bed rails. This placed residents at risk for potential accidents and/or injuries.
Inspectors wroteBased on interview and record review it was determined the facility failed to address pharmacy recommendations for 1 of 5 sampled residents (#3) reviewed for medications. This placed residents at risk for adverse outcomes associated with medication administration.
Inspectors wroteBased on observations, interviews, and record review it was determined the facility failed to ensure the medication error rate was less than five percent for 2 of 29 attempts. This placed residents at risk for adverse side effects related to medication errors.
Inspectors wroteBased on observations, interviews, and record review it was determined the facility failed to ensure medications were not expired for 1 of 4 medication carts and 1 of 2 medication room. This placed residents at risk for decreased efficiency of medications.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 5 sampled resident (#68) reviewed for respiratory care. This placed residents at risk for exposure and contraction of infectious diseases.
Inspectors wroteBased on interview and record review it was determined the facility failed to administer anti-seizure medication according to physician orders for 1 of 3 sampled residents (# 1) reviewed for medications. This placed residents at risk for adverse medication side effects and increased episodes of seizures.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received treatment and services necessary to prevent constipation for 1 of 3 sampled residents (#100) reviewed for bowel care. This failure resulted in the resident experiencing no bowel movements for seven days, which led to the need for emergency department evaluation and treatment due to a fecal impaction (a severe form of constipation where a large, hard mass of stool becomes lodged in the colon or rectum, preventing normal bowel movements). The facility's Bowel Management policy dated 4/2025 indicated the following: -Resident's bowel movements were recorded daily and reviewed by the licensed nurse. [...]
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to initiate treatment for a pressure injury present upon admission for 1 of 2 sampled residents (#173) reviewed for pressure ulcers. The wound progressed from a DTI (deep tissue injury) to unstageable and required medical intervention for debridement.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure staff wore appropriate hair restraints during meal preparation for 1 of 1 kitchen reviewed for sanitation and properly stored and labeled food for 2 of 2 resident refrigerators reviewed for storage. This placed residents at risk for unsanitary food and cross contamination. 1. Resident 4 admitted to the facility in 12/2022 with diagnoses including osteomyelitis (bone infection) and malnutrition. A 7/28/24 Annual MDS revealed Resident 4 was cognitively intact. [...]
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of annual in-service training for 4 of 5 randomly selected staff members (#s 19, 20, 21 and 22) reviewed for evidence of in-service training. This placed residents at risk for a lack of quality care.
Inspectors wroteBased on interview and record review it was determined the facility failed to inform residents and/or resident's responsible party of the risks and benefits, and to ensure consent was obtained for the use of psychotropic medications for 3 of 5 sampled residents (#s 14, 26, and 66) reviewed for unnecessary medications. This placed residents at risk for lack of informed consent.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure transfer notices with appeal rights were provided in writing to residents and their representatives, and to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalizations for 2 of 2 sampled residents (#s 42 and 44) reviewed for hospitalizations. This placed residents at risk for lack of information regarding their options, rights and lack of advocacy from the Ombudsman Office.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide residents with a written notice of the facility's bed hold policy at the time of transfer to the hospital for 2 of 2 sampled residents (#s 42 and 44) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities.
Inspectors wroteBased on record review and interview it was determined the facility failed to complete MDS assessments which reflected accurate mental health diagnoses for 1 of 5 sampled residents (#33) reviewed for unnecessary medications. This placed residents at risk for inaccurate assessment and care.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a baseline care plan was sufficient to meet the needs of a resident admitted with a pressure injury for 1 of 2 sampled residents (#173) reviewed for pressure ulcers. This placed residents at risk for a delay in treatment.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure care plans were revised to accurately to reflect the needs of residents for 3 of 7 sampled residents (#s 19, 66 and 67) reviewed for accidents, care plans and nutrition. This placed residents at risk for unmet needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure 1 of 1 Nurse Practitioner's (Former Staff 34) diagnostic practices were confined to his specified clinical discipline. This placed residents at risk for diagnosis by unqualified staff.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to maintain oxygen equipment for 1 of 1 sampled resident (#5) reviewed for oxygen therapy. This placed residents at increased risk for respiratory failure.
Inspectors wroteBased on interview and record review it was determined the facility failed to identify clinical indications for the use of an antipsychotic medication for 1 of 5 sampled residents (#33) reviewed for unnecessary medications. This placed residents at risk for the unnecessary use of psychotropic medication.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide timely incontinence care for 1 of 1 resident (# 5) reviewed for incontinence care. This placed residents at risk for unmet care needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide eating assistance and to monitor for aspiration for 1 of 2 sampled residents (#168) reviewed for nutrition. The facility's failure was determined to be an immediate jeopardy situation because it resulted in Resident 168's 4/23/23 hospitalization for aspiration pneumonia and a subsequent death on 4/27/23.
Inspectors wrote2. Based on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for delayed and unmet care needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to address QAPI (Quality Assurance and Performance Improvement) identified concerns regarding sufficient staff for 1 of 1 QA (Quality Assurance) committees reviewed for QAPI. This resulted in the failure to provide timely care and assistance to residents.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 4 of 5 sampled CNA staff (#s 19, 20, 22 and 23) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff.
Inspectors wroteBased on interview and record review it was determined the facility failed to protect residents' rights to make personal care decisions for 1 of 3 sampled residents (#267) reviewed for choices. This placed residents at risk for lack of personal care decisions for resident choices.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide written information to residents concerning the right to formulate an advance directive for 1 of 3 sampled residents (#9) reviewed for advance directives. This placed residents at risk for not having their health care decisions honored.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide a Notice of Medicare Non-coverage to 1 of 3 sampled residents (#118) reviewed for beneficiary notification. This placed residents at risk for unknown financial liabilities.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide an ongoing program of activities designed to meet the interests and psychosocial well-being for 1 of 2 sampled residents (#56) reviewed for activities. This placed residents at risk for unmet psychosocial needs and isolation.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow physician's orders for 3 of 6 sampled residents (#s 4, 9 and 319) reviewed for medication administration, bowel care and daily weights. This placed residents at risk for adverse medical consequences.
Inspectors wroteBased on interview and record review it was determined the facility failed to accurately assess a pressure ulcer and provide ordered pressure ulcer wound care for 3 of 6 sampled residents (#s 4, 32 and 168) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide nail care for 1 of 2 sampled residents (# 41) reviewed for nail care. This placed residents at risk for inadequate foot care.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide urinary catheter care as ordered for 1 of 3 sampled residents (#32) reviewed for urinary catheters. This placed residents at risk for UTI.
Inspectors wroteBased on interview and record review it was determined the facility failed to assess residents after dialysis for 1 of 1 sampled resident (#18) reviewed for dialysis. This placed residents at risk for complications related to dialysis.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure an RN was available for at least eight consecutive hours per day seven days per week for 4 of 44 days reviewed for staffing. This placed residents at risk for lack of timely RN assessments and care.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from unnecessary bowel medications for 1 of 5 sampled residents (#56) reviewed for unnecessary medications. This placed residents at risk for loose stools and diarrhea.
Inspectors wroteBased on observation and interview it was determined the facility failed to store treatment supplies and medications in locked compartments for 1 of 2 treatment carts randomly observed. This placed residents at risk for medication diversion and accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents received specialized rehabilitative services (OT services) at the frequency needed for donning/doffing splints for 1 of 2 sampled residents (#2) reviewed for therapy.
Inspectors wroteBased on interview and record review it was determined the facility failed to accurately document in the medical record for 2 of 5 sampled residents (#'s 27 and 168) reviewed for pressure ulcers. This placed residents at risk for inaccurate medical records and unmet treatment needs.
14 fire safety citations on file: 7 on December 19, 2025, 3 on August 30, 2024, 4 on May 23, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| June 17, 2025 | Fine | $19,949 |
| August 30, 2024 | Fine | $56,852 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 6.25 | 5.03 | 3.86 |
| Registered nurses | 1.00 | 0.72 | 0.69 |
| All nursing staff on weekends | 5.69 | 4.51 | 3.42 |
| Nurse aides | 4.12 | ||
| Licensed practical nurses | 1.13 | ||
| Nursing staff turnover (share who left in a year) | 66.2% | 47.4% | 45.8% |
| Registered nurse turnover | 73.7% | 51.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 5.49 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 6.48 on weekdays and 5.69 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 3.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 6.09 in April to June 2025 to 6.25 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 6.25 | 1.00 | 6.48 | 5.69 | 3.5% | 0 of 90 | 71 |
| Oct to Dec 2025 | 5.95 | 1.05 | 6.15 | 5.43 | 2.2% | 0 of 92 | 72 |
| Jul to Sep 2025 | 6.16 | 0.96 | 6.30 | 5.81 | 8.6% | 0 of 92 | 71 |
| Apr to Jun 2025 | 6.09 | 0.96 | 6.28 | 5.61 | 8.4% | 0 of 91 | 72 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Oregon, all employers | |||
| CNAs (nursing assistants) | $23.96 | $22.83 to $28.40 | 14,800 |
| LPNs and LVNs | $38.69 | $35.11 to $43.60 | 4,260 |
| Registered nurses | $62.02 | $51.55 to $64.63 | 39,730 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 17.9 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 2.0 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.4 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.5 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.6 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 8.6 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 10.1 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 20.8 | 13.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 28.6 | 21.4 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 18.2 | 16.1 | 12.0 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Gresham Post Acute Care and Rehabilitation's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (54.9% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
54.9% this home
No different from the national rate
US median of homes 51.5% · Oregon: 52 better, 3 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 84 eligible stays.
9.6% this home
No different from the national rate
US median of homes 10.7% · Oregon: 3 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 80 eligible stays.
6.1% this home
No different from the national rate
US median of homes 7.1% · Oregon: 0 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 52 eligible stays.
59.1% this home
Median of homes: Oregon59.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 22 residents counted.
0.0% this home
Median of homes: Oregon0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 42 residents counted.
0.0% this home
Median of homes: Oregon2.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 42 residents counted.
85.7% this home
Median of homes: Oregon98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 21 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: SAPPHIRE AT GRESHAM REHAB, LLC. CMS links this home to Sapphire Health Services, a group of 8 nursing homes averaging 2.1 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Becker, Andrew | 5% or greater direct ownership interest | Individual | 30% | 01/06/2020 |
| Hilty, Lisa | 5% or greater direct ownership interest | Individual | 25% | 01/06/2020 |
| Morris, Bryan | 5% or greater direct ownership interest | Individual | 5% | 01/06/2020 |
| Ricker, Kevin | 5% or greater direct ownership interest | Individual | 40% | 01/06/2020 |
| Sapphire Healthcare Srvs. | Operational/managerial control | Organization | 04/01/2020 | |
| Ferdowsali, Kameron | Operational/managerial control | Individual | 01/01/2025 | |
| Welker, David | Operational/managerial control | Individual | 08/12/2024 | |
| Sapphire Healthcare Srvs. | Adp of the SNF | Organization | 10/07/2025 | |
| Ferdowsali, Kameron | Adp of the SNF | Individual | 01/01/2025 | |
| Welker, David | Adp of the SNF | Individual | 08/12/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.