Gresham Post Acute Care and Rehabilitation
405 Ne 5th Street · Gresham, OR · 97030 · 5036665600
78 certified beds For profit - Limited Liability company Chain: Sapphire Health Services
Why this verdict
- Federal penalties on record: $76,801 in fines in the last 24 months.
- 4 citations involved actual harm to residents.
- Staffing hours comfortably above national benchmarks.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
2 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$76,801 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
100% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 5.95 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.05 | 0.55–0.75 |
| Weekend hours / resident-day | 5.43 | ≈ weekday level |
| Nursing turnover / year | 100% | median 45% |
| Fines (3-yr window) | 2 · $76,801 |
Inspection citations (51 in the current record)
-
Actual harm · G December 19, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected January 22, 2026 · Quality of Life and Care
-
Potential for harm · D December 19, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected January 22, 2026 · Resident Rights
-
Potential for harm · D December 19, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected January 22, 2026 · Resident Rights
-
Potential for harm · D December 19, 2025
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected January 22, 2026 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D December 19, 2025
Ensure each resident receives an accurate assessment.
Corrected January 22, 2026 · Resident Assessment and Care Planning
-
Potential for harm · D December 19, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected January 22, 2026 · Quality of Life and Care
-
Potential for harm · D December 19, 2025
Assist a resident in gaining access to vision and hearing services.
Corrected January 22, 2026 · Quality of Life and Care
-
Potential for harm · D December 19, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected January 22, 2026 · Quality of Life and Care
-
Potential for harm · D December 19, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected January 22, 2026 · Quality of Life and Care
-
Potential for harm · D December 19, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected January 22, 2026 · Quality of Life and Care
-
Potential for harm · D December 19, 2025
Provide care or services that was trauma informed and/or culturally competent.
Corrected January 22, 2026 · Quality of Life and Care
-
Potential for harm · D December 19, 2025
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected January 22, 2026 · Quality of Life and Care
-
Potential for harm · D December 19, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected January 22, 2026 · Pharmacy Service
-
Potential for harm · D December 19, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected January 22, 2026 · Pharmacy Service
-
Potential for harm · D December 19, 2025
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected January 22, 2026 · Pharmacy Service
-
Potential for harm · D December 19, 2025
Provide and implement an infection prevention and control program.
Corrected January 22, 2026 · Infection Control
-
Potential for harm · D December 19, 2025 · found via complaint
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected January 22, 2026 · Resident Rights
-
Potential for harm · D December 19, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected January 22, 2026 · Quality of Life and Care
-
Potential for harm · D November 24, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected December 4, 2025 · Quality of Life and Care
-
Actual harm · G June 17, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 1, 2025 · Quality of Life and Care
-
Actual harm · G August 30, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected October 14, 2024 · Quality of Life and Care
-
Potential for harm · D August 30, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected October 14, 2024 · Resident Rights
-
Potential for harm · D August 30, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected October 14, 2024 · Resident Rights
-
Potential for harm · D August 30, 2024
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected October 14, 2024 · Resident Rights
-
Potential for harm · D August 30, 2024
Ensure each resident receives an accurate assessment.
Corrected October 14, 2024 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| June 17, 2025 | Fine | $19,949 |
| August 30, 2024 | Fine | $56,852 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 385190 · certified since February 23, 1989. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.