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Nursing HomeMedicaid Investigative

Cedar Crossings

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

6003 Se 136th Avenue, Southeast Portland · Portland, OR 9723689 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
2.2/5

based on 31 Google reviews

5
4
3
2
1
Cedar Crossings Nursing Home in Portland, OR — Street View
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3/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • Above-median deficiencies (15 vs median 9.0)

Below average in OR · Below recommended RN staffing · Above recommended total nurse staffing · $44,133 in fines

Source: Medicare data

What this means for your family

Given the consistent reports of ignored call lights and dietary errors, this facility presents significant safety risks. If you must consider this location, we strongly advise you to visit frequently and unannounced to monitor your loved one's care, as communication with management is frequently cited as a major barrier.

Google Reviews

Google Reviews

31 reviews on Google
Cedar Crossings faces severe, recurring criticism regarding neglectful care, poor management, and significant communication failures. While a few reviewers praise individual staff members for kindness, the overwhelming pattern involves ignored call lights, dietary errors, and a lack of professional oversight that compromises resident safety.

Quality Themes

Tap a score for details
Food1.0Staff3.0Clean2.0ActivitiesN/AMeds2.0MemoryN/AComms1.0Value1.0

Strengths

  • Skilled physical and occupational therapy
  • Individual staff members noted for kindness
  • Respectful interactions observed by some families

Concerns

  • Neglected call lights and slow response times (mentioned by 6 reviewers)
  • Poor communication with families and management (mentioned by 5 reviewers)
  • Incompetent or unprofessional staff behavior (mentioned by 5 reviewers)
  • Dietary errors and failure to provide proper nutrition (mentioned by 3 reviewers)
  • Laundry and personal item management issues (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'15(1)'20(3)'22(2)'24(10)'26(1)

Distribution · 35 analyzed

5
7
4
2
3
0
2
4
1
22

How They Respond to Reviews

97%response rate

This facility actively engages with reviewer feedback.

Questions for Your Tour

  • 1I noticed that communication is a top priority for families; what specific protocols do you have in place to ensure we receive timely updates regarding our loved one's care?
  • 2Given that response times to call lights are a common concern for families, could you walk me through your current system for monitoring and responding to resident requests?
  • 3I appreciate that your team responds to every online review; how does that feedback loop translate into actual changes or improvements within the facility?
  • 4Regarding the dietary program, what steps are you taking to ensure that residents receive the correct meals and consistent nutritional support?
  • 5With the current staffing levels, how do you ensure that personal items and laundry are managed reliably so that residents' belongings don't go missing?
  • 6Since therapy services are a noted strength here, how do you integrate those physical and occupational therapy sessions into the daily routine to keep residents active?

Personalized based on this facility's data


Key Review Excerpts

The call lights were a joke. One night My roommate and I had our call light on for an hour and a half. I went looking for a CNA, found 1, she was asleep in a chair in a patients room.

Rehab patient · 2023★★☆☆☆

The facility is quite dated, and not fancy at all, but my condition improved thanks to the skilled PT/OT professionals who set me up with a daily routine and provided much encouragement.

Rehab patient · 2024★★★★★

My mother was there for 7 months and she also died there. They lost everything single piece of clothing we had brought her and put old stained gross clothes in her closet that were the wrong size and they weren't hers.

Long-term resident's family · 2025☆☆☆☆
Source: 31 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.52hrs
69%
Registered nurses for medical care
Total Nursing
5.43hrs
OK
All nurses + aides combined
Staff Turnover
100%
Lower is better (< 30% = good)
RN Turnover
100%
Lower is better (< 30% = good)

RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
5/ 5
Better Than Avg

8

measures

Worse Than Avg

4

measures

Mixed Results

5

measures

Long-Stay Residents
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility7.9%
Better than Avg
Here
7.9%
US
19.5%
OR
12.5%
Multnomah
12.0%
😔

Residents with depression symptoms

↓ Lower is better
This Facility4.4%
Mixed vs Avgs
Here
4.4%
US
12.1%
OR
4.9%
Multnomah
4.2%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility15.5%
Better than Avg
Here
15.5%
US
19.4%
OR
22.1%
Multnomah
22.5%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility16.0%
Mixed vs Avgs
Here
16.0%
US
15.3%
OR
22.5%
Multnomah
21.9%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility11.7%
Better than Avg
Here
11.7%
US
14.4%
OR
15.3%
Multnomah
15.8%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility17.3%
Worse than Avg
Here
17.3%
US
15.4%
OR
14.0%
Multnomah
13.3%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility77.3%
Worse than Avg
Here
77.3%
US
81.8%
OR
85.5%
Multnomah
84.4%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility76.7%
Worse than Avg
Here
76.7%
US
79.7%
OR
81.2%
Multnomah
81.2%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.7%
Worse than Avg
Here
2.7%
US
1.6%
OR
1.5%
Multnomah
1.9%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

15deficiencies
2penalties
Above state avg (10.4)
34 complaint-triggered
$44,133 in fines

Cedar Crossings shows concerning patterns with 95 deficiencies across 10 surveys, including 34 triggered by family complaints. The facility repeatedly struggles with accident prevention and safety hazards, medication management, and nursing staff supervision. While all deficiencies show correction dates, the same issues recur across multiple years, suggesting systemic problems. Recent 2024-2025 complaint-driven inspections continue finding safety and staffing violations, indicating ongoing care quality concerns families should carefully evaluate.

Jan 17, 2025Routine
11
0013Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop Emergency Preparedness policies and procedures.

0020Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Establish policies and procedures including evacuation.

0222Potential for harm · WidespreadCorrected

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0791Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

0324Potential for harm · IsolatedCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0372Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0711Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

0761Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Jan 17, 2025Complaint
14
0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

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.

0689Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0725Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0730Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0756Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

0814Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0947Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

0623Minimal · PatternCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0625Minimal · PatternCorrected

Resident Rights Deficiencies

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.

Oct 3, 2024Complaint
3
0660Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0626Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Jul 17, 2024Complaint
2
0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0791Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

Jun 17, 2024Complaint
3
0689Immediate jeopardy · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0865Potential for harm · WidespreadCorrected

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

0868Potential for harm · WidespreadCorrected

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Mar 22, 2024Complaint
2
0557Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Federal Penalties

Fine

Jun 17, 2024

$24,193

Fine

Nov 9, 2023

$8,190

Ownership & Operations

Who Operates This Facility

Owner / Operator

Cedar Crossings

Organization Type

for profit

Chain Affiliation

Chain Name

Sapphire Health Services

Chain Size

8 facilities nationwide

Chain avg rating: 1.8/5 · Rank 2 of 8

Ownership & Management

Owners

Becker, Andy

Owner

30%

Hilty, Lisa

Owner

25%

Morris, Bryan

Owner

5%

Ricker, Kevin

Owner

40%

Key personnel

Sapphire Healthcare Srvs.ManagerAmes, DeborahManagerMeeko, MaryManagerSapphire Healthcare Srvs.Adp of the SnfAmes, DeborahAdp of the Snf
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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