See every facility — official ratings, family reviews, no referral fees.
Nursing HomeMedicaid Investigative

Gresham Post Acute Care and Rehabilitation

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

405 Ne 5th Street, City Central · Gresham, OR 9703078 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
2.6/5

based on 52 Google reviews

5
4
3
2
1
Gresham Post Acute Care and Rehabilitation Nursing Home in Gresham, OR — Street View
Street View

Watch Gresham Post Acute Care and Rehabilitation

Get an email when new inspections, ratings, or penalties are published for this facility.

We’ll only email you about this — no spam, unsubscribe anytime.

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 (1/5 stars)
  • Above-median deficiencies (20 vs median 9.0)

Bottom 25% in OR · Meets national RN staffing standard · Above recommended total nurse staffing · Worst in SAPPHIRE HEALTH SERVICES chain · $136,749 in fines

Source: Medicare data

What this means for your family

While the physical therapy department is frequently cited as a strength, the recurring reports of severe neglect, medication errors, and unhygienic conditions are critical red flags. If you consider this facility, you must conduct an in-person visit during off-hours to observe staffing levels and cleanliness for yourself, and ensure you have a plan for active, daily family oversight of your loved one's medical care.

Google Reviews

Google Reviews

52 reviews on Google
Gresham Post Acute Care and Rehabilitation receives highly polarized feedback, with many families reporting severe neglect, poor communication, and dangerous lapses in medical care. While some patients praise the physical therapy department and specific staff members, a significant number of reviewers describe a facility plagued by understaffing, unhygienic conditions, and unresponsive nursing care.

Quality Themes

Tap a score for details
Food2.0Staff3.0Clean2.0Activities7.0Meds1.0MemoryN/AComms2.0ValueN/A

Strengths

  • Effective physical and occupational therapy department
  • Select compassionate and attentive individual staff members
  • Well-equipped therapy gym

Concerns

  • Severe understaffing leading to long wait times for call buttons and hygiene needs (mentioned by 12 reviewers)
  • Medication management errors and delays (mentioned by 6 reviewers)
  • Unsanitary facility conditions and unpleasant odors (mentioned by 5 reviewers)
  • Unprofessional, rude, or defensive staff interactions (mentioned by 7 reviewers)

Rating Trends

Tap a year to see what changed

234'16(2)'19(6)'21(3)'23(8)'25(11)'26(2)

Distribution · 55 analyzed

5
18
4
3
3
1
2
5
1
28

How They Respond to Reviews

90%response rate

This facility actively engages with reviewer feedback.

Questions for Your Tour

  • 1I noticed you have a very high response rate to online feedback; how do you use that family input to improve the daily experience for residents?
  • 2Given the importance of timely assistance, what is your current process for ensuring call buttons are answered promptly during peak hours and overnight shifts?
  • 3Can you walk me through the specific protocols in place to ensure medication management is accurate and that residents receive their doses on time?
  • 4I understand the facility has faced some recent challenges with environmental standards; what steps are being taken to ensure the living areas remain consistently clean and odor-free?
  • 5Since the therapy department is a known strength here, how do you coordinate that high-quality care with the nursing staff to ensure a resident's progress is maintained throughout the day?
  • 6What opportunities are there for residents to engage in social activities or communal dining, and how do you ensure these times are well-staffed and welcoming?

Personalized based on this facility's data


Key Review Excerpts

The staff treat the patients here worse than prisoners. The pathetic excuse of a sandwich is dinner. The single chicken strip and nine raw tots was lunch. No one comes to help with bathroom visits when one needs help.

Family member · 2021☆☆☆☆

The Physical Therapy Manager named Ty, and his dynamic team provide an experience that is one of a kind! The entire team of therapists are positive, uplifting, compassionate, and well educated.

Rehab patient · 2024★★★★★

My grandfather Frank was there for 9 days and We absolutely love this facility clean consistent the faculty is pleasant and well kept.. The exercising room was great they get you well to get you home.. Staff was top-notch.

Grandchild of resident · 2024★★★★★
Source: 52 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
1.05hrs
OK
Registered nurses for medical care
Total Nursing
5.95hrs
OK
All nurses + aides combined
Staff Turnover
100%
Lower is better (< 30% = good)
RN Turnover
100%
Lower is better (< 30% = good)

This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.

Quality Measures

Quality Measures

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

Medicare Rating
3/ 5
Better Than Avg

10

measures

Worse Than Avg

6

measures

Mixed Results

1

measures

Long-Stay Residents
🚶

Residents whose walking got worse

↓ Lower is better
This Facility7.4%
Better than Avg
Here
7.4%
US
15.3%
OR
22.5%
Multnomah
22.3%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
12.1%
OR
4.9%
Multnomah
4.4%

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

🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility22.8%
Worse than Avg
Here
22.8%
US
14.4%
OR
15.3%
Multnomah
15.4%
🩹

Residents with pressure sores (bedsores)

↓ Lower is better
This Facility12.1%
Worse than Avg
Here
12.1%
US
4.9%
OR
6.2%
Multnomah
6.7%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility99.2%
Better than Avg
Here
99.2%
US
93.4%
OR
95.3%
Multnomah
93.9%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
95.5%
OR
95.2%
Multnomah
94.7%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility94.7%
Better than Avg
Here
94.7%
US
79.7%
OR
81.2%
Multnomah
80.5%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility95.7%
Better than Avg
Here
95.7%
US
81.8%
OR
85.5%
Multnomah
83.7%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.2%
Worse than Avg
Here
2.2%
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

20deficiencies
3penalties
Well above state avg (10.4)
24 complaint-triggered
$136,749 in fines

This facility has a concerning pattern with 24 complaint-triggered deficiencies from families reporting problems, including ongoing issues with resident care quality, medication management, and safety hazards. Problems with proper treatment and care have persisted across multiple surveys from 2023 through 2025, and pressure ulcer care issues have recurred repeatedly. While the facility has corrected deficiencies when cited, the high volume of complaints and recurring care problems warrant careful consideration before placement.

Dec 19, 2025Routine
23
0686Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0007Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Address patient/client population and determine types of services needed.

0013Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop Emergency Preparedness policies and procedures.

0015Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

0041Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0604Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

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.

0685Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0699Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

0700Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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.

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.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0761Potential for harm · IsolatedCorrected

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.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0923Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Dec 19, 2025Complaint
2
0584Potential for harm · IsolatedCorrected

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.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Nov 24, 2025Complaint
1
0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Jun 17, 2025Complaint
1
0684Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

Aug 30, 2024Routine
15
0686Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0947Potential for harm · PatternCorrected

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.

0923Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0623Potential for harm · IsolatedCorrected

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.

0625Potential for harm · IsolatedCorrected

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.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0655Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

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

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

0753Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Oct 31, 2023Complaint
1
0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Federal Penalties

Fine

Jun 17, 2025

$19,949

Fine

Aug 30, 2024

$56,852

Fine

May 23, 2023

$59,948

Ownership & Operations

Who Operates This Facility

Owner / Operator

Gresham Post Acute Care and Rehabilitation

Organization Type

for profit

Chain Affiliation

Chain Name

Sapphire Health Services

Chain Size

8 facilities nationwide

Chain avg rating: 1.8/5 · Rank 6 of 8 (Worst)

Ownership & Management

Owners

Becker, Andy

Owner

30%

Hilty, Lisa

Owner

25%

Morris, Bryan

Owner

5%

Ricker, Kevin

Owner

40%

Key personnel

Sapphire Healthcare Srvs.ManagerFerdowsali, KameronManagerWelker, DavidManagerSapphire Healthcare Srvs.Adp of the SnfFerdowsali, KameronAdp 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.

Call