Cedar Crossings
6003 Se 136th Avenue · Portland, OR · 97236 · 9719781268
89 certified beds For profit - Corporation Chain: Sapphire Health Services
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results have improved across recent cycles.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
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: 2 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 5.43 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.52 | 0.55–0.75 |
| Weekend hours / resident-day | 5.12 | ≈ weekday level |
| Nursing turnover / year | 100% | median 45% |
| Fines (3-yr window) | 2 · $32,383 |
Inspection citations (58 in the current record)
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Potential for harm · D April 3, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 28, 2026 · Quality of Life and Care
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Potential for harm · D January 17, 2025
Provide or obtain dental services for each resident.
Corrected March 6, 2025 · Quality of Life and Care
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Potential for harm · E January 17, 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 March 6, 2025 · Resident Rights
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Potential for harm · D January 17, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 6, 2025 · Quality of Life and Care
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Potential for harm · E January 17, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 6, 2025 · Quality of Life and Care
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Potential for harm · D January 17, 2025 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected March 6, 2025 · Quality of Life and Care
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Potential for harm · D January 17, 2025 · found via complaint
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected March 6, 2025 · Quality of Life and Care
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Potential for harm · E January 17, 2025 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected March 6, 2025 · Nursing and Physician Services
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Potential for harm · E January 17, 2025 · found via complaint
Observe each nurse aide's job performance and give regular training.
Corrected March 6, 2025 · Nursing and Physician Services
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Potential for harm · D January 17, 2025 · found via complaint
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected March 6, 2025 · Pharmacy Service
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Potential for harm · E January 17, 2025 · found via complaint
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 March 6, 2025 · Pharmacy Service
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Potential for harm · D January 17, 2025 · found via complaint
Dispose of garbage and refuse properly.
Corrected March 6, 2025 · Nutrition and Dietary
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Potential for harm · D January 17, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected March 6, 2025 · Infection Control
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Potential for harm · D January 17, 2025 · found via complaint
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected March 6, 2025 · Nursing and Physician Services
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No harm found · B January 17, 2025 · found via complaint
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected March 6, 2025 · Resident Rights
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No harm found · B January 17, 2025 · found via complaint
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 March 6, 2025 · Resident Rights
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Potential for harm · D October 3, 2024 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected November 4, 2024 · Resident Rights
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Potential for harm · D October 3, 2024 · found via complaint
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected November 4, 2024 · Resident Rights
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Potential for harm · D October 3, 2024 · found via complaint
Plan the resident's discharge to meet the resident's goals and needs.
Corrected November 4, 2024 · Resident Assessment and Care Planning
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Potential for harm · D July 17, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected August 16, 2024 · Quality of Life and Care
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Potential for harm · D July 17, 2024 · found via complaint
Provide or obtain dental services for each resident.
Corrected August 16, 2024 · Quality of Life and Care
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Immediate jeopardy · J June 17, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 10, 2024 · Quality of Life and Care
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Potential for harm · F June 17, 2024 · found via complaint
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected July 10, 2024 · Administration
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Potential for harm · F June 17, 2024 · found via complaint
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected July 10, 2024 · Administration
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Potential for harm · D March 22, 2024 · found via complaint
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected April 5, 2024 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| June 17, 2024 | Fine | $24,193 |
| November 9, 2023 | Fine | $8,190 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 385284 · certified since July 1, 2021. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.