Cycle 1
Health 2024-12-06 · Fire 2024-12-06
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Gresham, OR
Fairlawn Health And Rehab Of Cascadia
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3457 Ne Division Street, Gresham, OR
(503) 667-1965
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cascadia Healthcare
Operator or chain grouping
Approved since
1976-06-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
44 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.80
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.44
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.71
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.06
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
5.06
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,902
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.05
Composite VBP score used to determine payment impact.
Payment multiplier
1.0005
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.61
Baseline 18.45% · Performance 19.30% · Measure score 4.61 · Achievement 4.61 · Improvement 0
Healthcare-associated infections
3.27
Baseline 5.40% · Performance 6.86% · Measure score 3.27 · Achievement 3.27 · Improvement 0
Total nurse turnover
5.33
Baseline 46.97% · Performance 41.89% · Measure score 5.33 · Achievement 5.33 · Improvement 1.80
Adjusted total nurse staffing
5.61
Baseline 4.33 hours · Performance 4.68 hours · Measure score 5.61 · Achievement 5.61 · Improvement 1.90
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.72% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 6.86% · Lower 95% interval 6.52% |
| Discharge to community | 63.49% |
50.57%
12.9 pts better
|
Better than the National Rate · Eligible stays 114 · Observed rate 60.53% · Lower 95% interval 53.55% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.75% |
95.27%
3.5 pts better
|
Numerator 79 · Denominator 80 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 80 |
| Discharge self-care score | 62.5% |
53.69%
8.8 pts better
|
Numerator 30 · Denominator 48 |
| Discharge mobility score | 58.33% |
50.94%
7.4 pts better
|
Numerator 28 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 1.25% |
2.29%
1 pts better
|
Numerator 1 · Denominator 80 · Adjusted rate 1.6% |
| Healthcare-associated infections requiring hospitalization | 6.86% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 5.88% · Lower 95% interval 4.06% |
| Staff COVID-19 vaccination coverage | 3.03% |
8.2%
5.2 pts worse
|
Numerator 4 · Denominator 132 |
| Staff flu vaccination coverage | 12.03% |
42%
30 pts worse
|
Numerator 48 · Denominator 399 |
| Discharge function score | 70.83% |
56.45%
14.4 pts better
|
Numerator 34 · Denominator 48 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 41 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 39.53% |
25.2%
14.3 pts better
|
Numerator 17 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.4% |
95.5%
7.1 pts worse
|
93.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.0% · Q2 85.7% · Q3 87.8% · Q4 94.0% · 4Q avg 88.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
95.2%
1.2 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
2.4%
1.4 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 2.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.7%
4.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 23.7% |
5.0%
18.7 pts worse
|
5.4%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 27.9% · Q3 25.0% · Q4 19.0% · 4Q avg 23.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.4% |
12.5%
9.9 pts worse
|
19.6%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 23.3% · Q3 24.4% · Q4 19.0% · 4Q avg 22.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.2% |
14.7%
6.5 pts better
|
16.7%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 7.9% · Q3 11.4% · Q4 8.3% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.0% |
24.1%
1.9 pts worse
|
16.3%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.9% |
15.8%
8.1 pts worse
|
14.9%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 28.6% · Q3 23.7% · Q4 15.8% · 4Q avg 23.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
1.7%
0.6 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.5% · Q3 1.3% · Q4 1.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
2.0%
1.5 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.6% |
22.2%
4.4 pts worse
|
19.8%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 24.9% · Q3 30.5% · Q4 28.2% · 4Q avg 26.6% |
| Percentage of long-stay residents with pressure ulcers | 9.4% |
6.5%
2.9 pts worse
|
5.1%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 12.1% · Q3 7.7% · Q4 7.9% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.5% |
85.4%
7.9 pts worse
|
81.7%
4.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 68.4% · Q2 74.2% · Q3 78.2% · Q4 86.6% · 4Q avg 77.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.6% |
15.1%
6.5 pts worse
|
12.0%
9.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 22.4% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.0% |
1.7%
0.3 pts worse
|
1.6%
0.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 4.1% · Q4 2.4% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.7% |
81.2%
4.5 pts better
|
79.7%
6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.6% |
21.6%
8 pts worse
|
23.9%
5.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.6% · Observed 30.3% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-21 · Fire 2020-01-21
18 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2018-05-14 · Fire 2018-05-14
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-22
D · Potential for more than minimal harm
2020-01-21
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-03-11
F · Potential for more than minimal harm
2018-05-14
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2018-08-01
F · Potential for more than minimal harm
2018-05-14
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2018-08-01
F · Potential for more than minimal harm
2018-05-14
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2018-08-01
F · Potential for more than minimal harm
2018-05-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2018-06-29
F · Potential for more than minimal harm
2018-05-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2018-06-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-06
F584 · Resident Rights Deficiencies
Health
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 2025-01-22
D · Potential for more than minimal harm
2024-12-06
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-12-06
F690 · Quality of Life and Care Deficiencies
Health
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 2025-01-22
D · Potential for more than minimal harm
2024-11-21
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-11-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-31
D · Potential for more than minimal harm
2024-05-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-10
D · Potential for more than minimal harm
2023-10-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-09
G · Actual harm
2020-01-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-03-11
F · Potential for more than minimal harm
2020-01-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-03-11
E · Potential for more than minimal harm
2020-01-21
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2020-03-11
E · Potential for more than minimal harm
2020-01-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2020-03-11
E · Potential for more than minimal harm
2020-01-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-21
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-21
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-03-11
D · Potential for more than minimal harm
2020-01-21
F690 · Quality of Life and Care Deficiencies
Health
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 2020-03-11
D · Potential for more than minimal harm
2020-01-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-01-03
D · Potential for more than minimal harm
2020-01-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-11
D · Potential for more than minimal harm
2018-05-14
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2018-07-03
D · Potential for more than minimal harm
2018-05-14
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2018-07-03
Penalties and ownership
What sits behind the stars
Ownership
Cascadia Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Cascadia Hc Group LLC
Operational/Managerial Control · Organization
Cascadia Healthcare LLC
Operational/Managerial Control · Organization
Cascadia Holdco LLC
Operational/Managerial Control · Organization
Cascadia Oregon Operations LLC
Operational/Managerial Control · Organization
Cascadia Services LLC
Operational/Managerial Control · Organization
Gresham 3457 Realty, LLC
5% Or Greater Security Interest · Organization
Hammond, Owen
Operational/Managerial Control · Individual
Laforte, Stephen
Operational/Managerial Control · Individual
Nelson, Timothy
Operational/Managerial Control · Individual
Vellody, Nita
Operational/Managerial Control · Individual
White Oak Healthcare Finance LLC
5% Or Greater Security Interest · Organization
Workman, Leslie
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Gresham Post Acute Care And Rehabilitation
Gresham, OR
1-star overall rating with 1-star inspections with $136,749 in total fines with 20 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Regency Gresham Nursing & Rehabilitation Center
Gresham, OR
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Village Manor Of Cascadia
Wood Village, OR
4-star overall rating with 3-star inspections with $13,520 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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