Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fairlawn Health And Rehab Of Cascadia during CMS and state inspections, most recent first.
Improper Food Storage and Inadequate Dish Sanitization: Food items in both kitchen areas were found undated, expired, or improperly stored, including dairy, produce, condiments, and frozen items. In one kitchen, the dishwasher sanitizer and sanitizing bucket tested below required ppm levels, and staff reported the dishwasher sanitizer dispenser was not functioning properly and had not been checked before dishwashing.
Failure to follow Contact Precautions and EBP was observed when staff entered a room with MRSA without donning PPE and when staff provided high-contact care in rooms posted for EBP without wearing gowns. Staff reported confusion about the PPE requirements, and the IP later confirmed PPE was required for room entry on Contact Precautions and for all direct high-contact care under EBP.
Meals were not consistently served at an appetizing temperature because trays were delivered in the hallways without plate warmers. Residents reported receiving cold food, and a CNA said she often had to re-heat meals. The Prep Cook confirmed the kitchen did not have enough plate warmers for all residents in the hallways, and the Dietary Manager and Administrator were unaware of the shortage.
The facility failed to properly label and store food, risking foodborne illness. Observations included unlabeled milk and juice, uncovered cereal, and dirty kitchen equipment. The Dietary Manager and Administrator acknowledged these issues, highlighting the need for improved cleanliness and food storage practices.
A resident with dementia and a periprosthetic fracture was discharged from an LTC facility without proper planning or education for the resident and their family. The resident required assistance with catheter care and medication management, but the family was not notified in advance or trained on these needs. Home health services were not arranged, and the discharge plan lacked necessary support, leading to a deficient discharge process.
A facility failed to maintain a homelike environment by not ensuring the cleanliness of a recliner in a resident's room. The chair was stained with an unknown residue and lacked a cleanable surface. Staff, including a CNA, Infection Preventionist, and Housekeeping, acknowledged the chair's filthy condition, and the Administrator confirmed it had a bad odor.
A resident with severe cognitive impairment and a history of falls was not provided with the prescribed fall prevention interventions. The resident's care plan required a low bed position with a fall mat, but observations showed the bed was elevated for transfers, contrary to the care plan. Staff confirmed the resident was part of a fall prevention program, yet the interventions were not consistently followed.
A resident with urine retention and a Foley catheter returned to the facility with orders for an immediate catheter change, which was not performed on the specified days. Staff acknowledged the oversight, with one intending to contact the physician but failing to do so, and another citing time constraints. The DNS confirmed the catheter was not changed as ordered.
A facility failed to complete a discharge summary for a resident with malnutrition who was discharged home. The care plan included referrals for home health and therapy services, but the Social Services Director confirmed the absence of a discharge summary in the resident's record. A home health staff member reported unreturned calls for necessary physician orders and instructions. The previous Social Services Director was unavailable for interview, and the facility administrator provided no further information.
The facility failed to follow physician orders for bowel care for two residents, leading to a deficiency in care. One resident with atrial fibrillation and constipation did not receive timely bowel medications, resulting in an 11-day period without a bowel movement. Another resident with a stroke diagnosis experienced delays in receiving prescribed bowel medications, with a six-day gap before a suppository was administered. Both cases highlight significant lapses in adhering to bowel care protocols.
The facility failed to follow physician orders for medication administration for a resident with a UTI, leading to multiple instances of delayed medication administration outside the prescribed two-hour window. The administrator confirmed these delays occurred on several dates in October 2023.
Improper Food Storage and Inadequate Dish Sanitization
Penalty
Summary
Food items were found improperly labeled and stored in both facility kitchens during a brief tour with the Dietary Manager. In the first kitchen freezer, three open cartons of ice cream, five popsicles, and a quarter of an angel food cake in a plastic bag were undated. In the second kitchen walk-in refrigerator, two pans of previously roasted potatoes dated 3/17/26 and one container of broccoli-cheese soup dated 3/17/26 were outdated, a large bag of shredded lettuce was wilted, and two five-pound bags each of white cheese and yellow cheese were undated. In the standing refrigerator, an opened jar of Cesar dressing, a pitcher of iced tea, a partial pitcher of orange juice, and an opened 12-ounce container of horseradish were undated, and a pitcher of apple juice had a use-by-date of 3/14/26. In the walk-in freezer, two dozen unbaked biscuit squares were undated and a bag of curly fries was dated 12/2025. The Dietary Manager confirmed the items were either undated or expired and stated they should have been dated and discarded when out of date. Dish sanitizing practices and sanitization of food preparation surfaces were not properly followed in one kitchen. A Dietary Aide tested the dishwasher sanitizer level by using a test strip in the residual water and twice obtained a white color, indicating 10 or less parts per million of sanitizer, which was below the required minimum concentration. The same aide tested the red bucket used for sanitizing the steam table and food preparation counters and obtained 0 parts per million of sanitizer. A vendor representative stated the dishwasher's sanitizing dispenser was not functioning properly and could not determine how long it had been out of service. Staff stated they had not tested the dishwasher sanitizer before washing dishes, and the Dietary Manager stated the dishwasher and sanitizing buckets did not meet the required sanitizing levels.
Failure to Follow Contact Precautions and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow infection control precautions for two of three sampled hallways reviewed for infection control, including north hall and west hall. Surveyors observed Staff 7 entering a room on Contact Precautions without donning PPE, despite a CDC Contact Precautions sign posted outside the room stating no entry without PPE and directing staff and visitors to put on a gown and gloves before room entry and discard them before exiting. Staff 7 stated individuals were allowed to enter the room without PPE if no care was being provided and said he was unsure why the sign was posted, while Staff 10 stated many people were confused about the PPE requirements for the room. The Infection Preventionist later confirmed that PPE was required for anyone entering the room because a resident in the room had MRSA and contact precautions were required. Surveyors also observed a room with a CDC Enhanced Barrier Precautions sign indicating gown and glove use for high-contact care activities. Staff were observed providing high-contact care to the residents in that room, but Staff 11 stated she had not worn a gown because she did not know she was supposed to, Staff 12 stated she did not believe the resident was on EBP, and Staff 13 stated PPE would only be needed when working directly with the gastrostomy tube or wound before later confirming that PPE was required for all high-contact care. In a separate room with an EBP sign, Staff 15 was observed assisting a resident with compression stocking and sock donning while wearing only gloves and stated she had provided lower body dressing care without a gown because she believed gowns were only required when cleaning or touching an area near a wound or opening. The Infection Preventionist confirmed that EBP were to be followed for any direct contact care, including socks and compression stocking donning.
Meals Served Cold Without Enough Plate Warmers
Penalty
Summary
The facility failed to ensure resident meals were served at an appetizing temperature in the hallways. Review of Resident Council meeting notes from 12/2025, 1/2026, and 2/2026 showed repeated resident concerns that hot food was being served cold. Resident 36, admitted in 2/2026 with sepsis and nutritional deficiency and assessed as cognitively intact on the admission MDS, stated on 3/23/26 that food was always served cold. Resident 69, admitted in 3/2026 with occlusion and stenosis of the left posterior cerebral artery and assessed as cognitively intact on the admission MDS, stated on 3/23/26 that food was delivered cold. Observation and staff interviews showed trays being delivered without plate warmers. On 3/26/26, Resident 90’s tray was observed delivered without a plate warmer, and Resident 36’s food was also observed delivered without a plate warmer; Resident 36 stated the food was cold and requested a CNA to re-heat it. Resident 90, admitted in 3/2026 with a fractured tibia and assessed as cognitively intact on the admission MDS, stated the meal plate was delivered without a plate warmer and the food was often served cold. A CNA stated resident plates were often served without plate warmers and she usually needed to re-heat meals. The Prep Cook and Dietary Manager stated plate warmers were used to keep meals at appetizing temperatures in the hallways, and the Prep Cook confirmed the kitchen did not have enough plate warmers to serve all residents in the hallways. The Administrator stated she expected residents to be served meals at an appetizing temperature and was unaware the facility did not have enough plate warmers for each resident at meals.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper labeling and storage of food and beverages, which placed residents at risk for foodborne illness. During an inspection, surveyors observed three trays of unlabeled and undated cups of milk and juice, an uncovered and unlabeled large plastic bin of dry oat cereal, an opened and undated five-pound plastic tub of peanut butter with smeared contents, an opened and undated bag of salad greens, and a plastic bin containing four eggs, one with a broken shell. The Dietary Manager acknowledged these issues, stating that items should be wrapped, labeled, and dated to prevent spoilage and cross-contamination. Additionally, the facility's equipment and kitchen cleanliness were found to be inadequate. The gaskets on the refrigerator doors were grimy and not sealing properly, and multiple in-floor drains were observed to be dirty with black grime and food debris. The Dietary Manager confirmed these observations, noting that the gaskets were old and did not close well, and that the drains needed cleaning. The facility administrator acknowledged these findings and stated that the kitchen staff was expected to maintain cleanliness and proper food storage practices.
Inadequate Discharge Planning for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who was admitted with a periprosthetic fracture and experienced dementia. The resident required assistance with various activities, including catheter care and medication management, and had ongoing health issues such as dizziness and unstable blood pressure. Despite these needs, the discharge plan was inadequately executed, with no evidence of proper education or preparation for the resident or their family. On the day of discharge, the resident was sent home with a foley catheter, but there was no documentation indicating that the resident or their family received instructions on catheter care or medication administration. The family was not notified of the discharge in a timely manner, and there was no confirmation that a family member would be present to assist the resident upon arrival home. Additionally, home health services were not arranged, leaving the resident without necessary support. Interviews with staff and family members revealed a lack of communication and preparation for the discharge. The resident's family was informed of the discharge only two hours before the resident's arrival home, and they were not trained on the care required for the resident's catheter or medications. Staff acknowledged the deficiencies, noting the need for better training and documentation to ensure safe discharges in the future.
Failure to Maintain a Homelike Environment Due to Unclean Recliner
Penalty
Summary
The facility failed to ensure a homelike environment for residents in one of the rooms reviewed. During an observation, a cloth recliner chair in the room was found to be stained with an unknown brown dried residue on the seat and armrests. Staff interviews revealed that the chair was considered filthy and lacked a cleanable surface. The CNA and Infection Preventionist both acknowledged the chair's dirty condition. The Housekeeping staff admitted to having a monthly cleaning schedule for recliners but did not clean the chair in question because it was made of cloth. The Administrator confirmed the chair's dirty state and noted it had a bad odor.
Failure to Follow Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that safety interventions for fall prevention were followed for a resident with severe cognitive impairment and a history of falls. The resident, who was admitted with diagnoses including age-related osteoporosis and severe vascular dementia, was assessed to be at risk for falls due to incontinence, impaired cognition, and impaired functional mobility. The care plan for the resident included having a low bed positioned against the wall and in the lowest position with a fall mat at the bedside to minimize injury risk from falls. However, observations on multiple occasions revealed that the resident's bed was elevated to a height suitable for wheelchair transfers and not in the low position as required by the care plan. There were no caregivers present in the room during these observations. Staff members, including a CNA and an RN, confirmed that the resident was part of the facility's Falling Star program, which required staff to ensure the bed was in the lowest position. Despite this, the bed was consistently found at a higher position, indicating a failure to adhere to the prescribed fall prevention interventions.
Failure to Follow Catheter Care Orders
Penalty
Summary
The facility failed to follow catheter care orders for a resident who was admitted with a diagnosis of urine retention and required the use of a Foley catheter. The resident had normal cognitive function and returned to the facility after a surgical procedure with specific instructions for the Foley catheter to be changed immediately. However, the catheter was not changed on the day of the resident's return or the following day, as confirmed by the resident and staff interviews. Staff members involved in the resident's care acknowledged the failure to change the catheter as ordered. One staff member intended to contact the physician for clarification but did not follow through, while another staff member cited time constraints as the reason for not completing the catheter change. The Director of Nursing Services confirmed that the catheter change was not performed as ordered, indicating a lapse in following medical orders and meeting the resident's care needs.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was admitted with diagnoses including malnutrition. The resident's care plan, revised on 9/29/23, indicated a planned discharge home with referrals for home health, physical and occupational therapy, and other medically related services. However, the Social Services Director confirmed that the resident did not have a discharge summary in their clinical record for 2023. A home health staff member reported attending a care conference before the resident's discharge, where the facility agreed to make necessary referrals and send paperwork to the home health agency. Despite multiple phone calls to the previous Social Services Director requesting physician orders and instructions, the home health staff did not receive a response. The resident's clinical record lacked a discharge summary, and progress notes indicated the resident was discharged home on 9/17/23. The previous Social Services Director was no longer employed at the facility and could not be interviewed. The facility administrator was informed of these findings but provided no additional information.
Failure to Follow Bowel Care Protocols for Two Residents
Penalty
Summary
The facility failed to adhere to physician orders for bowel care for two residents, leading to a deficiency in care. Resident 3, admitted with diagnoses including atrial fibrillation and constipation, had specific physician orders for bowel medications to be administered daily. Despite these orders, the resident's bowel logs for October 2023 showed no bowel movement from October 22 to October 31. The medication administration record (MAR) indicated that the bowel protocol was not followed correctly, with delays in administering prescribed medications such as Polyethylene Glycol Powder, Bisacodyl suppository, and Fleet Mineral Oil enema. The resident went without a bowel movement for 11 days, highlighting a significant lapse in following the bowel protocol. Similarly, Resident 4, admitted with a diagnosis of stroke, also experienced a failure in the administration of bowel medications as per physician orders. The resident's MAR revealed that Polyethylene Glycol Powder was not administered from October 20 to October 23, and a Bisacodyl suppository was only given on October 24, six days after the last recorded bowel movement. This delay in following the bowel protocol resulted in a deficiency in care for Resident 4. Both residents were no longer in the facility at the time of the investigation, and the facility's Director of Nursing Services confirmed the failure to follow the bowel protocol.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident, leading to delays in medication administration. The resident, admitted in September 2023 with a diagnosis of a urinary tract infection (UTI), had specific physician orders for medications to be administered at 7:15 AM. These medications included Polyethylene Glycol Powder, Potassium Chloride ER, Torsemide, Cipro, and Nitrofurantoin Macrocrystal. However, a review of the Medication Admin Audit Report for October 2023 revealed multiple instances where the medications were administered outside the prescribed two-hour window (6:15 AM to 8:15 AM). The administrator confirmed that the resident received medications outside of this timeframe on several dates, including October 5, 7, 13, 20, 21, 27, and 28.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gresham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gresham Post Acute Care And Rehabilitation | 1.5 mi | ★★★★★ | 26 | 0 |
| Regency Gresham Nursing & Rehabilitation Center | 1.9 mi | ★★★★★ | 12 | 0 |
| Village Manor Of Cascadia | 2.5 mi | ★★★★★ | 1 | 0 |
| Marquis Centennial Post Acute Rehab | 3 mi | ★★★★★ | 14 | 0 |
| Village Health Care | 4 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.