Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Gresham Post Acute Care And Rehabilitation during CMS and state inspections, most recent first.
A resident with quadriplegia, ventilator dependence, and high Braden risk developed a new Stage 2 pressure ulcer on a finger, but staff did not complete a timely skin form, staging, measurements, or treatment orders when the wound was first found. Observations showed the resident’s hand was often left pressed into the mattress or poorly positioned on a pillow so the wound still bore pressure, and staff gave inconsistent accounts of wound monitoring and offloading.
A resident with bipolar disorder, ADHD, and depression was started on bupropion after a physician order noted that consent was required before administration. The MAR showed the medication was given before any consent was found in the record, and an RCM/LPN confirmed nurses were expected to obtain consent for psychotropic meds before giving them.
A resident with quadriplegia and ventilator dependence repeatedly had a soft-touch call light placed out of reach while in bed, and staff left the room without confirming access after care. Another resident with muscle weakness had two overbed lights missing cords, leaving the room light controlled only by a switch at the entrance and requiring staff help to turn it on and off.
Failure to Reassess Ongoing Need for Left-Hand Mitten Restraint: A resident with diffuse TBI and a trach/g-tube had a left-hand mitten restraint used daily, but the record showed no clear reassessment of continued need or exploration of less restrictive alternatives. Care conference notes only indicated the device remained appropriate, the MDS showed no physical restraints or risky behaviors, and staff confirmed the restraint had not been reassessed despite the resident being observed using the left hand to communicate.
Inaccurate MDS Coding of Restraint Use: A resident with diffuse traumatic brain injury had a mitten hand restraint on the left hand documented in progress notes, physician orders, and MAR/TAR entries, and it was also observed during multiple random checks. However, the Annual MDS incorrectly indicated no physical restraints were in place, and the MDS Coordinator/LPN confirmed the restraint section was inaccurately coded.
Failure to provide grooming assistance: Two residents who depended on staff for personal hygiene and shaving were observed with unshaven facial hair. One resident with diffuse TBI had a care plan for daily shaving and two-person ADL care, yet staff gave inconsistent reports about who was responsible for shaving and family had already raised concerns that hygiene was not being completed daily. Another cognitively intact resident had a care plan for shaving assistance, but staff said they were uncomfortable asking about the service and did not offer it, despite leadership stating the care plan should be implemented.
A resident with bilateral hearing loss was care planned for hearing aids and requested a new pair after the old ones were lost during room moves. Staff, including Social Services, the LPN Resident Care Manager, and the DNS, acknowledged the request was not followed up and the resident remained without hearing aids despite being eligible for replacement.
Failure to assess continence and provide toileting assistance for a resident with dementia and mixed incontinence. The resident’s family stated the resident was continent at home, but staff reportedly did not take the resident to the bathroom and instead waited for incontinence before changing the resident. The care plan identified toileting assistance needs and incontinence risk, but no interventions were documented to help the resident remain continent, and staff stated the resident was not assessed for continence on admission.
Failure to Maintain Ordered Continuous Tube Feeding: A resident with TBI, persistent vegetative state, and dysphagia had an order for continuous tube feeding at 60 ml/hr, but the pump was found turned off, bags were not properly managed, and the feeding was disconnected during activities and transport. Staff confirmed the tube feed was supposed to run continuously and there were no orders to make up missed nutrition or fluids.
Respiratory Equipment Not Maintained: Two residents had issues with oxygen equipment maintenance and use. One resident, who was cognitively intact and had no order for ongoing O2 unless sats dropped below 92%, was still observed using an O2 NC connected to an O2 concentrator, and staff were unaware the oxygen was being used ongoing. Another resident with CHF and dysphagia had an O2 concentrator with a foam filter covered in dust, and staff stated there was no cleaning schedule for the filter.
Failure to assess and plan for trauma-related triggers. A resident admitted with PTSD and sleep terrors had no documented trauma assessment or care plan addressing triggers, despite the facility policy calling for evaluation of trauma symptoms and individualized planning. The resident reported loud noises and staff speaking loudly when waking from sleep caused startle responses, increased respirations, and pain, while staff were unaware of trauma-related concerns and the care plan did not include PTSD, trauma history, or triggers.
A resident with osteoporosis and muscle weakness was observed with bilateral quarter bed rails in place even though the care plan did not include them and no evaluation was found in the record. Staff confirmed there was no physician order, no assessment, and no care plan support for the bed rails, and the DNS acknowledged the required steps were not completed before the rails were used.
A resident with ALS received rivaroxaban for a clotting event, but the pharmacist’s medication regimen reviews identified that it should be given with food and that the resident should be monitored for bleeding. The clinical record showed no evidence that bleeding monitoring was in place or that the pharmacy recommendations were reflected in the physician orders, MAR/TAR, or care plan. Staff interviews confirmed the LPN and RN were unfamiliar with the medication, and the resident care manager acknowledged the resident was not being monitored as required.
Medication error rates were not kept below 5 percent, with 2 of 29 attempts in error. A resident with heart failure had orders for potassium chloride and torsemide, but a CMA was observed giving the wrong doses and later stated she was unaware the order had changed and acknowledged the error. The DNS stated staff are expected to administer medications per physician orders.
Expired vitamin B 12 was found in a medication cart, and two open, undated vials of Tubersol were observed in a medication room. A CMA confirmed the vitamin had expired, and an LPN and the DNS confirmed the Tubersol vials had no open dates and were to be destroyed.
A resident with CHF, dysphagia, and severe cognitive impairment had O2 ordered PRN. Staff found the resident’s nasal cannula and tubing on the floor, then an RN wiped the cannula with an alcohol wipe and placed it back on the resident’s bed. The IP and regional IP stated the tubing and cannula were contaminated and should not have been wiped and reused.
A resident's privacy curtain was observed with multiple stains and had reportedly been dirty for weeks despite repeated requests for it to be washed. Two residents also had personal fans coated with dust, including one fan blowing visible dust and another fan covered in dust and cobwebs while pointed toward the resident's face. Staff from housekeeping, maintenance, and nursing acknowledged the curtain and fans were not clean.
A resident with cerebellar ataxia had multiple falls with head or facial impact, but required neuro checks were incomplete after each event. Another resident with dysphagia and Bell’s palsy had speech therapy for swallowing dysfunction, yet was not seen as scheduled, medications were held, and swallowing ability was not reassessed before the hold. A third resident with a stroke history had a suction machine at the bedside without a physician order or care plan, and staff acknowledged the device required an order.
A resident with a seizure disorder did not receive prescribed anti-seizure medication for several days due to pharmacy supply issues and lack of timely review of new medication orders by staff. Multiple staff members confirmed that medication orders were not properly reviewed or followed up, resulting in missed doses.
A resident with severe cognitive impairment and multiple medical conditions did not receive timely bowel care interventions as required by facility policy, resulting in seven days without a bowel movement, fecal impaction, dehydration, and a UTI. Staff did not notify the medical provider or implement the bowel management protocol as indicated, leading to the resident's transfer to the emergency department for treatment.
A resident admitted with a sacral pressure injury did not receive timely wound care, leading to the wound's progression from a deep tissue injury to unstageable. The facility's admission process failed to identify the wound, and no treatment was initiated until six days later, despite the resident's paralysis and risk factors. The facility's protocol for entering generic wound care orders was not followed, contributing to the delay in care.
The facility failed to ensure proper food storage and labeling in residents' personal refrigerators and did not enforce the use of hair restraints by kitchen staff. Two residents had unlabeled and undated food items in their personal refrigerators, and kitchen staff were observed without hair restraints during meal preparation, contrary to FDA guidelines.
The facility did not ensure that CNA staff received the required 12 hours of annual in-service training. A review showed that four CNAs had insufficient training hours, with one completing only 1.1 hours and the others none. The HR staff confirmed this, and the administrator acknowledged the need for a tracking system to monitor training hours.
The facility failed to inform residents and/or their responsible parties about the risks and benefits of psychotropic medications and did not obtain consent before administration for three residents. One resident was prescribed citalopram hydrobromide without documented consent, another received aripiprazole without consent, and a third was given fluoxetine without proper documentation of consent. Staff confirmed that it was their responsibility to review these details with residents prior to medication administration, which was not done.
The facility failed to provide written transfer notices with appeal rights to residents and their representatives and did not notify the Office of the State Long-Term Care Ombudsman of resident hospitalizations. Two residents with chronic respiratory failure were transferred to the hospital multiple times without receiving the required notifications. Interviews revealed staff were either unaware of the notification requirements or unclear about their responsibilities, and the Administrator confirmed the deficiency.
The facility failed to provide written notice of the bed hold policy to two residents during hospital transfers. One resident, with chronic respiratory failure and quadriplegia, was transferred three times without receiving the policy notice. Another resident, also with chronic respiratory failure, was sent to the hospital four times without the policy being provided. Staff admitted to not providing the policy, and the administrator confirmed the oversight.
A facility failed to ensure accurate MDS assessments for a resident, leading to an inappropriate diagnosis of schizoaffective disorder. The diagnosis was entered without involvement from a mental health practitioner and was inaccurately coded as schizophrenia on subsequent MDS assessments. The pharmacy review later identified the diagnosis as inappropriate, and the DNS acknowledged the error.
A facility failed to create a sufficient baseline care plan for a resident admitted with a pressure injury. The resident, with paralysis and a documented sacral pressure injury, was admitted without the injury being noted on the Clinical Admission Form. The Initial Care Plan did not address the pressure injury until five days post-admission. An LPN was unable to assess the sacrum during admission, and the resident's refusal of a full assessment was undocumented, with no follow-up by subsequent shifts.
The facility failed to update care plans for three residents, leading to potential unmet needs. A resident with epilepsy lacked required fall mats and daily shaving, another with brain compression was observed without a protective helmet, and a third resident's care plan inaccurately listed dialysis treatments that had ceased. Staff acknowledged the need for care plan revisions.
A Nurse Practitioner diagnosed a resident with schizoaffective disorder without involving a mental health professional, despite lacking the appropriate clinical discipline. The resident, with a history of anxiety and depression, was prescribed quetiapine based on this diagnosis, which was later questioned by a physician and pharmacist. The diagnosis remained unaddressed in the resident's records, and the Nurse Practitioner was no longer employed at the facility.
A facility failed to maintain oxygen equipment for a resident with COPD who required continuous oxygen therapy. Despite a physician's order to clean the oxygen concentrator and filter weekly, observations showed the equipment was dusty, and records lacked documentation of cleaning. The resident did not recall any cleaning, and staff confirmed the oversight.
A resident with anxiety and depression was prescribed quetiapine without documented clinical indications or a plan for evaluating its effectiveness. The dosage was increased multiple times without rationale, and a new diagnosis of schizoaffective disorder was added without a mental health professional's evaluation. The DNS could not provide supporting documentation, and the diagnosis was questioned by the pharmacist and physician.
Failure to Assess and Offload a Resident’s New Pressure Ulcer
Penalty
Summary
The facility failed to assess, implement treatment, and provide ongoing monitoring to prevent pressure ulcers for a resident who was admitted with quadriplegia, ventilator dependence, and high pressure injury risk on the Braden Scale. The resident’s annual MDS indicated cognitive intactness, severe upper and lower extremity impairment, dependence on staff for all ADLs, and risk for pressure ulcers. The resident’s skin care plan identified existing pressure ulcers on the right gluteus, left plantar great toe, left medial ankle, and right elbow, and directed staff to notify the licensed nurse of any new skin issues and to document weekly wound measurements and other wound characteristics. A pressure ulcer was found on the resident’s right ring finger after the resident requested a dressing change, but the initial skin form did not include staging, size, wound bed appearance, exudate, or signs of infection, and did not identify who placed the dressing or why it had been applied. A progress note documented the wound and stated the resident’s right hand was to be elevated to relieve pressure. However, observations showed the resident’s right hand repeatedly pressed into the mattress without effective offloading, and at times no pillow or padding was in place. When a pillow was used, staff observed that the wound still pushed into the bed because of how the pillow was positioned. Staff statements showed inconsistent management of the wound and lack of timely assessment. One LPN stated she observed the wound during wound rounds weeks earlier but did not measure it, complete a skin integrity form, or obtain treatment orders, and was waiting for orders while treating it on her own. She also stated the wound was initially small and later increased to about the size of a quarter, and that it worsened on days she did not work because treatments were not completed. Other staff stated the resident’s hand should have been elevated at all times, that the resident wanted a pillow under the hand and did not refuse it, and that a skin integrity form should have been started when the wound was first discovered. The DNS stated the form should have been initiated at discovery so root cause analysis, timely treatment, and wound assessment including staging and measurement could have been completed.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to provide the risk and benefits for the use of a psychotropic medication to a resident before the medication was administered. Resident 2 was admitted with diagnoses of bipolar disorder, ADHD, and depression. A physician order added bupropion 75 mg on 12/9/25 and indicated that consent was required before the medication could be given. The MAR showed that bupropion 75 mg was administered starting 12/11/25, but the medical record contained no consent obtained prior to administration. On 12/18/25 at 1:15 PM, Staff 20, the Resident Care Manager/LPN, confirmed nurses were expected to obtain consent for psychotropic medications before administering them and acknowledged that consent had not been obtained before Resident 2 started bupropion 75 mg.
Call Lights and Overbed Lights Not Accessible
Penalty
Summary
The facility failed to ensure call devices were accessible for a resident with quadriplegia, ventilator dependence, and severe upper and lower extremity impairment who was cognitively intact and dependent on staff for all ADLs. The resident’s care plan directed use of a soft touch call light with the left hand, but on multiple observations the call light was placed too high or otherwise out of reach in bed. The resident stated the call light was placed out of reach on a daily basis and that she/he had to yell for staff attention. Survey observations also showed staff assisting the resident and leaving the room without confirming the resident could reach the call light, and staff statements indicated the placement was adjusted based on the resident’s strength and that staff were supposed to ensure reachability before leaving. The facility also failed to ensure overbed lights were accessible for another resident with muscle weakness and somatoform disorder who required extensive assistance with all ADLs. Two overbed lights in the resident’s room were missing their cords, and the resident stated staff had to use the call light to turn the light on and off because the only working light was controlled by a switch at the room entrance. Staff confirmed the missing cords, stated residents should not have to call staff to operate the overbed lights, and the administrator acknowledged the broken cords and stated all overhead lights should be available for residents to use.
Failure to Reassess Ongoing Need for Left-Hand Mitten Restraint
Penalty
Summary
The facility failed to accurately reassess the ongoing need for a mitten hand restraint for one resident with diffuse traumatic brain injury. The resident was admitted in 11/2023 and had a mitten restraint on the left hand documented in progress notes since 11/3/23, with a physician order for a weighted mitten restraint on the left hand dated 3/14/24 and a later order dated 2/20/25 directing staff to use the mitten, remove it every two hours for skin checks, and wash it every shift. A managed risk agreement dated 4/16/24 showed the family requested the mitten, a weighted elbow sleeve, and, as a last resort, soft wrist restraints because the resident frequently pulled out the tracheostomy tube and g-tube and injured self. The resident’s care plan stated restraint use interventions were initiated on 12/13/23 and directed staff to monitor, document, and report changes in effectiveness, less restrictive devices attempted, and any negative effects. However, care conference notes from 7/15/25 and 9/11/25 only marked the assistive/restrictive device as continuing to be appropriate, without details about alternate options, reassessment, or risks. The 11/2025 and 12/2025 MAR/TAR and task logs showed daily restraint use, while the annual MDS indicated no physical restraints in place and no behaviors posing a risk to self or others. The clinical record contained no evidence that the mitten was reassessed for continued need or that less restrictive alternatives were explored, and staff interviews confirmed the restraint had not been reassessed and family discussion about continued use or alternatives was needed.
Inaccurate MDS Coding of Restraint Use
Penalty
Summary
The facility failed to accurately identify restraint use in the comprehensive assessment for Resident 58, who was admitted in 11/2023 with diagnoses including diffuse traumatic brain injury. Progress notes showed the resident had a mitten hand restraint on the left hand since 11/3/23, and physician orders showed a weighted mitten hand restraint on the left hand since 3/14/24. The 11/2025 and 12/2025 MAR/TAR documented restraint use on every Day and NOC shift, and random observations from 12/15/25 through 12/19/25 between 8:00 AM and 4:30 PM showed the mitten on the resident’s left hand. However, the Annual MDS dated [DATE] indicated no physical restraints were in place. On 12/19/25 at 10:55 AM, the MDS Coordinator/LPN confirmed she completed the comprehensive MDS on 12/8/25 and that the restraint section was inaccurately coded.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to provide necessary care and assistance to maintain good grooming for two residents who were dependent on staff for personal hygiene and shaving. One resident, admitted with diffuse traumatic brain injury, had an annual MDS showing dependence on staff for personal hygiene and no rejection of care, and the care plan required two staff members for ADL care and daily shaving. Care conference notes documented family concerns that personal hygiene was not being completed daily. During observations over several days, the resident was seen with dark facial hair growing from the chin, and staff gave inconsistent accounts of who was responsible for shaving, with some stating the resident was shaved after showers, others saying shaving was done only when the resident wanted it, and another stating the resident was to be shaved daily and as needed. The second resident was cognitively intact but dependent for personal hygiene, including shaving, and the care plan required one staff member to assist with shaving. The resident was observed with unshaven facial hair above the upper lip and stated the resident usually shaved every two or three weeks and did not know staff could perform the task. Staff reported discomfort with asking the resident about shaving and did not offer the service, while the care manager stated staff were expected to implement the care plan, including shaving tasks. The DNS and regional nurse coordinator acknowledged the resident required assistance with shaving and that staff were expected to offer shaving services to residents who needed help.
Failure to Follow Up on Resident’s Request for New Hearing Aids
Penalty
Summary
The facility failed to follow up on a resident’s request for new hearing aids. Resident 6 was admitted in 2/2025 with bilateral hearing loss, and the care plan dated 8/29/25 identified a hearing deficit and directed staff to assist with putting hearing aids in every morning. The same care conference noted that the resident had hearing aids but requested a new pair. The resident later stated that the old hearing aids were lost during one of the room moves and that the resident was eligible for new hearing aids in 7/2025, but assistance with obtaining them had not been provided. During interviews, the Social Service Director stated she was unaware the hearing aids were missing and acknowledged she had not followed up on the resident’s request made at the care conference. A CNA stated the resident was hard of hearing but did not have hearing aids, and the LPN Resident Care Manager stated she was unaware whether the resident had hearing aids, although the resident was care planned for them. The DNS stated requests for new hearing aids should be followed up immediately, including determining eligibility, and acknowledged there had been no follow-up on the resident’s request.
Failure to Assess Continence and Provide Toileting Assistance
Penalty
Summary
The facility failed to assess bowel and bladder continence for one resident who was admitted with diagnoses including dementia and mixed incontinence. The resident’s family member stated the resident was continent of bowel and bladder at home, but after being in the facility for two weeks, staff did not take the resident to the bathroom and instead allowed the resident to be incontinent. The resident also stated that staff waited until the resident was incontinent and then changed the resident rather than taking the resident to the bathroom. The resident’s care plan dated 12/5/25 identified the resident as needing one-person extensive assistance for toileting and being at risk for incontinence, with a goal to always remain continent, but there were no documented interventions to assist the resident with remaining continent. Staff stated the resident was thought to be incontinent, that the resident did not ask to use the bathroom, and that the facility does not initiate toileting programs to assist residents in remaining continent. The LPN Resident Care Manager stated the resident was not assessed for continence on admission, and the DNS acknowledged that a record review of CNA charting was not sufficient for an assessment and that the resident was not assessed for continence upon admission.
Failure to Maintain Ordered Continuous Tube Feeding
Penalty
Summary
The facility failed to follow the nutritional orders and care plan for a resident admitted with diffuse traumatic brain injury, persistent vegetative state, and dysphagia. The resident’s care plan directed continuous tube feeding for 24 hours with Isosource 1.5 at 60 ml/hr for a total of 1440 ml per day, and required two licensed nurses to verify the correct tube feed and formula when placing a new bag, with all tube feeding bags labeled with two LN signatures and the date/time hung. During observation and interviews, the resident’s tube feeding was found connected but the pump was turned off, with two bags attached to the pump, including one labeled bag dated and timed the prior day and another unlabeled bag containing clear liquid. The bag was not changed until several hours later. Additional observations showed the tube feeding disconnected when the resident was taken to the dining room for an activity, the pump later alarming and remaining idle for ten minutes before the nurse responded, and the tube feeding disconnected again when the resident was transported to a medical appointment. Staff interviews confirmed the tube feeding was supposed to run continuously for 24 hours and that there were no orders to stop the feeding or provide bolus feedings, so missed time on the pump meant the resident was not receiving the ordered nutrition and fluids.
Respiratory Equipment Not Maintained
Penalty
Summary
The facility failed to ensure resident respiratory equipment was maintained for 2 of 3 sampled residents reviewed for respiratory care. Resident 10 was admitted with diabetes, was cognitively intact on the 12/2/25 Significant Change MDS, and did not require oxygen services. The record showed no current physician order for ongoing oxygen use unless the oxygen level dropped below 92%. However, on 12/15/25 and again on 12/17/25, Resident 10 was observed with an oxygen nasal cannula in place and connected to an oxygen concentrator. Staff 5 stated residents needed a physician order for ongoing oxygen use and that they were expected to be followed as written, and Staff 5 was not aware the resident was using oxygen ongoing. Staff 20 stated she completed an audit on 12/16/25, discovered Resident 10 had an oxygen concentrator in the room, and directed staff to remove it, but later confirmed the concentrator was still present and the resident was receiving oxygen via nasal cannula. Staff 20 stated the resident had an order for oxygen only if oxygen saturations dropped below 92% and vital signs did not indicate the need for oxygen. Resident 68 was admitted with congestive heart failure and dysphagia, and the 9/14/25 Quarterly MDS indicated severe cognitive impairment. The physician order dated 1/7/25 showed oxygen as needed. On 12/15/25, the oxygen concentrator was observed with a foam filter covered in a thick layer of dust. Staff 41 stated checking and cleaning oxygen filters was the nurse's responsibility and not a CNA duty. Staff 15 observed the concentrator and acknowledged the foam filter was very dirty and needed to be cleaned. Staff 2 stated the facility did not have a cleaning schedule for the oxygen filter and expected oxygen filters to be cleaned weekly.
Failure to Assess and Plan for Trauma-Related Triggers
Penalty
Summary
The facility failed to ensure that Resident 55 received trauma informed care. The resident was admitted with diagnoses including PTSD and sleep terrors, and the facility’s undated Trauma Informed Care and Culturally Competent Care policy stated that the assessment process should include an in-depth evaluation of trauma-related symptoms, identification of triggers, and an individualized care plan to address past trauma and decrease exposure to triggers that may re-traumatize the resident. However, Resident 55’s social service history, trauma, and SUD assessment indicated no trauma history, and the admission MDS showed the resident was cognitively intact and had a diagnosis of PTSD. No evidence was found in the clinical record that an assessment of trauma was completed or that a care plan was developed to address potential trauma triggers. During interviews, Resident 55 stated that loud noises and staff speaking loudly when waking the resident from sleep caused startle responses, increased respirations, and increased pain levels. Staff interviews showed that a CNA was not aware of any trauma-related concerns or triggers, an LPN stated the resident had a history of war-related trauma but was unaware of issues around loud noises, the RCM confirmed the care plan did not include trauma or triggers, and Social Services stated no further investigation was completed after the resident denied trauma on the assessment.
Bed Rails Used Without Assessment or Order
Penalty
Summary
The facility failed to conduct a safety assessment and obtain orders before initiating the use of bed rails for one resident. The resident was admitted with diagnoses including osteoporosis and muscle weakness, and the admission MDS dated 10/28/25 indicated the resident required substantial assistance for bed mobility and transfer out of bed. The resident’s current care plan did not include bed rails, and no evidence was found in the clinical record that an evaluation had been completed for their use. On 12/15/25, the resident was observed in bed with bilateral quarter rails in the upright position. On 12/16/25, a CNA stated she was aware the resident had bilateral bed rails in place but could not locate an order or care plan supporting their use. An LPN care manager confirmed there was no physician order for the bilateral bed rails and acknowledged they should not have been in place without an order. The DNS stated the expectation was that a physician order, assessment, and care plan update would be completed before bed rails were used, and confirmed those steps were not completed prior to the rails being in place.
Failure to Address Pharmacist Recommendations for Anticoagulant Use
Penalty
Summary
The facility failed to address pharmacy recommendations for one resident who was admitted with diagnoses including Amyotrophic Lateral Sclerosis (ALS), a progressive and fatal neurological disorder that causes weakness, paralysis, and respiratory failure. The pharmacist’s admission medication regimen review identified that rivaroxaban should be administered with food and that the resident should be monitored for signs and symptoms of bleeding due to use of the anticoagulant. A later pharmacist review again recommended that “give with evening meal” be added to the physician orders for rivaroxaban and/or that the administration time be adjusted if needed. The resident’s physician orders directed rivaroxaban once daily at bedtime for a clotting event, but there was no evidence in the clinical record that the resident was being monitored for bleeding or that follow-up to the pharmacist’s recommendations had been implemented. Staff interviews showed an LPN was unfamiliar with rivaroxaban and did not know whether it required monitoring or food, and an RN stated the resident did not have anticoagulant monitoring in place. The resident care manager confirmed the resident was supposed to be monitored for bleeding and was not, and the DNS stated pharmacy recommendations were to be responded to within a week and that the TAR and care plan should include anticoagulant monitoring.
Medication Administration Errors Exceeded the Allowed Rate
Penalty
Summary
Medication error rates were not kept below 5 percent, with 2 of 29 medication administration attempts found in error. Resident 62 was admitted to the facility in 2/2025 with a diagnosis of heart failure. Physician orders dated 12/16/25 directed potassium chloride oral packet 20 MEQ, 2 packets twice a day, and torsemide 100 mg, 0.5 tablet twice a day. On 12/17/25 at 8:28 AM, Staff 34, a CMA, was observed administering torsemide 100 mg and potassium chloride 20 MEQ, 1 packet. Later that morning, Staff 34 confirmed the resident had orders for torsemide 50 mg and potassium chloride 20 MEQ, 2 packets, and stated she was unaware the order had changed and acknowledged giving the wrong dose of both medications. On 12/19/25, the DNS stated staff are expected to administer medications per physician orders.
Expired and Undated Medications Found in Medication Storage Areas
Penalty
Summary
The facility failed to ensure medications were not expired in 1 of 4 medication carts and 1 of 2 medication rooms. During observation, an expired bottle of vitamin B 12 was found in the 100-hall medication cart, and a CMA confirmed that the bottle had expired in 8/2025. In the 200-hall medication room, two open vials of Tubersol were observed without dates indicating when they were opened. An LPN stated Tubersol is good for 30 days after opening and confirmed there was no open date on either vial and no indication of when they had been opened. The DNS later stated medications must be destroyed when expired and confirmed the two opened, undated vials of Tubersol were to be destroyed.
Infection Control Failure With Contaminated Oxygen Equipment
Penalty
Summary
The facility failed to follow infection control standards for one resident reviewed for respiratory care. The resident was admitted in 10/2019 with diagnoses including congestive heart failure and dysphagia, and the 9/14/25 Quarterly MDS indicated severe cognitive impairment. The resident had a physician order dated 1/7/25 for oxygen as needed. On 12/17/25 at 8:57 AM, the resident’s oxygen cannula and tubing were observed on the floor next to the bed. At 9:04 AM, an RN provided care for the resident and then picked up the nasal cannula and oxygen tubing from the floor, wiped the nasal cannula with an alcohol wipe, and placed the cannula and tubing on the resident’s bed. The RN stated that when the cannula and tubing were found on the floor, her process was to wipe the nasal cannula with an alcohol wipe to disinfect it before placing it back on the resident or on the resident’s bed. The Infection Preventionist and Regional Infection Preventionist stated that oxygen tubing and nasal cannulas found on the floor were considered contaminated, should not have been wiped with an alcohol wipe and reused, and should have been discarded and replaced.
Dirty privacy curtain and dusty personal fans
Penalty
Summary
The facility failed to ensure that a resident's privacy curtain was clean and that personal fans in resident rooms were clean. Resident 10, admitted with diabetes and assessed as cognitively intact, was observed with a privacy curtain that had multiple small stains on the lower half and a large brownish stain in the bottom right corner. The resident stated the curtain had been dirty for many weeks and that multiple staff had been asked to have it washed, and the resident did not like looking at the dirty curtain. Staff from housekeeping, nursing, and regional corporate nursing confirmed the curtain was not clean and needed to be changed. Resident 44, admitted with a history of stroke, had a black box fan in the room that was coated with dust and had visible strings of dust blowing from it. Staff from housekeeping, maintenance, nursing, and regional corporate nursing acknowledged the fan was dirty and stated staff were expected to keep it clean and free from dust. Resident 67, admitted with anoxic brain damage and spastic quadriplegic cerebral palsy, had a fan on the bedside table covered in a thick layer of dust and cobwebs; it was observed off and later on, pointed toward the resident's face while the resident's mouth was open. Staff from nursing, housekeeping, maintenance, and the DNS acknowledged the fan was dirty and pointed toward the resident's face.
Missed neuro checks, unassessed swallowing ability, and suction device without order
Penalty
Summary
The facility failed to complete neurological assessments after multiple falls for a resident admitted with cerebellar ataxia. The resident had an unwitnessed fall with head strike on 9/20/25, additional unwitnessed falls on 10/15/25, 10/18/25, and 11/3/25, and a witnessed fall with facial impact on 10/20/25, plus an unwitnessed fall with forehead impact on 10/25/25. Review of the neurological assessment flow sheets showed missing assessments for each of these events. Staff stated neurological checks were to be completed after unwitnessed falls and after witnessed falls when the resident hit their head, and also on a schedule of every 15 minutes for one hour, every 30 minutes for an hour, every hour for four hours, and every four hours for 24 hours, but the assessments were not completed as required. The facility also failed to reassess a resident’s ability to swallow medications. The resident had diagnoses including dysphagia and Bell’s palsy, and speech therapy evaluated the resident with a plan to treat swallowing dysfunction three times per week. Speech therapy notes showed the resident was not seen on some scheduled days because of scheduling conflicts, was asleep or not alert enough for safe oral intake trials on other days, and refused treatment on one day. A physician order was entered to hold all medications from 12/12/25 until 12/15/25, and the record showed the resident ate meals during that period, but there was no documentation of increased swallowing difficulty and no evidence that swallowing ability was reassessed before medications were held. The facility also failed to obtain a physician order for a suction machine used by another resident. That resident, who had a history of stroke, stated the suction machine at the bedside was used by the resident, and the device was observed on the bedside table. Record review found no physician order for suction machine use and no plan of care for it. Staff acknowledged the resident had previously used a suction machine, that the device was present at the bedside, and that ongoing use required a physician order, but the chart contained no health indication or assessment supporting its use.
Failure to Administer Anti-Seizure Medication as Ordered
Penalty
Summary
A resident with a history of seizures and respiratory failure was admitted to the facility with a physician's order for felbamate, an anti-seizure medication, to be administered twice daily. Despite this order, the medication was not administered for three days, resulting in five missed doses, due to complications in obtaining the medication from the pharmacy. Progress notes indicated staff were aware of the delay, but the medication was not delivered until several days after the order was written. Interviews with facility staff revealed that orders were not reviewed as required, and there was a lack of oversight in ensuring the medication was obtained and administered as prescribed. Staff also confirmed that when the Resident Care Manager was unavailable, other staff did not review new admission medications, contributing to the delay.
Failure to Prevent and Manage Constipation Resulting in Fecal Impaction
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent constipation for a resident with severe cognitive impairment, central cord syndrome, and toxic encephalopathy. The resident was admitted with significant care needs, including substantial to maximal assistance for toileting and was prescribed both polyethylene glycol and sennosides for constipation. Despite these interventions, the resident experienced a decline in oral intake and had no recorded bowel movements for seven consecutive days. According to the facility's Bowel Management policy, residents who do not have a bowel movement for three days should be placed on the bowel program and, if ineffective, the medical provider should be notified within 24 to 32 hours for further orders. Documentation and staff interviews revealed that the resident was not placed on the bowel program as required, and the medical provider was not notified of the ongoing constipation. Multiple staff members confirmed that the resident's lack of bowel movements should have triggered additional interventions and provider notification, but there was no evidence of such actions in the medical record. As a result of these omissions, the resident developed a fecal impaction, significant rectal distention, dehydration, and a urinary tract infection, necessitating emergency department evaluation and treatment. The medical provider was only contacted after seven days without a bowel movement, and new orders were obtained following the resident's return from the hospital. Staff and leadership interviews confirmed that the facility's bowel management protocol was not followed, and the required notifications and interventions were not implemented in a timely manner.
Failure to Initiate Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to initiate treatment for a pressure injury present upon admission for a resident with a history of pressure injury to the sacrum. The resident was admitted with diagnoses including paralysis of the lower extremities, diabetes, and obesity. The hospital records indicated a new pressure injury to the sacrum, described as a deep tissue injury (DTI), was present before admission. However, the facility's Clinical Admission form did not identify the wound, and the admission orders did not include wound care instructions. The Braden Scale assessment inaccurately reported no sensory perception impairment, despite the resident's paralysis. The resident's care plan was updated several days after admission to address potential skin impairment, but no wound care was initiated until six days post-admission. Staff confirmed that the resident's pressure injury was not assessed or treated until the facility's certified wound specialist evaluated it, finding it unstageable and requiring debridement. The facility's protocol for entering generic wound care orders upon admission was not followed, and there was no documentation of the resident refusing a full assessment. The lack of timely wound care led to the progression of the pressure injury, necessitating medical intervention.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure proper food storage and labeling in residents' personal refrigerators, as well as the use of appropriate hair restraints by kitchen staff during meal preparation. Resident 4, who was admitted with osteomyelitis and malnutrition, had a personal refrigerator containing several items that were not labeled or dated, including milk, pudding, and ranch dip. The resident reported that no one checked the temperatures or expiration dates of the items in their refrigerator. Staff 7, an LPN-Resident Care Manager, acknowledged that the items should have been dated or discarded, and removed the undated and expired foods. The facility administrator admitted that there was no policy or procedure for managing residents' personal refrigerators, attributing the oversight to staff turnover. Similarly, Resident 21, who was admitted with kidney disease and hypertension, had a personal refrigerator with unlabeled and undated items, including orange juice, yogurt, and chicken nuggets with sauce. The resident also confirmed that staff did not check the refrigerator for expired foods. Staff 7 again acknowledged the need for proper labeling and disposal of expired items. Additionally, during a lunch service observation, several kitchen staff members, including a dietary aide, cook, and dietary manager, were seen without hair restraints, contrary to the US FDA Food Code 2022 requirements. The dietary manager admitted that it was expected for all kitchen staff to wear hair restraints at all times.
Deficiency in CNA Annual In-Service Training
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of annual in-service training. This deficiency was identified during an interview and record review, which revealed that four out of five randomly selected staff members did not meet the training requirements. Specifically, one CNA had only completed 1.1 hours of training, while the other three CNAs had not completed any training hours. The Human Resources staff confirmed the lack of training, and the facility administrator acknowledged the requirement for 12 hours of annual in-service training, noting the need for a tracking system to monitor training hours.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties about the risks and benefits of psychotropic medications and did not obtain consent before administration for three residents. Resident 66, admitted with major depressive disorder, was prescribed citalopram hydrobromide without documented consent or information provided about the medication's risks and benefits until over a month after administration began. Staff confirmed that it was the nursing staff's responsibility to review these details with residents prior to medication administration, which was not done in this case. Similarly, Resident 26, with diagnoses of depression and anxiety, was prescribed aripiprazole without documented consent or information provided about the medication's risks and benefits until several years after the prescription was initiated. Additionally, Resident 14, admitted with anxiety disorder and major depressive disorder, received fluoxetine without documented consent or a review of the medication's risks and benefits. Staff verified that the consent documentation did not include fluoxetine, indicating a failure to ensure informed consent was obtained prior to administration.
Failure to Provide Transfer Notices and Notify Ombudsman
Penalty
Summary
The facility failed to provide written transfer notices with appeal rights to residents and their representatives, and did not notify the Office of the State Long-Term Care Ombudsman of resident hospitalizations. This deficiency was identified for two residents who were transferred to the hospital multiple times. Resident 44, admitted with chronic respiratory failure and quadriplegia, was transferred to the hospital on three occasions without receiving the required transfer notices or having the Ombudsman notified. Similarly, Resident 42, also with chronic respiratory failure, was sent to the hospital four times without the necessary notifications being provided. Interviews with facility staff revealed a lack of awareness and responsibility regarding the notification requirements. The Social Service Director was unaware of the need to notify the Ombudsman, while another staff member knew of the requirement but did not know who was responsible for it. The Administrator confirmed that the facility did not provide the required written notices or inform the Ombudsman of the transfers, indicating a systemic issue in the facility's processes for handling resident transfers and discharges.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide residents with a written notice of the bed hold policy at the time of transfer to the hospital, affecting two residents reviewed for hospitalization. Resident 44, admitted in November 2022 with chronic respiratory failure and quadriplegia, was transferred to the hospital on three occasions in 2024. There was no evidence in the health record that a written notice of the bed hold policy was provided during these transfers. Staff 26, the Social Service Director, admitted unfamiliarity with the bed hold policy and confirmed that no written notice was given to Resident 44 during the transfers. Similarly, Resident 42, admitted in March 2024 with chronic respiratory failure, was sent to the hospital four times in 2024. Again, there was no documentation indicating that the resident or their representative received a written notice of the bed hold policy. Staff 6, an LPN, stated that he did not provide the policy to residents or their representatives at the time of transfer. The facility's administrator confirmed these findings, acknowledging the lack of written notification provided to residents or their representatives regarding the bed hold policy during hospital transfers.
Inaccurate MDS Assessment and Diagnosis
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for a resident, which led to an inappropriate diagnosis being recorded. The resident, who was readmitted with diagnoses of generalized anxiety disorder and major depressive disorder, was suggested to have schizoaffective disorder by a physician. However, there was no evidence that a mental health practitioner was involved in confirming this diagnosis, nor was there documentation that the resident met the diagnostic criteria for schizoaffective disorder. Despite this, the diagnosis was entered into the medical record by a former nurse practitioner. The inappropriate diagnosis was further compounded when it was inaccurately coded as schizophrenia on subsequent MDS assessments. The pharmacy review later identified that the resident had no history of schizoaffective disorder, and the diagnosis was deemed inappropriate. The Director of Nursing Services acknowledged that the diagnosis should not have been coded on the MDS, highlighting a failure in ensuring accurate mental health diagnoses and assessments for the resident.
Failure to Address Pressure Injury in Baseline Care Plan
Penalty
Summary
The facility failed to ensure a baseline care plan was sufficient to meet the needs of a resident admitted with a pressure injury. Resident 173 was admitted with a recent onset of paralysis of the lower extremities and a documented history of a pressure injury to the sacrum, identified during hospitalization. The hospital records indicated the presence of a deep tissue injury (DTI) on the sacrum, requiring specific treatments such as protective ointment, foam dressing, frequent repositioning, and pressure reduction. However, the facility's Clinical Admission Form did not document the presence of this wound, and the Initial Care Plan did not address the actual pressure injury until five days after admission. Staff 4, an LPN, stated that she completed the resident's admission but was unable to visualize the sacrum at that time, despite receiving information about the pressure wound from the hospital. The resident refused a full assessment upon admission, but this refusal was not documented, and subsequent shifts did not follow up. Staff 2 (DNS) and Staff 3 (LPN, Resident Care Manager) confirmed that the Baseline Care Plan was based on the Clinical Admission Form data, which lacked the necessary information about the pressure injury.
Care Plan Inaccuracies for Three Residents
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect the needs of three residents, leading to potential risks for unmet needs. Resident 19, admitted with dysphagia and epilepsy, had a care plan indicating the use of bilateral fall mats and daily shaving. However, observations revealed the absence of fall mats and unshaven facial hair, contrary to the care plan. Staff interviews indicated that the resident no longer required fall mats and was not shaved daily, highlighting a discrepancy between the care plan and the resident's current needs. Resident 66, with a diagnosis of brain compression, had a care plan requiring a protective helmet when out of bed. Observations showed the resident without a helmet while in a wheelchair, and staff were unclear about the helmet's necessity, indicating a need for care plan revision. Resident 67, admitted with acute kidney failure, had a care plan for dialysis treatments, but the resident reported cessation of dialysis weeks prior, which was not updated in the care plan. The Director of Nursing Services acknowledged the need for care plan revisions for these residents.
Inappropriate Diagnosis by Nurse Practitioner
Penalty
Summary
The facility failed to ensure that a Nurse Practitioner, identified as Former Staff 34, adhered to the professional standards of quality by diagnosing a resident with a condition outside of their clinical discipline. The Nurse Practitioner, accredited as an Adult-Gerontology Primary Care Nurse Practitioner (AGPCNP), diagnosed a resident with schizoaffective disorder without involving a mental health professional. This diagnosis was made despite the resident's history of generalized anxiety disorder and major depressive disorder, and without clear evidence that the resident met the diagnostic criteria for schizoaffective disorder. The diagnosis was questioned by both a physician and a pharmacist, who noted the inappropriateness of the diagnosis and the lack of a history of schizoaffective disorder in the resident's medical records. The resident, who was readmitted to the facility with significant anxiety and depression, was prescribed quetiapine, an antipsychotic medication, based on the inappropriate diagnosis. Despite recommendations from a pharmacy review to address the issue, no response or corrective action was documented, and the diagnosis remained on the resident's active diagnoses list at the time of the survey. The Director of Nursing Services (DNS) confirmed the diagnosis was made by the Nurse Practitioner without mental health professional involvement and acknowledged the concerns raised by the pharmacist and physician, but no further follow-up was provided. Former Staff 34 was no longer employed at the facility at the time of the survey.
Failure to Maintain Oxygen Equipment
Penalty
Summary
The facility failed to maintain oxygen equipment for a resident with chronic obstructive pulmonary disease, who required continuous oxygen therapy. The resident was admitted in June 2024 and was cognitively intact. A physician's order from early June 2024 specified that the resident's oxygen concentrator and filter should be cleaned every Tuesday night shift. However, observations in late August 2024 revealed that the oxygen concentrator was covered in dust, and the external filter had a thick gray layer of dust. The resident reported not recalling any staff cleaning the equipment during their stay. Review of the Treatment Administration Records (TAR) for June, July, and August 2024 showed no documentation indicating that the night shift staff cleaned the concentrator and filter as ordered. Staff interviews confirmed the responsibility of the night shift to perform this task, and acknowledgment was made that the equipment had not been cleaned as expected.
Failure to Justify Antipsychotic Medication Use
Penalty
Summary
The facility failed to identify clinical indications for the use of an antipsychotic medication for a resident diagnosed with cancer, generalized anxiety disorder, and major depressive disorder-recurrent. The resident was readmitted in October 2023, and their behavior was monitored, showing episodes of difficulty sleeping but no other significant behaviors or concerns. Despite this, on March 1, 2024, quetiapine, an antipsychotic medication, was prescribed for depression without documented clinical indications or a plan for evaluating its effectiveness. The dosage was increased multiple times without clinical rationale, and a new diagnosis of schizoaffective disorder was added without support from a mental health professional's evaluation. The facility's documentation did not provide a rationale for the prescription or dosage increases of quetiapine, nor did it involve a mental health professional in diagnosing schizoaffective disorder. The Director of Nursing Services (DNS) was unable to provide supporting documentation for the prescription, and the diagnosis was questioned by both the pharmacist and physician. The lack of documentation and professional involvement placed the resident at risk for unnecessary use of psychotropic medication.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 466 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gresham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fairlawn Health And Rehab Of Cascadia | 1.5 mi | ★★★★★ | 4 | 0 |
| Marquis Centennial Post Acute Rehab | 1.9 mi | ★★★★★ | 14 | 0 |
| Village Health Care | 2.5 mi | ★★★★★ | 12 | 0 |
| Village Manor Of Cascadia | 2.6 mi | ★★★★★ | 1 | 0 |
| Regency Gresham Nursing & Rehabilitation Center | 3 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Gresham Post Acute Care And Rehabilitation.
100% money-back within 48 hours.
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.