Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Regency Gresham Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Expired medications were found in a medication cart and a medication storage room, including an open bottle of calcium citrate plus vitamin D and several OTC products such as suppositories, antifungal cream, hydrogel, and oral pain relief gel. An LPN, the IP, and the DNS acknowledged the expired items and stated medications in carts and supply rooms are expected to be discarded when expired.
Surveyors found multiple unlabeled, undated, uncovered, and expired food items in kitchen and resident refrigerators, including meat spread, gelatin, beverages, dairy items, fruit, take-out food, and resident-owned foods. A Dietary Manager and CMA confirmed the items were not properly labeled or dated, expired items were not discarded, and some refrigerators lacked current temperature monitoring logs.
A resident who was dependent on staff for personal hygiene and grooming was repeatedly observed with a significant amount of visible facial hair. The resident stated a preference not to have facial hair and relied on staff for shaving assistance, but CNAs said they did not routinely assess or offer shaving unless requested, and an LPN said shaving was done only on scheduled shower days. The DNS stated the resident’s shaving preferences were expected to be followed.
Failure to provide trauma-informed care for two residents with PTSD. The facility did not document trauma assessments or identify triggers in the care plans for two cognitively intact residents, and staff interviews showed they were unaware of the residents’ specific PTSD triggers. One resident said yelling was a trigger, while the other said the facility never asked about trauma history or triggers.
A resident with HTN had orders for Metoprolol Succinate ER and Prazosin to be held when BP was below ordered parameters, but staff documented both meds as given on multiple occasions when the resident's BP was below those limits. A CMA acknowledged one dose of Metoprolol should have been held, another CMA said she may have held some doses but not others, and the resident's progress notes did not show the meds were held.
A resident with an indwelling urinary catheter was observed multiple times with the catheter bag and tubing in direct contact with the floor while in bed or in a wheelchair. A CNA, an LPN, and the DNS all confirmed the bag and tubing should be kept off the floor and below the bladder level, but it was still found on the floor.
The facility did not ensure residents were aware of their right to review survey results, nor were these results readily accessible, especially for second-floor residents. During a resident meeting, it was found that none of the residents knew about the survey results' location on the first floor. The Activities Director noted that survey results were previously available on the second floor but were removed during a remodel. The Administrator confirmed that survey results were only available on the first floor, and second-floor residents would need staff assistance to access them.
The facility failed to maintain a homelike environment, with issues such as wall damage, broken picture frames, and burned-out lights. A resident reported their room was excessively cold, requiring extra comforters and wearing a hat indoors. Despite complaints, the room's temperature fluctuated significantly, and the Maintenance Director did not regularly check the temperature. Temperature readings confirmed the room and bathroom were colder than typical comfort levels.
The facility failed to notify the Office of the State Long Term Care Ombudsman about the hospitalization of three residents, which is a requirement for ensuring advocacy. Residents with conditions such as dementia, heart disease, spinal cord compression, and congestive heart failure were hospitalized without the Ombudsman being informed. Staff members, including the administrator and social services director, were unaware of the notification requirement.
The facility failed to properly label and store food items in the kitchen and snack/resident refrigerators, leading to potential risks of food spoilage and cross-contamination. Observations revealed undated or expired items, including macaroni, whipped topping, gelatin, waffles, garden burgers, garlic bread sticks, meat, Danish rolls, and cheese. Staff confirmed the improper practices, and the administrator acknowledged the expectation for proper labeling and dating of all food.
A facility failed to provide a resident with a written notice of its bed hold policy at the time of transfer to a hospital. The resident, admitted with dementia and heart disease, was discharged to an acute care hospital without receiving the required notification. This lack of documentation was confirmed by the DNS.
A resident admitted with paralysis and infection had a care plan indicating a preference for wearing a shirt and using a call light. Observations showed the resident wearing a hospital gown and rarely using the call light, instead calling out for assistance. Staff confirmed these changes, but the care plan was not updated, risking unmet care needs.
A facility failed to inform a resident's representative, who was the POA, of changes in financial coverage. The resident, with severe cognitive impairment, signed a NOMNC form without the representative's knowledge, leading to private pay status without notification. The Social Services Director and Administrator acknowledged the oversight.
Expired Medications Found in Cart and Storage Room
Penalty
Summary
The facility failed to ensure medications were not expired in 2 of 8 medication storage areas. In the 300-hall medication cart, an open bottle of calcium citrate plus vitamin D was observed with an expiration date of 8/2025, and Staff 22, the LPN Resident Care Manager, acknowledged that medications were to be discarded when expired. In the medication storage room, expired items were observed including Major Bisacodyl Suppositories with an expiration of 4/2025, Good Sense Hemorrhoidal Suppositories with an expiration of 11/2024, Antifungal cream with an expiration of 11/2024, Hydrogel with an expiration of 10/2024, and Instant toothache oral pain relief gel with an expiration of 6/2025. Staff 26, the Infection Preventionist, acknowledged the expired medications and stated he was not auditing the OTC medications for expiration dates. Staff 2, the DNS, also acknowledged that medications in the supply rooms and medication carts are expected to be discarded when expired.
Food Storage and Labeling Deficiencies in Multiple Refrigerators
Penalty
Summary
The facility failed to ensure food and beverages were labeled and stored in a manner to minimize spoilage and cross contamination in 3 of 3 unit refrigerators and 1 of 2 kitchen refrigerators reviewed for sanitary conditions. Surveyors observed multiple unlabeled, undated, uncovered, or expired food items in the non-produce kitchen refrigerator, including a container of meat spread, a large pan of orange gelatin, two five-gallon containers of liquid, all without use-by dates. Staff 4, the Dietary Manager, confirmed the items were not properly labeled and dated. Surveyors also found unlabeled and undated food items in the second-floor unit resident and nourishment refrigerator, including a container of meat spread and a brown paper bag of food items marked WK, which Staff 23, a CMA, confirmed were not properly labeled and dated. In the Main Dining Room resident refrigerator, surveyors observed numerous unlabeled, undated, or expired items, including beverages, dressings, dairy products, fruit, take-out food, and containers of food, along with no temperature monitoring log for the refrigerator. In the first-floor resident and nourishment refrigerator, surveyors found three opened containers of ice cream that were unlabeled and undated, expired cheese and meat sticks, expired hummus containers, and the last temperature monitoring log dated July 2024. Staff 4 confirmed the items were not properly labeled and dated, expired items were not discarded, and refrigerators needed temperature monitoring to ensure foods and liquids were stored at 41 degrees F or less.
Failure to Provide Needed Shaving Assistance
Penalty
Summary
The facility failed to ensure a dependent resident received required assistance with ADLs, specifically personal hygiene and grooming. Resident 98, admitted in 7/2025 with diagnoses including CHF and anxiety, had a Significant Change MDS indicating dependence on staff for personal hygiene and grooming. The resident was observed on 9/15/25, 9/16/25, and 9/18/25 with a significant amount of visible facial hair. During interview, the resident stated a desire not to have facial hair and said staff should take care of shaving and that the resident relied on staff for this assistance. Staff interviews showed that a CNA reviewed shower schedules and included shaving residents, but did not routinely assess or offer shaving assistance unless residents requested it. Another CNA acknowledged the resident had noticeable facial hair and used the Kardex for care information. An LPN stated the facility’s process was to shave residents on scheduled shower days and acknowledged the resident should have been care planned for shaving needs. The DNS stated it was her expectation that the resident’s shaving preferences be followed.
Failure to Assess and Care Plan Trauma Triggers for Residents with PTSD
Penalty
Summary
The facility failed to ensure trauma-informed care was provided for 2 of 3 sampled residents reviewed for mood, both of whom had diagnoses including PTSD. The facility’s revised 10/2022 Trauma Informed Care Policy required screening residents on admission for trauma-informed care needs, including identifying triggers and history of trauma, using family, friends, or responsible parties as needed, and incorporating triggers into the care plan. For Resident 68, admitted in 3/2025 and assessed by the MDS as cognitively intact with PTSD, the record contained no evidence that trauma triggers were assessed or that a care plan was developed to address potential re-traumatization. The resident stated that yelling may trigger a negative response, but staff interviewed were unable to identify triggers, and the Administrator confirmed staff were expected to assess all residents for trauma-informed care needs at admission and identify triggers for care planning. For Resident 49, admitted in 8/2025 with PTSD and able to make self understood and understand others without difficulty, the clinical record also lacked evidence of a trauma assessment or care plan addressing trauma triggers. The resident stated the facility had not asked about trauma history or potential triggers. Staff interviews showed the CNA was unaware of the PTSD diagnosis because it was not listed on the Kardex, the LPN stated there were no specific triggers on the care plan and that it was not resident-specific, and the Social Services Director acknowledged the omission of potential triggers from the care plan was an oversight. The DNS stated Resident 49 should have been assessed on admission for PTSD, including identification of potential triggers.
Failure to Hold BP Medications per Physician Orders
Penalty
Summary
Ensure each resident's drug regimen was free from unnecessary drugs was not met when staff failed to follow physician orders for blood pressure medications for one resident with a history of hypertension. The resident had orders for Metoprolol Succinate ER to be held if blood pressure was below 100/60 or heart rate was below 60 beats per minute, and Prazosin HCL to be held if blood pressure was below 100/60. On 9/18/25, the resident's blood pressure was 106/54, yet Metoprolol Succinate ER was documented as given by a CMA, and the CMA later acknowledged it should have been held. Review of the MAR showed multiple additional instances in August and September 2025 when Prazosin and Metoprolol Succinate ER were documented as given despite blood pressure readings below the ordered parameters. One CMA stated that when she held a medication, she would document it in the progress notes, but acknowledged that on some days she probably held the medications and on some days she did not. The resident's progress notes contained no indication that Metoprolol Succinate ER or Prazosin was held on the listed dates. The DNS stated staff were expected to follow physician orders and acknowledged the medications should have been held when the resident's blood pressure was below the ordered parameters.
Catheter bag and tubing left on the floor
Penalty
Summary
The facility failed to ensure infection control practices were implemented for one resident with an indwelling urinary catheter. Resident 49, admitted with diagnoses including PTSD and urine retention, had a catheter evaluation on 9/5/25 indicating the need for an indwelling urine catheter. On 9/15/25, 9/17/25, and 9/18/25, the resident was observed in bed or in a wheelchair with the catheter bag and tubing in direct contact with the floor. Staff 25, a CNA, stated the catheter bag and tubing should not touch the floor and that she would pick it up if observed there. Staff 9, an LPN, confirmed the catheter bag and tubing was on the floor and stated it should be kept off the floor and below the level of the bladder to prevent infection and ensure proper drainage. Staff 2, the DNS, stated the catheter bag and tubing was expected to be kept off the floor at all times.
Failure to Ensure Resident Access to Survey Results
Penalty
Summary
The facility failed to ensure that residents were aware of their right to review survey results and did not make these results readily accessible, particularly for residents on the second floor. During a resident meeting, it was revealed that none of the eight residents present were aware of the survey results' location on the first floor near the elevator. Additionally, it was noted that most second-floor residents could not easily access the first floor without staff assistance. Observations confirmed that no survey results were accessible on the second floor. The Activities Director mentioned that survey results were previously available on the second floor but were removed during a remodel, and she believed most residents were unaware of their availability. The Administrator confirmed that survey results were only available by the first-floor entrance and had not been on the second floor for six years, suggesting that second-floor residents could request staff assistance to view them.
Environmental and Temperature Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a homelike and comfortable environment for residents, as evidenced by multiple observations of environmental deficiencies across two of the three halls reviewed. Specific issues included wall damage with missing paint and exposed drywall in several rooms, a broken picture frame with sharp edges in the 300 hall, and burned-out overhead lights in the dining room and hallways. These deficiencies were acknowledged by the facility's Administrator and Maintenance Director, indicating a need for corrective action. Additionally, a resident admitted with a right foot wound reported that their room was excessively cold, requiring extra comforters and wearing a hat indoors to stay warm. Despite complaints to staff, the room's temperature fluctuated significantly, sometimes being too hot or too cold. The Maintenance Director admitted to not regularly checking the room's temperature, despite its history of temperature complaints. Temperature readings taken during the survey confirmed the resident's room and bathroom were colder than typical comfort levels, with temperatures recorded at 69 degrees in the room and 65 degrees in the bathroom.
Failure to Notify Ombudsman of Resident Hospitalizations
Penalty
Summary
The facility failed to notify the Office of the State Long Term Care Ombudsman about the hospitalization of three residents, which is a requirement for ensuring advocacy. Resident 40, who was admitted with dementia and heart disease, was discharged to an acute care hospital, but there was no documentation indicating that the Ombudsman was informed. The facility's administrator confirmed that they did not notify the Ombudsman of discharged residents. Similarly, Resident 87, admitted with spinal cord compression, was sent to the hospital without the Ombudsman being notified. Staff 13, responsible for social services, was unaware of the requirement to notify the Ombudsman. Resident 339, with congestive heart failure, was also hospitalized without notification to the Ombudsman. Both the social services director and the administrator confirmed the lack of notification for these hospitalizations.
Improper Food Storage and Labeling in Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of food items in the kitchen and snack/resident refrigerators, which could lead to food spoilage and cross-contamination. During an observation, several items were found undated or past their expiration dates, including a plastic container of macaroni with red meat sauce, whipped topping, and gelatin. In the freezer, there were waffles dated over two months prior, garden burgers with freezer burn, and undated garlic bread sticks and meat. The walk-in refrigerator contained Danish rolls with unclear freezing and thawing dates, whipped topping, and cheese, all improperly labeled or stored. Staff members, including a cook and the dietary manager, confirmed the improper storage and labeling of these items. The dietary manager discarded the expired items and acknowledged the lack of proper labeling and dating. Additionally, a snack/resident refrigerator contained an undated and unlabeled plate of food from a previous meal, which was removed by the administrator, who also acknowledged the expectation for all food to be labeled and dated. These deficiencies in food storage practices placed residents at risk for potential infections from foodborne pathogens.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a written notice of its bed hold policy to residents at the time of transfer to a hospital, as required. This deficiency was identified during a review of the case of Resident 40, who was admitted to the facility in December 2023 with diagnoses including dementia and heart disease. On February 26, 2024, Resident 40 was discharged to an acute care hospital. However, a review of the resident's health record revealed no documentation indicating that the resident was notified of or provided with a copy of the facility's bed hold policy prior to the discharge. This oversight was confirmed by Staff 2, the Director of Nursing Services (DNS), on July 1, 2024.
Failure to Update Care Plan for Resident's Clothing Preferences and Call Light Use
Penalty
Summary
The facility failed to revise and update the care plan for a resident who was admitted in November 2023 with diagnoses including paralysis and infection. The resident's comprehensive care plan indicated a preference for wearing a shirt even when staying in bed and required the call light to be within reach, encouraging its use. However, observations from June 24 to June 27, 2024, showed the resident wearing a hospital gown throughout the day, contrary to the care plan. Interviews with staff members revealed that the resident rarely used the call light and instead called out for assistance, indicating a change in behavior and preferences that were not reflected in the care plan. Staff members, including CNAs and an RN, confirmed that the resident did not express a preference for wearing a shirt or gown and did not consistently use the call light as previously noted. Despite these changes, the care plan was not updated to reflect the resident's current needs and preferences. This oversight placed the resident at risk for unmet care needs, as the care plan did not accurately guide staff in providing personalized care based on the resident's current condition and preferences.
Failure to Notify Resident's Representative of Financial Coverage Changes
Penalty
Summary
The facility failed to ensure that the representative of a resident with severe cognitive impairment was informed in writing of changes in financial coverage. The resident, diagnosed with Alzheimer's disease, was admitted for skilled care and was unable to make serious medical decisions. Despite this, the facility provided a Notice of Medicare Non-Coverage (NOMNC) form to the resident, who signed it, indicating that covered services would end on a specific date. The resident continued to stay in the facility as a private pay resident after the coverage ended, but there was no evidence that the resident's representative, who was also the Power of Attorney (POA), was informed of this change or the right to appeal. The resident's representative, identified as Witness 2, stated that she had informed the Social Services Director of her role as POA and her responsibility for making all medical and financial decisions for the resident. However, she was not provided with the NOMNC or any notification of financial liabilities. The facility's Administrator admitted to having the resident sign the form due to time constraints and did not notify the representative. This oversight placed the resident and their representative at risk of unknown financial liabilities and a lack of knowledge regarding the right to appeal the decision.
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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) |
|---|---|---|---|---|
| Fairlawn Health And Rehab Of Cascadia | 1.9 mi | ★★★★★ | 4 | 0 |
| Gresham Post Acute Care And Rehabilitation | 3 mi | ★★★★★ | 26 | 0 |
| Village Manor Of Cascadia | 4.2 mi | ★★★★★ | 1 | 0 |
| Marquis Centennial Post Acute Rehab | 4.8 mi | ★★★★★ | 14 | 0 |
| Village Health Care | 5.3 mi | ★★★★★ | 12 | 0 |
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