Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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 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 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.
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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 | 1.5 mi | — | 4 | 0 |
| Marquis Centennial Post Acute Rehab | 1.9 mi | — | 1 | 0 |
| Village Health Care | 2.5 mi | — | 2 | 0 |
| Village Manor Of Cascadia | 2.6 mi | — | 0 | 0 |
| Regency Gresham Nursing & Rehabilitation Center | 3 mi | — | 12 | 0 |
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