Regency Gresham Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Regency Gresham Nursing & Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF761Sep 19, 2025

  Based on observations, interviews, and record review it was determined the facility failed to ensure medications were not expired for 2 of 8 medication storage areas. This placed residents at risk for decreased medication efficiency. Findings include:On 9/18/25 at 8:41 AM, an observation was made in the 300-hall medication cart with Staff 21 (CMA). An open bottle of calcium citrate plus vitamin D was observed in the medication cart with an expiration of 8/2025.On 9/18/25 at 8:52 AM, Staff 22 (LPN Resident Care Manager) acknowledged the expired bottle of calcium citrate plus vitamin D and stated medications were to be discarded when expired.On 9/18/2025 at 10:04 AM, Medication Storage room [ROOM NUMBER] was observed with Staff 26 (Infection Preventionist), the following expired medication… […]

• No harm, potential for more than minimal, patternF812Sep 19, 2025

  Based on observation, interview and record review it was determined the facility failed to ensure food and beverages were labeled and stored in a manner to minimize spoilage and cross contamination for 3 of 3 unit refrigerators and 1 of 2 kitchen refrigerators reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include:Review of the US FDA 2022 Food Code indicated the following:-Food prepared and held cold must be clearly marked with date prepared or by day which the food shall be consumed or discarded.-Food must be labeled with a use-by date if stored for at least 24 hours. -Time/temperature control for safety foods must be stored within refrigeration units and held at temperatures of 41 degrees F or below. […]

• No harm, potential for more than minimal, patternF577Jul 1, 2024

  Based on observation and interview it was determined the facility failed to ensure residents were aware of the right to review survey results for 2 of 2 floors and failed to make survey results were readily accessible for 1 of 2 floors reviewed for resident rights. This placed residents and the public at risk for not being informed of the facility's survey history. Findings include: On 6/27/24 at a resident meeting at 2:00 PM residents asked if they were allowed to know the results of the current survey when it was completed. None of the 8 residents attending were aware there was a copy of the survey results located on the first floor near the elevator. Residents further stated most second floor residents could not easily access the first floor without assistance from staff. […]

• No harm, potential for more than minimal, patternF584Jul 1, 2024

  Based on observation and interview it was determined the facility failed to maintain a homelike and comfortable environment for 2 of 3 halls reviewed for environment. This placed residents at risk for living in an unkempt and uncomfortable environment. Findings include: 1. Observations of the facility's general environment and residents' rooms from 6/24/24 through 7/1/24 identified the following issues: -room [ROOM NUMBER] had wall damage behind the bed with missing paint and exposed drywall; -room [ROOM NUMBER] had wall damage behind the bed with missing paint, exposed drywall, several brown spots on the ceiling and a fan with dirty blades; -room [ROOM NUMBER] had wall damage on the right side of the bed with missing paint and exposed drywall; -room [ROOM NUMBER] had damage to the lower… […]

• No harm, potential for more than minimal, patternF623Jul 1, 2024

  Based on interview and record review it was determined the facility failed to ensure the Office of the State Long Term Care Ombudsman was notified of resident hospitalization s for 3 of 3 sampled residents (#s 40, 87 and 339) reviewed for hospitalization . This placed residents at risk for lack of advocacy by the Ombudsman's office. Findings include: 1. Resident 40 was admitted to the facility in 12/2023 with diagnoses including dementia and heart disease. Resident 40's 2/26/24 Discharge MDS indicated the resident was discharged to an acute care hospital. Review of Resident 40's health record revealed no documentation to indicate the state/local Ombudsman was notified Resident 40 was discharged to a hospital. […]