Deficiency Records for Regency Gresham Nursing and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Regency Gresham Nursing and Rehab Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-21 | 2023-05-30 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-04-21 | 2023-05-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-04-21 | 2023-05-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-21 | 2023-05-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-21 | 2023-05-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-21 | 2023-05-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-21 | 2023-05-30 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-04-21 | 2023-05-30 | Y |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-04-19 | 2023-05-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-19 | 2023-05-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-19 | 2023-05-30 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-19 | 2023-05-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-03 | 2022-06-08 | Y |
| Post nurse staffing information every day. | Health | 2022-05-03 | 2022-06-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-03 | 2022-05-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-06 | 2019-06-17 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-05-06 | 2019-06-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-05-06 | 2019-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-06 | 2019-06-17 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-05-06 | 2019-06-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-05-06 | 2019-06-17 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-04-25 | 2019-06-17 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-04-25 | 2019-06-17 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-04-25 | 2019-06-17 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-04-25 | 2019-06-17 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-04-25 | 2019-06-17 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-04-25 | 2019-06-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-04-25 | 2019-06-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-04-25 | 2019-06-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-25 | 2019-06-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-25 | 2019-06-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-05-06 | 2018-10-29 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-10-06 | 2017-11-08 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-10-06 | 2017-11-08 | N |
| Install proper backup exit lighting. | Fire Safety | 2017-10-03 | 2017-11-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-10-03 | 2017-11-08 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-10-03 | 2017-11-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-10-03 | 2017-11-08 | N |
