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Inspection visit

Inspection

REGENCY GRESHAM NURSING & REHABILITATION CENTERCMS #38501512 citations on this visit
12 citations recorded

Citations

12 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0223GeneralS&S Dpotential for harm

    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  • 0324GeneralS&S Dpotential for harm

    Provide properly protected cooking facilities.

  • 0372GeneralS&S Dpotential for harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  • 0761GeneralS&S Fpotential for harm

    F761 - Labeling of Drugs and Biologicals

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  • 0558GeneralS&S Dpotential for harm

    F558 - The right to reside and receive services in the facility with reasonable

    Reasonably accommodate the needs and preferences of each resident.

  • 0578GeneralS&S Epotential for harm

    F578 - The right to request, refuse, and/or discontinue treatment, to participate in or

    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.

  • 0584GeneralS&S Dpotential for harm

    F584 - Safe Environment

    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.

  • 0657GeneralS&S Epotential for harm

    F657 - Comprehensive Care Plans

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  • 0677GeneralS&S Dpotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0689GeneralS&S Dpotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0725GeneralS&S Dpotential for harm

    F725 - Nursing Services

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

FAQ · About this visit

Common questions about this visit

What happened during the April 21, 2023 survey of REGENCY GRESHAM NURSING & REHABILITATION CENTER?

This was a inspection survey of REGENCY GRESHAM NURSING & REHABILITATION CENTER on April 21, 2023. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at REGENCY GRESHAM NURSING & REHABILITATION CENTER on April 21, 2023?

Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smok..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.