Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

REGENCY GRESHAM NURSING & REHABILITATION CENTER

GRESHAM, OR · 128 certified beds · Last Life Safety survey September 19, 2025

CMS Certification Number 385015 · first certified January 1967

Ownership

Operated by REGENCY PACIFIC MANAGEMENT · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

8
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
1
Tags cited more than once
Across separate surveys
6
Inspection & testing records
Of the citations on file

Position within OR

8 citations — more than 22% of the 128 certified nursing homes in OR. Compared within OR rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 3 citations; the earlier surveys in the window averaged 2.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens December 2026 — about 3 months from now. This facility’s last Life Safety survey was September 2025. Facilities in OR are typically surveyed 15–17 months after the last one (median 16), measured over 188 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 8 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0584 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.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in OR, and nationally. Surveyors differ markedly between states, so the OR figure is the meaningful one.

This facility8OR median11National median11
Citations on file over three years, compared
MeasureCitations
This facility8
Median facility in OR11
Median facility nationally11

Survey history

Citations at each Life Safety survey
42023-0412024-0732025-09
Citations at each Life Safety survey
Survey dateCitations
April 21, 20234
July 1, 20241
September 19, 20253

Most-cited tags

Most-cited tags at this facility
K-09232K-03551K-03241K-03721K-07411K-07611K-02231
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0923Have proper medical gas storage and administration areas.22025-09-19
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.12025-09-19
K-0324Provide properly protected cooking facilities.12023-04-21
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.12023-04-21
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.12025-09-19
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.12023-04-21
K-0223Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.12023-04-21

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 3
  • Gas, Vacuum, and Electrical Systems Deficiencies 2
  • Miscellaneous Deficiencies 2
  • Egress Deficiencies 1
Citations by CMS category
CategoryCitations
Smoke Deficiencies3
Gas, Vacuum, and Electrical Systems Deficiencies2
Miscellaneous Deficiencies2
Egress Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

September 19, 2025 — 3 citations

Citations issued on September 19, 2025
TagWhat the surveyor checksStatus
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (October 21, 2025)
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.Deficient, Provider has date of correction (October 21, 2025)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (October 21, 2025)

July 1, 2024 — 1 citation

Citations issued on July 1, 2024
TagWhat the surveyor checksStatus
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (August 6, 2024)

April 21, 2023 — 4 citations

Citations issued on April 21, 2023
TagWhat the surveyor checksStatus
K-0223Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.Deficient, Provider has date of correction (May 30, 2023)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (May 30, 2023)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (May 30, 2023)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (May 30, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.