Gresham Pointe Senior Living

Last inspection

July 23, 2026

Inspections

8, 48 deficiencies cited

Substantiated abuse

19

Substantiated licensing violations

6

Regulatory actions

2

Fines assessed

$8,501.00 (18 violations)

Current owner since

October 1, 2025

License conditions and other regulatory actions

• February 13, 2024 to June 7, 2024: License Condition, Failed to provide safe environment RCFCD24-00205; incident: CALMS - 00052535
  The following statement of violation(s) stem from evidence and interviews collected from re-licensure re-visit #1 (3XKJ12) conducted on February 1, 2024.
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0034 (Resident Move-In and Evaluation); 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services); 411-054-0055 (Medications and Treatments); 411-054-0090 (Fire and Life Safety); 411-054-0105 (Inspections and Investigations); 411-054-0200 (Residential Care Facility Building Requirements)
• October 3, 2023 to March 12, 2025: License Condition, Failed to use an ABST RCFCD23-01202; incident: OR0003958900
  The facility failed to fully implement an Acuity Based Staffing Tool in accordance with OAR 411-054-0037(1).
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• July 23, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
• March 6, 2026: Change of Owner, 16 deficiencies cited report
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Widespread
  • C0160: Reasonable Precautions severity level 2, scope L2 Pattern
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0295: Infection Prevention & Control severity level 2, scope L2 Pattern
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern
  • C0325: Systems: Self-Administration of Meds severity level 2, scope L2 Pattern
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Pattern
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0363: Acuity Based Staffing Tool - Updates & Staffing Plan severity level 2, scope L2 Widespread
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
  • L0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
• June 9, 2025: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Pattern
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
• March 14, 2024: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected May 13, 2024
• October 16, 2023: Validation, 16 deficiencies cited report
  • C0000: Comment severity level 0
  • C0150: Facility Administration: Operation severity level 3, scope L3 Isolated, corrected April 16, 2024
  • C0152: Facility Administration: Required Postings severity level 2, scope L2 Widespread, corrected April 16, 2024
  • C0160: Reasonable Precautions severity level 2, scope L2 Isolated, corrected December 18, 2023
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Pattern, corrected April 16, 2024
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected December 18, 2023
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected April 16, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected June 28, 2024
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern, corrected April 16, 2024
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated, corrected April 16, 2024
  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected April 16, 2024
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern, corrected April 16, 2024
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected April 16, 2024
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected December 18, 2023
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected April 16, 2024
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated, corrected December 18, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected January 31, 2025
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected December 18, 2023
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected April 16, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected January 31, 2025
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected April 16, 2024
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected April 16, 2024

Substantiated abuse or neglect

• November 21, 2025: Failed to intervene when resident's condition changed Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $500.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0045 (Resident Health Services)
  State’s findings

  The Alleged Victim (AV) resided at the facility and relies on staff for some assistance with activities of daily living. According to an investigation, on or about November 21, 2025, AV had a fall resulting in a fractured finger and wrist. AV was assessed at the hospital and returned to the facility wearing a brace. The after-care documentation provided to the facility instructed staff to make an appointment for AV with an orthopedic doctor within 5 days. In the days following the fractures, AV was not assessed by a facility RN and there was no orthopedic follow-up done. On December 28, 2025, AV complained of severe pain to the elbow area of the affected arm and was set to the hospital, resulting in diagnosis of open wound with exposed hardware of the elbow. There was no documented evidence the facility had assessed AV or provided monitoring of the change in condition following the fall with fractures in November. The facility failed to provide oversight and monitoring of a change of condition, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 31, 2025: Failed to provide service Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) relies on the facility for assistance with catheter care. According to an investigation, on or about February 7, 2025, AV did not receive proper assistance with catheter care when the tubing became kinked and twisted, resulting in AV experiencing pain and having to be transferred to the emergency department for treatment. AP1 did not have trained staff available to provide care, resulting in AV experiencing unreasonable discomfort. On March 30, 2025, AV had to wait for an extended period of time for staff to provide catheter care. The facility failed to provide appropriate care, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 5, 2024: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  According to the documentation, the Alleged Perpetrator 2 (AP2) failed to provide a safe medication administration system for the Alleged Victim (AV). The AV was prescribed 5 mg of a narcotic medication as needed for pain. When inputting the 5 mg order, the AP2 put 5 ml instead of mg. On or about December 05, 2024, a facility med tech administered the medication as it was input in the MAR. The dose administered was more than what was prescribed and led to the AV to become nauseous and vomiting, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to provide a safe medication administration system which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 22, 2024: Failed to follow care plan Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  According to the documentation, the facility failed to follow the service plan for the Alleged Victim (AV) for incontinence care and skin checks, resulting in the AV having a urine-soaked mattress and fungal infections. On or about November 20, 2024, an assessment was completed on the AV due to seeing sores on their skin. The AV was diagnosed with a fungal infection with mushroom like sores on their skin. The AV’s mattress was observed to be soaked in urine and a pool of urine was found underneath the resident’s bed. The Mattress needed to be thrown away due to the amount of urine on the mattress for a prolonged period. The failure to follow the service plan for incontinence care and skin checks caused the AV to suffer from a fungal infection and skin breakdown, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 11, 2024: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  According to the documentation, the facility failed to provide a safe environment for the Alleged Victim (AV) by not having enough staff on duty to prevent an elopement. On or about February 11, 2024, at approximately 6:06 pm, the AV was not found inside the facility. After a search of the exterior of the building, staff found the AV in a blackberry bush, sustaining scratches. Upon investigation, it was found the front door to the locked community had an egress from the inside which allowed the AV to elope from the secured facility, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• May 22, 2026: Failed to make facility or resident records accessible Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

• July 22, 2025: Failed to assure resident rights Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to make records available to the Department upon request in accordance with OAR 411-054-0105(1)(a).

• July 22, 2025: Failed to assure resident rights Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to make records available to the Department upon request in accordance with OAR 411-054-0105(1)(a).

• July 22, 2025: Failed to assure resident rights Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  The facility failed to ensure the preparation, completeness, accuracy, and preservation of resident records in accordance with OAR 411-054-0025(8).

• October 30, 2023: Failed to protect resident from inappropriate sexual contact Licensing Violation; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections)
  State’s findings

  According to the documentation, the Alleged Perpetrator (AP2) sexually abused the Alleged Victim (AV) by exposing their genitals and forced AV to touch them. On or about October 30, 2023, AP2 was seen going into the AV’s room numerous times by a camera that was placed in their room. AP2 was seen on camera exposing their genitals to the AV and had AV touch their exposed genitals. Law enforcement investigated and found probable cause to arrest the AP2. AP2 pleaded guilty to two counts of attempted sexual abuse 1, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to protect the AV from sexual abuse which is violation of Oregon Administrative Rules.

• July 18, 2023: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to ensure that a resident that self-administers their medication has an approved physician order, has been evaluated to self-administer at least quarterly and keep prescriptions in their unit. An investigation determined this is a violation of Oregon Administrative Rules.

Read the full record on the state’s site →

ODHS lists only substantiated violations: “either a substantiated instance of abuse or a licensing violation. Open investigations and complaints that are being appealed by the provider are not listed.” Oregon counts neglect as a form of abuse; see the state’s definitions of abuse. Each violation shows the level ODHS gives it, in the state’s words (for example “2 - Minor harm or potential for moderate harm”), and any fine ODHS assessed. Inspection citations show the state’s severity level and scope, and the date ODHS recorded the problem as corrected when it lists one. Rule names come from the Oregon Administrative Rules. ODHS: “Formal regulatory actions can range from a condition placed upon a license due to non-compliance or a notice to revoke a license.” This community is licensed for 88 residents; larger communities are inspected and reported on more often, so read counts with size in mind. Source: Oregon Department of Human Services, Long-Term Care Licensing, data as of October 15, 2026, showing the last five years. Always visit in person and ask the community about anything listed here.