Gresham Post Acute Care: Treatment Order Failures - OR
Federal inspectors found that Gresham Post Acute Care and Rehabilitation failed to administer felbamate, an anti-seizure medication, according to physician orders for a resident admitted in September 2025. The resident was diagnosed with seizures and respiratory failure.
The physician ordered felbamate twice daily on September 22. The medication didn't arrive until September 25 — three days and five doses later.
Staff knew there was a problem. A September 24 progress note documented that "staff were working on obtaining Resident 1's anti-seizure medication and that there were complications with receiving the medication."
But nobody followed through.
The Resident Care Manager told inspectors on October 22 that "orders were not reviewed and staff missed the nurses struggle to obtain the medication from the pharmacy." The manager also said the pharmacy didn't have felbamate on hand and "struggled to obtain the medication as well."
The Director of Respiratory Therapy said they don't review medications for newly admitted residents. When the Resident Care Manager wasn't available, "a nurse or the DNS would review medications for new admits," the director explained.
That review never happened.
The Administrator and Director of Nursing Services acknowledged the medication wasn't given on time. They told inspectors there "continue to be pharmacy difficulties that still needed to be addressed."
Felbamate is prescribed to prevent seizures in patients with epilepsy and other seizure disorders. Missing doses can trigger breakthrough seizures and create withdrawal effects as the medication level drops in the patient's system.
The inspection, conducted in response to a complaint, found the facility placed residents "at risk for adverse medication side effects and increased episodes of seizures" through the delayed administration.
The case reveals a breakdown in the facility's medication management system. While the pharmacy faced supply issues obtaining felbamate, the nursing home's internal processes failed to catch the delay or escalate the problem appropriately.
Staff acknowledged they missed the struggle to obtain the medication, despite progress notes documenting the complications. The facility's backup system — having a nurse or Director of Nursing Services review medications when the Resident Care Manager was unavailable — also failed.
The resident's medication administration record confirmed no felbamate was given from September 22 through September 24, despite the twice-daily order. The first dose wasn't administered until September 25, when the medication finally arrived from the pharmacy.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" but noted it affected the medication management practices that protect all residents from similar delays.
The Administrator and Director of Nursing Services' acknowledgment that pharmacy difficulties "still needed to be addressed" suggests ongoing supply chain problems that could affect other residents requiring specialized medications.
For the seizure patient, those three days without medication represented a critical gap in care. Each missed dose increased the risk of breakthrough seizures while the resident recovered from respiratory failure in the nursing home setting.
The facility must now demonstrate how it will prevent similar medication delays and ensure proper oversight of pharmacy supply issues that could leave vulnerable residents without prescribed treatments.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gresham Post Acute Care and Rehabilitation from 2025-11-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR was cited for violations during a health inspection on November 24, 2025.
The resident was diagnosed with seizures and respiratory failure.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.