GRESHAM, OR - Federal health inspectors identified 18 separate deficiencies at Gresham Post Acute Care and Rehabilitation during a complaint investigation concluded on December 19, 2025, including failures in bladder and catheter care that placed residents at risk for urinary tract infections and related complications.
Complaint Investigation Reveals Widespread Deficiencies
The inspection, triggered by a formal complaint, resulted in one of the higher deficiency counts among Oregon skilled nursing facilities in recent months. Among the findings, regulators documented that the facility failed to provide appropriate care for residents managing bowel and bladder continence, failed to deliver proper catheter maintenance, and did not take adequate steps to prevent urinary tract infections.
The catheter care deficiency was classified under federal regulatory tag F0690, which addresses a facility's obligation to assist residents in maintaining continence and to provide catheter care that minimizes infection risk. Inspectors assigned the finding a Scope/Severity Level D, indicating an isolated incident with no documented actual harm but with potential for more than minimal harm to residents.
While the designation of "no actual harm" may sound reassuring, the clinical implications of improper catheter care are well established. Catheter-associated urinary tract infections, known as CAUTIs, are among the most common healthcare-associated infections in long-term care settings. They can rapidly progress from localized discomfort to systemic bloodstream infections, particularly in elderly residents with compromised immune function.
Why Catheter Care Protocols Matter
Indwelling urinary catheters require strict adherence to evidence-based maintenance protocols. Proper care includes regular hygiene of the catheter insertion site, maintaining a closed drainage system, ensuring the collection bag remains below bladder level, and conducting routine assessments of whether the catheter is still medically necessary.
When these protocols break down, bacteria can enter the urinary tract within 24 to 48 hours. For nursing home residents — many of whom are over 75 and managing multiple chronic conditions — a urinary tract infection can trigger confusion, falls, sepsis, and in severe cases, death. The Centers for Disease Control and Prevention has identified CAUTI prevention as a top patient safety priority in long-term care facilities nationwide.
Federal regulations under 42 CFR §483.25(e) require that nursing facilities provide services to restore or maintain a resident's ability to manage bladder function independently when possible. When catheterization is necessary, facilities must demonstrate that the device is medically justified and that infection prevention measures are consistently followed.
The Broader Picture at Gresham Post Acute
The catheter care violation was just one component of the facility's 18 total deficiencies. A count of 18 deficiencies in a single inspection cycle is notable. For context, the national average for skilled nursing facility inspections is approximately 7 to 8 deficiencies per survey, according to data compiled from the Centers for Medicare & Medicaid Services. A facility receiving more than double the national average during a complaint-driven investigation suggests systemic compliance challenges rather than an isolated oversight.
The breadth of the findings indicates that inspectors identified concerns across multiple areas of resident care and facility operations. Complaint investigations are typically more targeted than routine annual surveys, which means inspectors may have uncovered additional issues beyond the original complaint's scope.
Facility Response and Correction Timeline
Gresham Post Acute Care and Rehabilitation submitted a plan of correction following the inspection and reported that corrective actions were completed by January 16, 2026 — approximately four weeks after the inspection date. A plan of correction requires the facility to outline specific steps it will take to address each deficiency, prevent recurrence, and monitor ongoing compliance.
The submission of a correction plan does not guarantee that the issues have been fully resolved. CMS and state survey agencies may conduct follow-up inspections to verify that corrective measures have been implemented and are effective.
Gresham Post Acute Care and Rehabilitation is located in Gresham, Oregon, a city of approximately 114,000 residents east of Portland. The full inspection report, including details on all 18 deficiencies, is available through the CMS Care Compare database and on NursingHomeNews.org's facility profile page.
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 2025-12-19 including all violations, facility responses, and corrective action plans.
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