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Complaint Investigation

Gresham Post Acute Care And Rehabilitation

November 24, 2025 · Gresham, OR · 405 Ne 5th Street
Citations 1
CMS Rating 1/5
Beds 78
Provider ID 385190
Healthcare Facility
Gresham Post Acute Care And Rehabilitation
Gresham, OR  ·  View full profile →
Inspection Summary

GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR — inspection on November 24, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0684
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

Based on interview and record review it was determined the facility failed to administer anti-seizure medication according to physician orders for 1 of 3 sampled residents (# 1) reviewed for medications.

This placed residents at risk for adverse medication side effects and increased episodes of seizures.

Findings include:Resident 1 admitted to the facility on 9/2025, with diagnoses including seizures and respiratory failure. A 9/22/25 Physician Order noted felbamate (an anti-seizure medication) was to be administered twice a day for seizures. A 9/24/25 Progress Note noted staff were working on obtaining Resident 1's anti-seizure medication and that there were complications with receiving the medication, which as not delivered until 9/25/25. Resident 1's 9/2025 MAR indicated the resident's felbamate medication was not administered until 9/25/25 (three days, and five doses after the order date of 9/22/25). On 10/22/25 at 8:56 AM, Staff 3 (Resident Care Manager) stated orders were not reviewed and staff missed the nurses struggle to obtain the medication from the pharmacy.

Staff 3 also stated the pharmacy did not have the medication felbamate on hand and struggled to obtain the medication as well. On 10/22/25 at 10:22 AM, Staff 5 (Director of Respiratory therapy) stated they were not a nurse and does not review newly admitted residents' medications.

Staff 5 stated when Staff 3 was not available, a nurse or the DNS would review medications for new admits.

Staff 5 confirmed this did not occur. On 10/22/25 at 10:41 AM, Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 1's medication was not administered timely and there continue to be pharmacy difficulties that still needed to be addressed.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GRESHAM, OR, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GRESHAM POST ACUTE CARE AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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