Complaint Investigation

Gresham Post Acute Care And Rehabilitation

November 24, 2025 · Gresham, OR · 405 Ne 5th Street

Citations 1

CMS Rating 2/5

Beds 78

Provider ID 385190

Healthcare Facility

Gresham Post Acute Care And Rehabilitation

Gresham, OR · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

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.

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.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.