Gresham Post Acute Care And Rehabilitation
Inspection Findings
F-Tag F0552
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0552 during a standard health inspection conducted on 2025-12-19.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Ensure that residents are fully informed and understand their health status, care and treatments.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0558
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0558 during a standard health inspection conducted on 2025-12-19.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Reasonably accommodate the needs and preferences of each resident.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0584
F 0584
quadriplegic cerebral palsy (severe stiffness in limbs and severe mobility limitations).
Level of Harm - Minimal harm or potential for actual harm
The Annual MDS with an ARD of 12/1/25 revealed Resident 67 had a BIMS score of 0, which indicated the resident had severe cognitive impairment. The resident was in a persistent vegetative state with no discernible consciousness.
Residents Affected - Few
On 12/15/25 at 2:55 PM, Resident 67's bedside table was observed to have a fan covered in a thick layer of dust and cobwebs. The fan was off and pointed towards Resident 67's face.
On 12/16/25 at 2:13 PM and on 12/17/25 at 9:04 AM, Resident 67's fan was observed to have a thick layer of dust, was turned on and pointed towards her/his face. Resident 67's mouth was observed to be open on both occasions.
On 12/17/25 at 11:53 AM, Staff 39 (Lead CNA) stated nursing staff only cleaned bodily fluids in a resident's room.
On 12/17/25 at 12:11 PM, Staff 37 (Housekeeping) stated she and housekeeping staff were not responsible for cleaning the personal fans of residents.
On 12/17/25 at 1:35 PM, Staff 38 (Housekeeping Manager) and at 3:14 PM Staff 15 (Maintenance Director) both entered Resident 67's room acknowledged the thick layer of dust on Resident 67's fan. Staff 38 and Staff 15 both stated they were not responsible for cleaning the personal fans in resident's rooms.
On 12/17/25 at 3:26 PM, Staff 2 (DNS) entered Resident 67's room and acknowledged her/his fan was on, dirty and pointed towards Resident 67's face.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/19/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gresham Post Acute Care and Rehabilitation
405 NE 5th Street Gresham, OR 97030
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0604
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0604 during a standard health inspection conducted on 2025-12-19.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0641
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0641 during a standard health inspection conducted on 2025-12-19.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Ensure each resident receives an accurate assessment.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0677
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0677 during a standard health inspection conducted on 2025-12-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm
giving Resident 12 her/his medications crushed in pudding, and they tried to get her/him to take the medication in one big bite, which was too much for Resident 12 to swallow.
On 12/17/25 at 10:58 AM, Staff 32 (CNA) stated Resident 12 was having a hard time swallowing last week but was eating and swallowing better this week.
Residents Affected - Few
On 12/17/25 at 11:51 AM, Staff 3 (LPN Resident Care Manager) stated she placed Resident 12's medications on hold on 12/12/25 because Resident 12 was having a hard time swallowing anything and everyone was scared, she/he would aspirate. Staff 3 stated she was unsure if Resident 12 had speech therapy since admission.
On 12/18/25 Staff 31 (Speech Therapist) stated Resident 12 was overall very weak and had delayed swallowing. Staff 31 stated she had not seen Resident 12 since the evaluation on 12/5/25 due to days where Resident 12 was too sleepy to participate or there were scheduling conflicts. Staff 31 stated she was
the only speech therapist in the facility and attempted to see residents as often as she was able. Staff 31 stated she was not informed about Resident 12's inability to swallow on 12/12/25 and was not informed Resident 12's medications were held over the weekend.
On 12/19/25 at 8:32 AM Staff 2 (DNS) acknowledged Resident 12's speech therapy plan of care was to be seen three times a week for dysphagia. Staff 2 stated he expected Resident 12 to be seen per the plan of care and acknowledged Resident 12 was not seen three days a week per the plan of care. Staff 2 stated Resident 12 was eating over the weekend per the documentation, and he expected Resident 12's swallowing to be reassessed for her/his ability to swallow medications as she/he was able to swallow food.
Staff 2 acknowledged there was no evidence Resident 12's swallowing ability was assessed or reassessed from 12/12/25 through 12/15/25. 3.Resident 8 admitted to the facility in 2016 with diagnoses including a stroke.
Resident 8's 10/22/25 Annual MDS Assessment indicated she/he was cognitively intact and used no suction machine (a medical device that creates a vacuum to remove fluids for a person's airway).
On 12/15/25 at 12:44 PM Resident 8 stated she/he used the suction machine at her/his bedside. A suction machine was observed on the left side of her/his bedside table.
Record review of Resident 8's health record on 12/16/25 revealed there was no physician order for the use of a suction machine and no plan of care was found for the use of a suction machine.
On 12/17/25 at 11:16 AM Staff 20 (Resident Care Manager/LPN) stated Resident 8 had previously used a suction machine and acknowledged the suction machine was on Resident 8's bedside table. Staff 20 stated
the resident did not have a physician order for the use of the suction machine and stated the ongoing use of
a suction machine required a physician order. She stated Resident 8 did not have any health indication or assessment in her/his health record which indicated the need for the use of a suction machine.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
F-Tag F0685
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0685 during a standard health inspection conducted on 2025-12-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Assist a resident in gaining access to vision and hearing services.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0686
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-12-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.
Actual harm to residents was documented as a result of this deficiency.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0690
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0690 during a standard health inspection conducted on 2025-12-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0692
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0692 during a standard health inspection conducted on 2025-12-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide enough food/fluids to maintain a resident's health.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0695
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-12-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0699
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0699 during a standard health inspection conducted on 2025-12-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide care or services that was trauma informed and/or culturally competent.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0700
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0700 during a standard health inspection conducted on 2025-12-19.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0756
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0756 during a standard health inspection conducted on 2025-12-19.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0759
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0759 during a standard health inspection conducted on 2025-12-19.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure medication error rates are not 5 percent or greater.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0761
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-12-19.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
F-Tag F0880
Federal health inspectors cited GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-12-19.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 18 deficiencies cited during this inspection of GRESHAM POST ACUTE CARE AND REHABILITATION.
Correction Status: Deficient, Provider has plan of correction.
The facility reported correction as of 2026-01-16.
GRESHAM POST ACUTE CARE AND REHABILITATION in GRESHAM, OR inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.