Gresham Post Acute Care and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Gresham Post Acute Care and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 23, 2023

  Based on interview and record review it was determined the facility failed to provide eating assistance and to monitor for aspiration for 1 of 2 sampled residents (#168) reviewed for nutrition. The facility's failure was determined to be an immediate jeopardy situation because it resulted in Resident 168's [DATE] hospitalization for aspiration pneumonia and a subsequent death on [DATE]. Findings include: Resident 168 admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) and chronic respiratory failure. The [DATE] Admission Orders included an order for oxygen three liters via nasal cannula during the day. The [DATE] Physician Order revealed Resident 168 was to be alert and to sit up at 90 degrees for all meals. […]

• Immediate jeopardy, isolatedF725May 23, 2023

  1. Based on interview and record review it was determined the facility failed to respond to a residents call lights timely for 4 of 12 sampled residents (#s 32, 39, 41 and 168) reviewed for staffing. This facility's failure was determined to be an immediate jeopardy situation because it resulted in Resident 168's in delay of care, transfer to the hospital, subsequent death and placed all residents at risk for untimely and unmet care needs. Findings include: 1. Resident 168 admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing) and chronic respiratory failure. a. […]

• Actual harm, widespreadF865May 23, 2023

  Based on interview and record review it was determined the facility failed to address QAPI (Quality Assurance and Performance Improvement) identified concerns regarding sufficient staff for 1 of 1 QA (Quality Assurance) committees reviewed for QAPI. This resulted in the failure to provide timely care and assistance to residents. Findings include: The 4/19/22 Annual Survey identified nurse staffing as an area requiring correction in order to provide adequate care to residents. A 2/12/23 complaint investigation identified nurse staffing as an area requiring continued correction with deficient practice identified from 8/2022 through 12/2022. Review of QAPI Meeting Minutes from 1/2023 identified nurse staffing as an area to address and review in future QAPI meetings. […]

• Actual harm, isolatedF686Dec 19, 2025

  Based on observation, interview and record review it was determined the facility failed to assess, implement treatment and provide on-going monitoring to prevent pressure ulcers for 1 of 2 sampled residents (#30) reviewed for pressure ulcers. This failure resulted in Resident 30 developing a facility acquired Stage 2 pressure ulcer (a shallow wound involving partial skin loss). Findings include: The facility's 10/2024 Skin Management Policy and Procedure directed the following:-If new skin impairments are found, the licensed nurse will notify the resident, notify the provider, obtain treatment orders, initiate and document pertinent details in the risk management, document findings in the clinical record and place the resident on alert. […]

• Actual harm, isolatedF684Jun 17, 2025

  Based on interview and record review it was determined the facility failed to ensure residents received treatment and services necessary to prevent constipation for 1 of 3 sampled residents (#100) reviewed for bowel care. This failure resulted in the resident experiencing no bowel movements for seven days, which led to the need for emergency department evaluation and treatment due to a fecal impaction (a severe form of constipation where a large, hard mass of stool becomes lodged in the colon or rectum, preventing normal bowel movements). The facility's Bowel Management policy dated 4/2025 indicated the following: -Resident's bowel movements were recorded daily and reviewed by the licensed nurse. […]