Gresham Post Acute Care and Rehabilitation

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a standard inspection and a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

23 of 128 Oregon homes (18%) got a citation at the actual harm level in 2025.

• Citation F0686. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for F0686 3 times since 2023.

• Citation F0552. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for F0552 2 times since 2024.

• Citation F0558. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on January 22, 2026.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on January 22, 2026.

• Citation F0604. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  CMS lists it as corrected on January 22, 2026.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for F0641 2 times since 2024.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on January 22, 2026.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for F0684 4 times since 2023.

• Citation F0685. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assist a resident in gaining access to vision and hearing services.

  CMS lists it as corrected on January 22, 2026.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for F0690 3 times since 2023.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on January 22, 2026.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for F0695 2 times since 2024.

• Citation F0699. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care or services that was trauma informed and/or culturally competent.

  CMS lists it as corrected on January 22, 2026.

• Citation F0700. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 22, 2026.

• Citation F0756. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on January 22, 2026.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on January 22, 2026.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for F0761 2 times since 2023.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on January 22, 2026.

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CMS lists this as a standard inspection.

• Citation E0007. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Address patient/client population and determine types of services needed.

  CMS lists it as corrected on January 22, 2026.

• Citation E0013. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop Emergency Preparedness policies and procedures.

  CMS lists it as corrected on January 22, 2026.

• Citation E0015. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Address subsistence needs for staff and patients.

  CMS lists it as corrected on January 22, 2026.

• Citation E0041. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Implement emergency and standby power systems.

  CMS lists it as corrected on January 22, 2026.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on January 22, 2026.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for K0920 2 times since 2024.

• Citation K0923. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on January 22, 2026.

  CMS has cited this home for K0923 2 times since 2024.

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CMS lists this as a complaint inspection.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on December 4, 2025.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

23 of 128 Oregon homes (18%) got a citation at the actual harm level in 2025.

• Citation F0684. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on July 1, 2025.

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CMS fine of $19,949 on June 17, 2025.

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• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 1 of 5.

CMS lists this as a standard inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

30 of 128 Oregon homes (23%) got a citation at the actual harm level in 2024.

• Citation F0686. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on October 14, 2024.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on October 14, 2024.

• Citation F0947. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

  CMS lists it as corrected on October 14, 2024.

• Citation F0552. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.

  CMS lists it as corrected on October 14, 2024.

• Citation F0623. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

  CMS lists it as corrected on October 14, 2024.

• Citation F0625. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

  CMS lists it as corrected on October 14, 2024.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on October 14, 2024.

• Citation F0655. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  CMS lists it as corrected on October 14, 2024.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on October 14, 2024.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on October 14, 2024.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on October 14, 2024.

• Citation F0758. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

  CMS lists it as corrected on October 14, 2024.

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CMS lists this as a standard inspection.

• Citation K0923. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on October 14, 2024.

• Citation K0753. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have restrictions on the use of highly flammable decorations.

  CMS lists it as corrected on October 14, 2024.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on October 14, 2024.

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CMS fine of $56,852 on August 30, 2024.

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• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 4 of 5.

• Ownership

  CMS lists this home under a new chain.

• Fine

  CMS changed the fine from May 23, 2023 from $58,240 to $59,947.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

CMS lists this as a complaint inspection.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on December 5, 2023.

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CMS lists this as a standard inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

13 of 128 Oregon homes (10%) got a citation at the immediate jeopardy level in 2023.

• Citation F0689. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on June 22, 2023.

• Citation F0725. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on June 22, 2023.

• Citation F0865. Severity I: actual harm, widespread.

  The rule CMS cited: Have a plan that describes the process for conducting QAPI and QAA activities.

  CMS lists it as corrected on June 22, 2023.

• Citation F0730. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Observe each nurse aide's job performance and give regular training.

  CMS lists it as corrected on June 22, 2023.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on June 22, 2023.

• Citation F0578. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  CMS lists it as corrected on June 22, 2023.

• Citation F0582. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

  CMS lists it as corrected on June 22, 2023.

• Citation F0679. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on June 22, 2023.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on June 22, 2023.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on June 22, 2023.

• Citation F0687. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate foot care.

  CMS lists it as corrected on June 22, 2023.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on June 22, 2023.

• Citation F0698. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe, appropriate dialysis care/services for a resident who requires such services.

  CMS lists it as corrected on June 22, 2023.

• Citation F0727. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

  CMS lists it as corrected on June 22, 2023.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on June 22, 2023.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on June 22, 2023.

• Citation F0825. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide or get specialized rehabilitative services as required for a resident.

  CMS lists it as corrected on June 22, 2023.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on June 22, 2023.

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CMS lists this as a standard inspection.

• Citation E0020. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures including evacuation.

  CMS lists it as corrected on June 22, 2023.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on June 22, 2023.

• Citation K0761. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on June 22, 2023.

• Citation K0372. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on June 22, 2023.

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