Deficiency Records for Gresham Post Acute Care and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Gresham Post Acute Care and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-31 | 2023-12-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-23 | 2023-06-22 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-23 | 2023-06-22 | Y |
| 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. | Health | 2023-05-23 | 2023-06-22 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-05-23 | 2023-06-22 | Y |
| Provide activities to meet all resident's needs. | Health | 2023-05-23 | 2023-06-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-23 | 2023-06-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-23 | 2023-06-22 | Y |
| Provide appropriate foot care. | Health | 2023-05-23 | 2023-06-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-23 | 2023-06-22 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-05-23 | 2023-06-22 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-05-23 | 2023-06-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-23 | 2023-06-22 | Y |
| 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. | Health | 2023-05-23 | 2023-06-22 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-05-23 | 2023-06-22 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-05-23 | 2023-06-22 | Y |
| 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. | Health | 2023-05-23 | 2023-06-22 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-05-23 | 2023-06-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-23 | 2023-06-22 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-05-23 | 2023-06-22 | Y |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-05-16 | 2023-06-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-16 | 2023-06-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-16 | 2023-06-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-16 | 2023-06-22 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-02-13 | 2023-03-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-13 | 2023-03-29 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-13 | 2023-03-29 | Y |
| Post nurse staffing information every day. | Health | 2023-02-13 | 2023-03-29 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-19 | 2022-06-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-19 | 2022-06-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-04-19 | 2022-06-02 | N |
| Dispose of garbage and refuse properly. | Health | 2022-04-19 | 2022-06-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-19 | 2022-06-02 | Y |
| 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. | Health | 2022-04-19 | 2022-06-02 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2022-04-19 | 2022-06-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-19 | 2022-06-02 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-19 | 2022-06-02 | Y |
| 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. | Health | 2022-04-19 | 2022-06-02 | Y |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2022-04-19 | 2022-06-02 | Y |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2022-04-13 | 2022-06-02 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-13 | 2022-06-02 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-04-13 | 2022-06-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-13 | 2022-06-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-13 | 2022-06-02 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2022-04-13 | 2022-06-02 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-13 | 2022-06-02 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-11-03 | 2022-02-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-11-03 | 2021-12-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-03 | 2021-12-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-03 | 2021-12-15 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-11-03 | 2021-12-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-03 | 2021-12-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-03 | 2021-12-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-03 | 2021-12-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-03 | 2021-12-15 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-11-03 | 2021-12-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-03 | 2021-12-15 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-18 | 2019-02-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-12-18 | 2019-02-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-18 | 2019-02-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-12-18 | 2019-02-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-18 | 2019-02-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-12-18 | 2019-02-06 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-12-18 | 2019-02-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-12-18 | 2019-02-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-12-18 | 2019-02-06 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-12-18 | 2019-02-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-18 | 2019-02-06 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-12-18 | 2019-01-23 | N |
| Provide emergency officials' contact information. | Fire Safety | 2018-12-18 | 2019-01-23 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-12-18 | 2019-01-23 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-12-18 | 2019-01-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-12-18 | 2019-01-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-12-18 | 2019-01-23 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-12-18 | 2019-01-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-12-18 | 2019-01-23 | N |
