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Deficiency Records for Gresham Post Acute Care and Rehabilitation
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.
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? |
|---|---|---|---|---|
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-08-30 | 2024-10-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-08-30 | 2024-10-14 | N |
| 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. | Health | 2024-08-30 | 2024-10-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-08-30 | 2024-10-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-08-30 | 2024-10-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-08-30 | 2024-10-14 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-08-30 | 2024-10-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-30 | 2024-10-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-30 | 2024-10-14 | N |
| 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. | Health | 2024-08-30 | 2024-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-30 | 2024-10-14 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-08-30 | 2024-10-14 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-09-04 | 2024-10-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-09-04 | 2024-10-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-09-04 | 2024-10-14 | N |
| 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 |
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