Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rivercrest Post Acute during CMS and state inspections, most recent first.
Two residents received medication in error due to staff failing to follow physician orders and proper identification procedures. One resident was administered more oxycodone than prescribed, while another received a roommate's antidepressant after an LPN used the wrong name and did not verify identity. Both incidents were acknowledged by facility leadership.
Two residents experienced falls that were not thoroughly evaluated, and there was no documentation to show that care plan interventions were followed. One resident with heart failure slid out of bed and sustained a skin tear, while another with failure to thrive had an unwitnessed fall with an incomplete investigation. Facility staff confirmed that comprehensive analyses were not completed for these incidents.
A resident with advanced pressure ulcers received a dressing change from an LPN who did not change gloves between handling soiled and clean dressings and improperly removed her PPE gown, coming into contact with the contaminated exterior. The LPN acknowledged awareness of proper procedures, and facility leadership confirmed expectations for correct glove and gown use.
The facility did not have the Medical Director attend the QAA/QAPI meetings from April to September 2024, as required. The Former Medical Director refused to participate in these meetings, either in person or via Skype, which posed a risk for unidentified resident needs.
The facility failed to ensure a safe and homelike environment, with observations of heavily stained carpets, a missing floor latch socket creating a hole, and damaged bathroom floors. Room doors were also found with rough, damaged surfaces. The Maintenance Director confirmed these issues, and the Facility Administrator acknowledged the need for a plan to address them.
A facility failed to develop a comprehensive care plan for a resident with diabetes, COPD, and other conditions. The care plan lacked interventions to reduce incontinence episodes and did not address a prescribed fluid restriction, despite the risk of dehydration. Additionally, the resident was offered an Advance Directive form but did not have one in place. The DNS confirmed the care plan was not accurate or individualized.
A resident admitted with a stroke required substantial assistance for showers but only received a bed bath without hair washing, resulting in greasy hair. Staff confirmed that residents were scheduled for showers or bed baths twice weekly, and all body parts, including hair, should be washed. The oversight was acknowledged by staff.
A resident with COPD, obstructive sleep apnea, and heart failure did not receive continuous humidified oxygen as ordered. Observations showed the resident's portable oxygen tank was often empty, and the oxygen was not humidified. Staff were unaware of the resident's continuous oxygen needs, leading to incidents where the resident was without oxygen, including nearly fainting during a bathroom visit.
A resident with anxiety and schizoaffective disorder was informed they would have to move from their long-term room to a shared space, causing significant distress. Despite being cognitively intact, the resident's preferences were not honored, leading to increased anxiety and sleep disturbances. Staff noted the resident's struggle with change and privacy needs, but the facility did not adequately support their right to self-determination.
A resident with lower extremity paraplegia was not informed in writing of changes in financial coverage after being discharged from Medicare Part A services, despite having 37 skilled days remaining. The facility failed to provide the necessary Notice of Medicare Non-coverage (NOMNC) or Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN), as confirmed by interviews with the Social Services Coordinator and Director.
A resident with an intracranial abscess had a private medical conversation with a Physician's Assistant in a dining room, which was overheard by surveyors due to inadequate privacy measures. The resident expressed discomfort with the lack of privacy in the facility, particularly in shared rooms. Interviews revealed a lack of private meeting spaces, with staff acknowledging the need for more appropriate areas for confidential discussions.
A facility failed to provide adequate support for a resident's continence management, leading to frequent incontinence episodes. The resident, with conditions like COPD and heart failure, required assistance with toileting. Despite a care plan addressing skin breakdown due to incontinence, it lacked specific strategies for managing the resident's mixed incontinence. Interviews revealed slow call light responses contributed to the issue, and staff confirmed the absence of interventions to reduce incontinence frequency.
The facility failed to ensure medication storage areas were free of expired medications, risking diminished treatment efficacy. Observations revealed expired tuberculin and acidophilus in the medication storage room refrigerator, and expired Bacitracin ointment on a treatment cart. Staff confirmed these findings, indicating a lapse in proper medication storage protocols.
Failure to Follow Physician Orders and Proper Resident Identification in Medication Administration
Penalty
Summary
The facility failed to follow physician orders for two residents in relation to medication administration. One resident, admitted with depression and adjustment disorder and experiencing pain from recent surgery and multiple fractures, had a physician order for oxycodone not to exceed 40 mg per day. On one occasion, the resident received 50 mg of oxycodone in a single day, exceeding the prescribed limit. Documentation showed that the medication was signed out and administered by an LPN, and the error was later acknowledged by the Director of Nursing Services. Another resident, admitted with depression, was given the wrong medication after an LPN addressed the resident by the incorrect name and administered the roommate's morning medication, which included 60 mg of duloxetine. The resident did not notice the error at the time and took the medication. The LPN, who was working through a staffing agency and unfamiliar with the residents, realized the mistake only after attempting to give medication to the correct resident. The error was acknowledged by both the LPN and the facility administrator.
Failure to Evaluate Falls and Follow Care Plan Interventions
Penalty
Summary
The facility failed to ensure that falls were properly evaluated and that care plan interventions were followed for two residents. One resident, admitted with heart failure, slid out of bed and sustained a skin tear, after which there was no documentation indicating whether the fall was witnessed or unwitnessed, nor evidence that the fall was evaluated or that care plan interventions were reviewed. The resident was sent to the hospital at their request and did not return. Another resident, admitted with failure to thrive, experienced an unwitnessed fall, but the fall investigation was incomplete, lacking analysis and documentation to show the incident was evaluated or that care plan interventions were followed. This resident had a history of previous falls in the facility. Facility staff confirmed that thorough and complete analyses were not conducted for either incident.
Failure to Follow Contact Precautions During Wound Care
Penalty
Summary
Staff failed to follow proper infection control procedures during a dressing change for a resident with stage 3 and stage 4 pressure ulcers. During the dressing change, the LPN did not change gloves between handling soiled and clean dressings, and improperly removed her PPE gown by coming into contact with the exterior side. The LPN acknowledged awareness of the correct procedures for glove changes and gown removal. The Director of Nursing Services and RN consultant confirmed that the facility's expectation was for gloves to be changed between dirty and clean portions of the procedure and for gowns to be removed properly.
Medical Director's Absence from QAA/QAPI Meetings
Penalty
Summary
The facility failed to ensure the Medical Director's attendance at the Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee meetings, which is a requirement. Documentation of the QAA/QAPI meeting minutes from April 2024 through September 2024 showed that the Former Medical Director did not attend any of these meetings. Interviews with the Administrator revealed that the Former Medical Director refused to attend the meetings either in person or via Skype. This absence placed residents at risk for unidentified needs.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of damaged and worn surfaces. The hall carpet throughout the facility was heavily stained and worn, despite regular steam cleaning. A metal floor latch socket was missing below the fire doors, creating a hole in the flooring that posed a risk for canes and walkers to catch on. Additionally, the floor covering surrounding the base of the toilet in certain rooms was damaged, exposing an uncleanable surface. The bathroom floor was also worn with patches of gray discoloration. Further observations revealed that the doors to several rooms had rough, damaged surfaces, with one door having a deeply gouged and splintered surface with sharp edges. The Maintenance Director confirmed the condition of the carpet and acknowledged the need to fill the hole in the floor and repair the damaged doors. However, he was not specifically aware of the damage to the bathroom floor. The Facility Administrator was informed of these findings and acknowledged that the facility was working on a plan to address the flooring and door issues.
Incomplete Care Plan for Resident with Multiple Health Conditions
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a recently admitted resident with multiple health conditions, including diabetes, chronic obstructive pulmonary disease, a history of lung cancer, heart failure, and generalized weakness. The resident was frequently incontinent of urine due to weakness and diuretic medication use, requiring staff assistance with toileting. The care plan identified bladder incontinence related to diuretic use and impaired mobility, directing staff to check and change frequently. However, it lacked interventions to reduce incontinent episodes. Additionally, the care plan did not address the resident's prescribed 2000 ml per day fluid restriction, despite the risk for dehydration or electrolyte imbalance due to diabetes and diuretic use. The care plan included an intervention to encourage increased oral fluids, which contradicted the fluid restriction order. Furthermore, the resident was offered a blank Advance Directive form upon admission but did not have one in place. The Director of Nursing Services confirmed that the care plan was not completely accurate or individualized.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADL) for a resident who required substantial/maximal assistance due to a stroke. The resident was admitted in October 2024 and was noted to need help with showers. However, the resident only received a bed bath since admission, and their hair was not washed, leading to greasy hair. Observations over several days confirmed the resident's hair remained greasy, and the resident expressed a desire for their hair to be washed. Staff interviews revealed that residents were scheduled for showers or bed baths twice weekly, and it was expected that all body parts, including hair, would be washed during a bed bath. Staff acknowledged that the resident's hair was not washed as required.
Failure to Provide Continuous Humidified Oxygen
Penalty
Summary
The facility failed to adhere to physician's orders for continuous humidified oxygen for a resident with chronic respiratory conditions, including COPD, obstructive sleep apnea, and heart failure. The resident was admitted for rehabilitation and required continuous humidified oxygen at 6 liters per minute to maintain oxygen saturation between 89 and 92%. However, observations revealed that the resident's portable oxygen tank was frequently empty, and the oxygen was not humidified as ordered. On multiple occasions, the resident was found without adequate oxygen supply, including an incident where the resident was assisted to the toilet without oxygen and nearly fainted. Staff interviews confirmed a lack of awareness and understanding of the resident's oxygen needs. A CNA admitted to not knowing the resident required continuous oxygen, and staff sometimes forgot to turn off the oxygen tank when switching to the in-room concentrator, leading to depletion of the portable tank. Additionally, the resident reported dryness due to the lack of humidification, and staff confirmed the absence of a humidifier on the oxygen concentrator. These oversights placed the resident at risk for complications related to their chronic respiratory disease.
Failure to Promote Resident Self-Determination
Penalty
Summary
The facility failed to promote self-determination for a resident who was cognitively intact, as evidenced by a BIMS score of 15. The resident, diagnosed with anxiety and schizoaffective disorder, was informed by management that they would have to move from their current room, where they had resided for two years, to a shared room with three other female residents. This information caused the resident significant distress, as they expressed dissatisfaction with the move and reported difficulty sleeping since the conversation. Staff members, including an LPN and CNAs, observed an increase in the resident's anxiousness and noted that the resident was very private, did not like their room touched, and struggled with change. The Social Service Director and Social Services staff confirmed that the resident had mentioned the impending room change, which contributed to their anxiety. The Director of Nursing Services (DNS) stated that the facility was considering converting a therapy room into a four-person space for long-term care female residents, including the resident in question. The DNS acknowledged the resident's suspicion of new situations and their tendency to hoard, which further complicated the situation. Despite the resident's concerns and the lack of a set timeline for the move, the facility's actions did not adequately support the resident's right to self-determination and choice regarding their living arrangements.
Failure to Provide Required Medicare Non-coverage Notices
Penalty
Summary
The facility failed to inform residents in writing of changes in financial coverage, specifically for one resident who was reviewed for advance beneficiary notification. This deficiency was identified through interviews and record reviews, which revealed that the facility did not provide the necessary Notice of Medicare Non-coverage (NOMNC) or Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to the resident. The resident, who was admitted with lower extremity paraplegia, was discharged from Medicare Part A services while still having 37 skilled days remaining. Despite this, there was no documentation in the resident's electronic health record indicating that they received the required notices. Interviews with facility staff, including the Social Services Coordinator and the Social Services Director, confirmed the absence of these notifications. The Social Services Coordinator was unable to locate the NOMNC or SNF ABN for the resident, and the Social Services Director acknowledged that the facility did not provide these notices. This oversight placed the resident at risk for unknown financial liabilities and a lack of knowledge regarding their right to appeal the decision.
Privacy Breach During Medical Consultation
Penalty
Summary
The facility failed to ensure personal privacy for a resident, identified as Resident 187, who was admitted with an intracranial abscess. During an observation, the resident was seen having a medical conversation with a Physician's Assistant, Staff 27, in a corner of the main dining room. This conversation, which included private health information such as diagnoses, symptoms, medications, and prognosis, was overheard by the survey team in an adjacent room separated only by a curtain. The resident expressed discomfort with the lack of privacy, particularly due to sharing a room with three roommates, and mentioned a desire to leave the facility because of this issue. Interviews conducted with Staff 27, Resident 187, the Social Services Director (Staff 3), and the Administrator (Staff 1) revealed a lack of adequate private meeting spaces within the facility. Staff 27 acknowledged that the conversation should have been held in a more private area and was unaware of any private meeting areas. Resident 187 confirmed the difficulty in finding private spaces for conversations or phone calls. Staff 3 mentioned using the Social Services office or outdoor areas for privacy but expressed concerns about future changes affecting privacy. Staff 1 stated that residents could request to use staff offices for private meetings, although Resident 187 did not make such a request for the meeting with Staff 27.
Inadequate Support for Continence Management
Penalty
Summary
The facility failed to provide adequate support to maintain continence for a resident who was frequently incontinent of urine. The resident, admitted with diagnoses including chronic obstructive pulmonary disease, heart failure, and generalized weakness, required staff assistance with toileting. The resident's care plan identified moisture-associated skin breakdown due to incontinence and directed staff to keep the resident's skin clean and dry. However, the care plan did not address the specific type of incontinence or include strategies to reduce the frequency of incontinent episodes. Interviews with the resident and staff revealed that the resident experienced slow call light response times, leading to incontinence. The resident expressed that waiting five to ten minutes was too long, especially due to the urgency caused by diuretic medication. Staff confirmed that interventions to reduce incontinence frequency were not in place, and the resident's preference to avoid using briefs was not addressed. This lack of timely assistance and specific interventions placed the resident at risk for skin breakdown and loss of dignity.
Expired Medications Found in Storage Areas
Penalty
Summary
The facility failed to ensure that medication storage areas were free of expired medications and biologicals, which placed residents at risk for diminished treatment efficacy. During an observation of the medication storage room refrigerator, a vial of tuberculin used for tuberculosis screening was found to be opened and not discarded after 30 days, as confirmed by Staff 2 (DNS). Additionally, a bottle of acidophilus with an expired date was located in the refrigerator's door compartment, which Staff 2 also confirmed as expired. Further observations of one of the facility's treatment carts revealed a vial of Bacitracin ointment with an expired date. Staff 2 confirmed that the used tube of Bacitracin was expired. These findings indicate a failure to adhere to proper medication storage protocols, potentially compromising the efficacy of treatments provided to residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oregon City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marquis Oregon City Post Acute Rehab | 0.6 mi | — | 5 | 0 |
| Avamere Rehabilitation Of Oregon City | 1.2 mi | — | 0 | 0 |
| Rose Linn Care Center | 3.1 mi | — | 0 | 0 |
| Avamere Rehabilitation Of Clackamas | 3.1 mi | — | 6 | 0 |
| Fernwood Supportive Living At Madrona Grove | 6.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.