Inspection Reports for River Park Senior Living
1350 W Main St, Sheridan, OR 97378, United States, OR, 97378
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Inspection Report
Complaint Investigation
Census: 47
Capacity: 68
Deficiencies: 26
Oct 10, 2025
Visit Reason
State-compiled facility profile showing multiple inspections from 2022 to 2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections, the facility exhibited numerous deficiencies including failures in kitchen sanitation, resident rights, service plan accuracy and availability, abuse reporting, medication administration, staffing adequacy, fire and life safety compliance, and building maintenance. Deficiencies were noted in administrative oversight, staff training, and resident care monitoring.
Complaint Details
Complaint investigations conducted on 01/28/2025 and earlier dates revealed multiple substantiated deficiencies including failure to implement smoking policy, failure to report abuse incidents, failure to ensure implementation of services, failure to carry out medication orders, insufficient staffing, failure to provide pre-service training, and failure to maintain a clean and odor-free environment.
Deficiencies (26)
| Description |
|---|
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure kitchen practices and protocols were in accordance with Food Sanitation Rules, including unclean kitchen areas and improper food storage. |
| C0150 - Facility Administration: Operation: Failed to provide effective oversight to ensure quality of care and services rendered in the facility. |
| C0200 - Resident Rights and Protection - General: Failed to ensure residents were given informed choice and opportunity to select food choices. |
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to promptly investigate and report incidents of abuse or suspected abuse to local authorities. |
| C0260 - Service Plan: General: Failed to ensure service plans were available, reflective of current care needs, and provided clear directions to staff. |
| C0262 - Service Plan: Service Planning Team: Failed to ensure service plans were developed by a Service Planning Team including required participants. |
| C0270 - Change of Condition and Monitoring: Failed to determine, communicate, and document resident-specific actions or interventions following changes of condition. |
| C0280 - Resident Health Services: Failed to ensure RN assessments were completed documenting findings and interventions for residents with significant changes of condition. |
| C0303 - Systems: Treatment Orders: Failed to ensure physician orders were carried out as prescribed and documented. |
| C0305 - Systems: Resident Right to Refuse: Failed to notify physician/practitioner when residents refused consent to orders. |
| C0310 - Systems: Medication Administration: Failed to maintain accurate MARs including reasons for use and resident-specific parameters. |
| C0361 - Acuity Based Staffing Tool - Elements: Failed to implement an acuity-based staffing tool meeting regulatory requirements. |
| C0362 - Acuity Based Staffing Tool - ABST Time: Failed to accurately capture care time and care elements for residents in the ABST. |
| C0363 - Acuity Based Staffing Tool - Updates & Staffing Plan: Failed to update ABST no less than quarterly and with significant changes of condition. |
| C0370 - Staffing Requirements and Training – Pre-service: Failed to ensure newly hired caregivers completed required pre-service orientation training. |
| C0372 - Training Within 30 Days of Hire – Direct Care Staff: Failed to ensure newly hired direct care staff demonstrated competency within 30 days of hire. |
| C0374 - Annual and Biennial Inservice for All Staff: Failed to ensure long-term staff completed required annual in-service training including dementia care and HCBS training. |
| C0420 - Fire and Life Safety: Safety: Failed to conduct and document fire drills every other month and provide fire and life safety training on alternate months. |
| C0610 - General Building Exterior: Failed to maintain all exterior pathways in good repair, creating potential fall hazards. |
| C0613 - General Building: Doors-Walls, Cleanable: Failed to keep all interior and exterior materials and surfaces clean, in good repair, and free from odors. |
| C0154 - Facility Administration: Policy & Procedure: Failed to implement a smoking policy and ensure effective methods of responding to and resolving resident complaints. |
| C0360 - Staffing Requirements and Training: Staffing: Failed to provide sufficient direct care staff to meet resident needs and fire safety evacuation standards. |
| C0513 - Doors, Walls, Elevators, Odors: Failed to ensure the interior of the facility was free from unpleasant odors. |
| C0325 - Systems: Self-Administration of Meds: Failed to obtain signed orders and conduct quarterly evaluations for residents self-administering medications. |
| C0330 - Systems: Psychotropic Medication: Failed to include specific reasons for use and document non-pharmacological interventions prior to administering PRN psychotropic medications. |
| C0650 - Electrical Systems: Not detailed in findings but listed as a deficiency citation. |
Report Facts
Inspections on page: 10
Total deficiencies: 69
Total licensing violations: 10
Total notices: 9
Facility licensed beds: 68
Facility census: 47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Vincent | Administrator | Named as Administrator in Facility Information |
| Staff 1 | Executive Director (ED) | Named in multiple deficiency findings and acknowledgments |
| Staff 3 | Wellness Director | Named in multiple deficiency findings and acknowledgments |
| Staff 25 | Registered Nurse (RN) | Named in multiple deficiency findings and acknowledgments |
| Staff 26 | Vice President of Health Services | Named in ABST related findings and interviews |
| Staff 4 | Business Office Manager (BOM) | Named in training and administrative findings |
| Staff 2 | Facility Service Director | Named in fire and life safety and building maintenance findings |
| Staff 24 | Facility Service Aide | Named in building maintenance findings |
| Staff 11 | Medication Technician (MT) | Named in medication administration and training findings |
| Staff 14 | Caregiver (CG) | Named in training and annual in-service findings |
| Staff 8 | Med Tech | Named in smoking policy deficiency and training findings |
| Staff 12 | Med Tech | Named in pre-service training and medication administration findings |
| Staff 15 | Caregiver (CG) | Named in odor and medication refusal findings |
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