Inspection Reports for Rivercrest Post Acute
148 Hood Street, Oregon City, OR, 97045
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
20.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
203% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
87% occupied
Based on a November 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 46
Capacity: 53
Deficiencies: 4
Date: Nov 19, 2025
Visit Reason
Multiple deficiencies including medication errors with oxycodone dosing and medication administration errors affecting residents. None of the deficiencies were corrected at the time of visit.
Findings
Multiple deficiencies including medication errors with oxycodone dosing and medication administration errors affecting residents. None of the deficiencies were corrected at the time of visit.
Deficiencies (4)
F0000 - INITIAL COMMENTS
F0684 - Quality of Care
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Census: 46
Capacity: 53
Deficiencies: 2
Date: Nov 6, 2025
Visit Reason
Two deficiencies noted including initial comments. Both deficiencies were not corrected at the time of visit.
Findings
Two deficiencies noted including initial comments. Both deficiencies were not corrected at the time of visit.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Census: 46
Capacity: 53
Deficiencies: 5
Date: Apr 18, 2025
Visit Reason
Deficiencies included failure to ensure falls were evaluated, infection prevention and control issues, and failure to follow state administrative rules. Some deficiencies were corrected on revisit but others remained not corrected.
Findings
Deficiencies included failure to ensure falls were evaluated, infection prevention and control issues, and failure to follow state administrative rules. Some deficiencies were corrected on revisit but others remained not corrected.
Deficiencies (5)
F0000 - INITIAL COMMENTS
F0689 - Free of Accident Hazards/Supervision/Devices
F0880 - Infection Prevention & Control
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Census: 46
Capacity: 53
Deficiencies: 23
Date: Nov 22, 2024
Visit Reason
Extensive deficiencies including failure to ensure resident self-administration of medications was clinically appropriate, failure to notify residents of room changes in writing, failure to provide advanced directive information, failure to protect residents from abuse and timely reporting, failure to ensure timely quarterly assessments and care plans, infection control program deficiencies including immediate jeopardy related to glucometer disinfection, and failure to ensure competent nursing staff. Many deficiencies were corrected on revisit but several remained not corrected.
Findings
Extensive deficiencies including failure to ensure resident self-administration of medications was clinically appropriate, failure to notify residents of room changes in writing, failure to provide advanced directive information, failure to protect residents from abuse and timely reporting, failure to ensure timely quarterly assessments and care plans, infection control program deficiencies including immediate jeopardy related to glucometer disinfection, and failure to ensure competent nursing staff. Many deficiencies were corrected on revisit but several remained not corrected.
Deficiencies (23)
F0000 - INITIAL COMMENTS
F0554 - Resident Self-Admin Meds-Clinically Approp
F0559 - Choose/Be Notified of Room/Roommate Change
F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir
F0582 - Medicaid/Medicare Coverage/Liability Notice
F0600 - Free from Abuse and Neglect
F0609 - Reporting of Alleged Violations
F0610 - Investigate/Prevent/Correct Alleged Violation
F0638 - Qrtly Assessment at Least Every 3 Months
F0656 - Develop/Implement Comprehensive Care Plan
F0657 - Care Plan Timing and Revision
F0658 - Services Provided Meet Professional Standards
F0684 - Quality of Care
F0689 - Free of Accident Hazards/Supervision/Devices
F0698 - Dialysis
F0726 - Competent Nursing Staff
F0756 - Drug Regimen Review, Report Irregular, Act On
F0757 - Drug Regimen is Free from Unnecessary Drugs
F0758 - Free from Unnec Psychotropic Meds/PRN Use
F0867 - QAPI/QAA Improvement Activities
F0868 - QAA Committee
F0880 - Infection Prevention & Control
F0947 - Required In-Service Training for Nurse Aides
Inspection Report
Complaint Investigation
Census: 46
Capacity: 53
Deficiencies: 12
Date: Oct 11, 2024
Visit Reason
Ten deficiencies including failure to promote self determination, failure to provide advance beneficiary notification, failure to ensure personal privacy, failure to maintain safe environment, failure to develop comprehensive care plans, failure to provide ADL care, failure to support continence, failure to follow respiratory orders, failure to label/store drugs properly, and failure to have medical director attend QAA meetings. Some deficiencies were corrected on revisit but many remained not corrected.
Findings
Ten deficiencies including failure to promote self determination, failure to provide advance beneficiary notification, failure to ensure personal privacy, failure to maintain safe environment, failure to develop comprehensive care plans, failure to provide ADL care, failure to support continence, failure to follow respiratory orders, failure to label/store drugs properly, and failure to have medical director attend QAA meetings. Some deficiencies were corrected on revisit but many remained not corrected.
Deficiencies (12)
F0000 - INITIAL COMMENTS
F0561 - Self-Determination
F0582 - Medicaid/Medicare Coverage/Liability Notice
F0583 - Personal Privacy/Confidentiality of Records
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0656 - Develop/Implement Comprehensive Care Plan
F0677 - ADL Care Provided for Dependent Residents
F0690 - Bowel/Bladder Incontinence, Catheter, UTI
F0695 - Respiratory/Tracheostomy Care and Suctioning
F0761 - Label/Store Drugs and Biologicals
F0868 - QAA Committee
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Census: 46
Capacity: 53
Deficiencies: 2
Date: Aug 13, 2024
Visit Reason
Two deficiencies noted including initial comments. Both deficiencies were not corrected at the time of visit.
Findings
Two deficiencies noted including initial comments. Both deficiencies were not corrected at the time of visit.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Census: 46
Capacity: 53
Deficiencies: 1
Date: Jan 2, 2024
Visit Reason
One deficiency related to failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency was not corrected at time of visit.
Findings
One deficiency related to failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency was not corrected at time of visit.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Complaint Investigation
Census: 46
Capacity: 53
Deficiencies: 2
Date: Oct 10, 2023
Visit Reason
Two deficiencies including initial comments. Both deficiencies were not corrected at the time of visit.
Findings
Two deficiencies including initial comments. Both deficiencies were not corrected at the time of visit.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Census: 46
Capacity: 53
Deficiencies: 9
Date: Jul 14, 2023
Visit Reason
Seven deficiencies including failure to follow physician orders for medications, failure to provide competent nursing staff, failure to maintain adequate staffing, failure to ensure physician visit notes in records, failure to complete nurse aide in-service training, and failure to follow respiratory orders. Some deficiencies were corrected on revisit but many remained not corrected.
Findings
Seven deficiencies including failure to follow physician orders for medications, failure to provide competent nursing staff, failure to maintain adequate staffing, failure to ensure physician visit notes in records, failure to complete nurse aide in-service training, and failure to follow respiratory orders. Some deficiencies were corrected on revisit but many remained not corrected.
Deficiencies (9)
F0000 - INITIAL COMMENTS
F0684 - Quality of Care
F0695 - Respiratory/Tracheostomy Care and Suctioning
F0730 - Nurse Aide Peform Review-12 hr/yr In-Service
F0761 - Label/Store Drugs and Biologicals
F0842 - Resident Records - Identifiable Information
M0000 - Initial Comments
M0183 - Nursing Services: Minimum CNA Staffing
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Census: 46
Capacity: 53
Deficiencies: 1
Date: Jan 3, 2023
Visit Reason
One deficiency related to failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency was not corrected at time of visit.
Findings
One deficiency related to failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency was not corrected at time of visit.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
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