Inspection Reports for Rivers Edge Rehabilitation and Care
411 SE Sheridan Road, OR, 97378
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Inspection Report
Complaint Investigation
Capacity: 51
Deficiencies: 45
Oct 9, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2021 to 2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2021 to 2025, the facility exhibited numerous deficiencies including failures in resident rights, abuse prevention, infection control, medication management, environment maintenance, staffing ratios, and care planning. Several deficiencies were corrected while others remained uncorrected at the time of the latest inspections.
Complaint Details
Multiple complaint investigations were conducted including allegations of sexual abuse, failure to report abuse, and failure to investigate abuse. Immediate jeopardy was identified related to sexual abuse allegations involving Resident 1, with subsequent removal plan implemented.
Severity Breakdown
Level 1: 0
Level 2: 43
Level 3: 3
Deficiencies (45)
| Description | Severity |
|---|---|
| F0000 - INITIAL COMMENTS | — |
| M0000 - Initial Comments | — |
| F0550 - Resident Rights/Exercise of Rights: Failed to ensure residents were treated with dignity and respect, including privacy during care and roommate body removal after death. | Level 2 |
| F0552 - Right to be Informed/Make Treatment Decisions: Failed to ensure informed consent for psychotropic medications and treatment decisions. | Level 2 |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to maintain resident equipment, windows, walls, bathroom lighting, and hot water. | Level 2 |
| F0585 - Grievances: Failed to follow up on grievances related to staffing and call light concerns. | Level 2 |
| F0600 - Free from Abuse and Neglect: Failed to protect resident from physical abuse by another resident and failed to investigate and report sexual abuse allegations. | Level 3 |
| F0684 - Quality of Care: Failed to provide bowel care and follow physician medication orders. | Level 2 |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to ensure cigarette lighters were not stored in resident rooms. | Level 2 |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failed to maintain respiratory equipment properly. | Level 2 |
| F0698 - Dialysis: Failed to provide care and monitoring related to dialysis access. | Level 2 |
| F0699 - Trauma Informed Care: Failed to provide trauma-informed care for a trauma survivor resident. | Level 2 |
| F0730 - Nurse Aide Peform Review-12 hr/yr In-Service: Failed to ensure annual performance reviews for CNAs. | Level 2 |
| F0745 - Provision of Medically Related Social Service: Failed to provide medically-related social services for mental health follow-up. | Level 2 |
| F0756 - Drug Regimen Review, Report Irregular, Act On: Failed to act upon pharmacist recommendations for unnecessary medications. | Level 2 |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failed to provide rationale and care plan for PRN psychotropic medication use. | Level 2 |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to store food in a sanitary manner in resident refrigerator. | Level 2 |
| F0825 - Provide/Obtain Specialized Rehab Services: Failed to ensure therapy evaluation was obtained for discharge planning. | Level 2 |
| F0847 - Entering into Binding Arbitration Agreements: Failed to ensure residents understood binding arbitration agreements. | Level 2 |
| F0883 - Influenza and Pneumococcal Immunizations: Failed to offer pneumonia vaccines to eligible residents. | Level 2 |
| F0887 - COVID-19 Immunization: Failed to offer COVID-19 vaccines to eligible residents. | Level 2 |
| F0947 - Required In-Service Training for Nurse Aides: Failed to provide dementia training for CNAs. | Level 2 |
| M0143 - Employees: Criminal Record Checks: Failed to complete timely background checks for staff employed two or more years. | Level 2 |
| M0185 - Bariatric Criteria and Services: Failed to maintain minimum bariatric CNA staffing ratios for multiple days. | Level 2 |
| F0582 - Medicaid/Medicare Coverage/Liability Notice: Failed to provide Advance Beneficiary Notification to resident. | Level 2 |
| F0640 - Encoding/Transmitting Resident Assessments: Failed to transmit Discharge and Quarterly MDS assessments timely. | Level 2 |
| F0688 - Increase/Prevent Decrease in ROM/Mobility: Failed to provide restorative therapy as ordered. | Level 2 |
| F0759 - Free of Medication Error Rts 5 Prcnt or More: Medication error rate exceeded 5% with three errors in 27 opportunities. | Level 2 |
| F0584 - Safe/Clean/Comfortable/Homelike Environment: Failed to ensure sufficient linens for resident use. | Level 2 |
| F0609 - Reporting of Alleged Violations: Failed to report allegations of sexual abuse to State Agency and law enforcement timely. | Level 3 |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failed to investigate allegation of sexual abuse. | Level 3 |
| F0679 - Activities Meet Interest/Needs Each Resident: Failed to implement ongoing resident centered activities program. | Level 2 |
| F0680 - Qualifications of Activity Professional: Activities program not directed by qualified professional. | Level 2 |
| F0740 - Behavioral Health Services: Failed to address behavioral concerns and hygiene for residents. | Level 2 |
| F0880 - Infection Prevention & Control: Failed to wear and use PPE correctly increasing risk of respiratory illness. | Level 2 |
| F0921 - Safe/Functional/Sanitary/Comfortable Environ: Failed to ensure functional, clean, and comfortable environment. | Level 2 |
| F0657 - Care Plan Timing and Revision: Failed to update care plan to reflect increased need for oral hygiene assistance. | Level 2 |
| F0677 - ADL Care Provided for Dependent Residents: Failed to assist resident with cleaning partial dentures. | Level 2 |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to provide supervision to prevent accidents. | Level 2 |
| F0757 - Drug Regimen is Free from Unnecessary Drugs: Failed to ensure medications had indications for use. | Level 2 |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failed to discontinue psychotropic medication as ordered. | Level 2 |
| F0804 - Nutritive Value/Appear, Palatable/Prefer Temp: Failed to ensure food was palatable, attractive and at proper temperature. | Level 2 |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to ensure food safety requirements in kitchen. | Level 2 |
| F0842 - Resident Records - Identifiable Information: Failed to maintain complete and accurate medical records. | Level 2 |
| F0919 - Resident Call System: Failed to ensure residents' call lights were functional. | Level 2 |
Report Facts
Inspections on page: 10
Total deficiencies: 59
Total surveys: 10
Licensing violations: 20
Notices: 1
Licensed beds: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Samantha Perrin | Administrator | Named in multiple findings and plan of correction sections |
| Staff 1 | Administrator | Named in multiple findings and interviews related to abuse and reporting |
| Staff 2 | DNS (Director of Nursing Services) | Named in multiple findings and interviews related to medication, care planning, and infection control |
| Staff 3 | LPN/Resident Care Manager | Named in multiple findings and interviews related to resident care and medication |
| Staff 5 | Maintenance Director / Agency LPN | Named in findings related to environment and abuse |
| Staff 7 | Social Services Director | Named in findings related to grievances, trauma informed care, and binding arbitration |
| Staff 8 | LPN | Named in medication and dialysis related findings |
| Staff 9 | CNA | Named in privacy and environment findings |
| Staff 10 | CMA / LPN | Named in medication and restorative care findings |
| Staff 11 | LPN | Named in abuse findings |
| Staff 12 | Food Service Director / CNA | Named in food safety and supervision findings |
| Staff 13 | CNA / Cook | Named in environment and food safety findings |
| Staff 14 | Dietary Aide | Named in infection control and food safety findings |
| Staff 16 | CNA / Cook | Named in infection control and dialysis findings |
| Staff 17 | Activities Director / CNA | Named in smoking and restorative care findings |
| Staff 18 | CNA | Named in smoking and restorative care findings |
| Staff 21 | CNA | Named in performance review and dementia training findings |
| Staff 22 | CNA | Named in dementia training findings |
| Staff 23 | CNA | Named in performance review and dementia training findings |
| Staff 24 | Staffing Director / CNA | Named in background check and activities findings |
| Staff 26 | CMA / LPN | Named in background check and medical record findings |
| Staff 27 | CMA | Named in background check and medical record findings |
| Staff 29 | Regional Nurse Consultant | Named in grievance and medication findings |
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