Inspection Reports for
Rivers Edge Rehabilitation and Care
411 SE Sheridan Road, Sheridan, OR, 97378
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
24.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
261% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Complaint Investigation
Capacity: 51
Deficiencies: 2
Date: Oct 9, 2025
Visit Reason
Survey with 0 deficiencies; initial comments noted but not corrected at visit.
Findings
Survey with 0 deficiencies; initial comments noted but not corrected at visit.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 51
Deficiencies: 24
Date: Mar 3, 2025
Visit Reason
Survey with 22 deficiencies including resident rights, environment, abuse prevention, medication management, and care planning. Many deficiencies corrected after first visit but not corrected at second visit.
Findings
Survey with 22 deficiencies including resident rights, environment, abuse prevention, medication management, and care planning. Many deficiencies corrected after first visit but not corrected at second visit.
Deficiencies (24)
F0000 - INITIAL COMMENTS
F0550 - Resident Rights/Exercise of Rights
F0552 - Right to be Informed/Make Treatment Decisions
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0585 - Grievances
F0600 - Free from Abuse and Neglect
F0684 - Quality of Care
F0689 - Free of Accident Hazards/Supervision/Devices
F0695 - Respiratory/Tracheostomy Care and Suctioning
F0698 - Dialysis
F0699 - Trauma Informed Care
F0730 - Nurse Aide Peform Review-12 hr/yr In-Service
F0745 - Provision of Medically Related Social Service
F0756 - Drug Regimen Review, Report Irregular, Act On
F0758 - Free from Unnec Psychotropic Meds/PRN Use
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0825 - Provide/Obtain Specialized Rehab Services
F0847 - Entering into Binding Arbitration Agreements
F0883 - Influenza and Pneumococcal Immunizations
F0887 - COVID-19 Immunization
M0000 - Initial Comments
M0143 - Employees: Criminal Record Checks
M0185 - Bariatric Criteria and Services
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 3, 2025
Visit Reason
The inspection was conducted following a complaint involving resident-to-resident physical abuse and concerns related to respiratory care, mental health services, and medication management.
Complaint Details
The complaint investigation was triggered by a Facility Reported Incident on 1/18/25 alleging Resident 20 hit Resident 39 on the head several times. The facility substantiated the abuse and took appropriate actions including police notification and alert charting. The investigation also revealed failures in respiratory care, mental health follow-up, and medication management.
Findings
The facility substantiated abuse between residents and failed to provide adequate respiratory equipment maintenance, medically-related social services for mental health follow-up, and timely action on pharmacist recommendations for medication management.
Deficiencies (4)
F 0600: The facility failed to protect a resident from physical abuse by another resident, resulting in a substantiated abuse incident with no injuries noted.
F 0695: The facility failed to ensure respiratory equipment was maintained for a resident, with the oxygen concentrator not cleaned for 6-9 months contrary to policy.
F 0745: The facility failed to provide medically-related social services for arranging mental health services for two residents after a resident-to-resident abuse incident.
F 0756: The facility failed to act upon pharmacist recommendations for one resident's unnecessary medications, resulting in no psychiatric consult after a gradual dose reduction order.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Dates: Jan 18, 2025
Dates: Jan 20, 2025
Dates: Mar 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 11 | LPN | Provided statements regarding abuse incident on 1/18/25 |
| Staff 3 | LPN/Resident Care Manager | Provided statements regarding abuse incident and respiratory care |
| Staff 2 | DNS | Acknowledged failures in respiratory care, mental health follow-up, and medication management |
| Staff 1 | Administrator | Stated facility lacked mental health provider and was working to obtain one |
Inspection Report
Annual Inspection
Deficiencies: 19
Date: Mar 3, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements across multiple areas including resident rights, medication management, environment, abuse prevention, and care services.
Findings
The facility was found deficient in multiple areas including failure to protect resident rights and dignity, inadequate medication consent and management, environmental safety issues, failure to follow up on grievances, abuse prevention, respiratory and dialysis care, vaccination offerings, staff training, and documentation of care plans.
Deficiencies (19)
F 0550: The facility failed to honor residents' rights to dignity and self-determination, including leaving a deceased resident's body in a shared room for several hours and inadequate incontinence care for residents.
F 0552: The facility failed to ensure informed consent was obtained for psychotropic medications for 1 of 5 sampled residents.
F 0584: The facility failed to maintain a safe, clean, and homelike environment, including broken beds, cracked windows, cold water, dim lighting, and unrepaired walls for multiple residents.
F 0585: The facility failed to follow up on grievances related to staffing and call light response for 1 resident.
F 0600: The facility failed to protect a resident from physical abuse by another resident, substantiated by an incident where one resident hit another on the head multiple times.
F 0684: The facility failed to provide bowel care and follow physician orders for medication parameters for 3 residents, placing them at risk for constipation and adverse medication effects.
F 0689: The facility failed to ensure cigarette lighters were not stored in resident rooms for 1 resident, placing residents at risk for burns.
F 0695: The facility failed to maintain respiratory equipment properly for 1 resident, with oxygen concentrators not cleaned as required.
F 0698: The facility failed to provide safe and appropriate dialysis care, including lack of care plan instructions and monitoring of dialysis access site for 1 resident.
F 0699: The facility failed to provide trauma-informed care for 1 resident with PTSD, including lack of timely assessment and care planning.
F 0730: The facility failed to ensure annual performance reviews for 2 CNAs, risking lack of competent care.
F 0745: The facility failed to provide medically-related social services for arranging mental health services for 2 residents after abuse incidents.
F 0756: The facility failed to provide rationale and care planning for PRN psychotropic medication use for 1 resident, risking sedation.
F 0812: The facility failed to store food in a sanitary manner in a resident's refrigerator, including undated and expired food items.
F 0825: The facility failed to ensure a therapy evaluation was obtained for 1 resident, resulting in no therapy services provided despite physician orders.
F 0847: The facility failed to ensure a resident was fully informed about a binding arbitration agreement, risking uninformed legal rights.
F 0883: The facility failed to offer pneumonia vaccines to 5 eligible residents, placing them at risk for pneumonia.
F 0887: The facility failed to offer COVID-19 vaccines to 3 eligible residents, placing them at risk for respiratory illness.
F 0947: The facility failed to provide dementia training for 5 CNAs, risking inadequate care for residents with dementia.
Report Facts
Residents affected: 2
Residents affected: 5
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
CNAs: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 5
Residents affected: 3
CNAs: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 7 | Social Services Director | Named in resident rights and grievance follow-up findings |
| Staff 3 | LPN Resident Care Manager | Named in medication consent, abuse, dialysis, and respiratory care findings |
| Staff 2 | DNS (Director of Nursing Services) | Named in multiple findings including medication, vaccines, mental health, and care planning |
| Staff 1 | Administrator | Named in environmental, mental health, binding arbitration, and grievance findings |
| Staff 8 | LPN | Named in medication and bowel care findings |
| Staff 10 | CMA | Named in bowel care findings |
| Staff 5 | Maintenance Director | Named in environmental maintenance findings |
| Staff 11 | LPN | Named in abuse incident findings |
| Staff 12 | Food Service Director | Named in food storage findings |
| Staff 21 | CNA | Named in training and performance review findings |
| Staff 23 | CNA | Named in training and performance review findings |
Inspection Report
Complaint Investigation
Capacity: 51
Deficiencies: 2
Date: Mar 13, 2024
Visit Reason
Survey with 0 deficiencies; initial comments noted but not corrected at visit.
Findings
Survey with 0 deficiencies; initial comments noted but not corrected at visit.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 51
Deficiencies: 2
Date: Jan 8, 2024
Visit Reason
Survey with 0 deficiencies; initial comments noted but not corrected at visit.
Findings
Survey with 0 deficiencies; initial comments noted but not corrected at visit.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 51
Deficiencies: 9
Date: Oct 6, 2023
Visit Reason
Survey with 6 deficiencies including resident rights, Medicaid/Medicare coverage, environment, MDS transmission, restorative care, and medication error rate. Some deficiencies corrected after first visit but not corrected at second visit.
Findings
Survey with 6 deficiencies including resident rights, Medicaid/Medicare coverage, environment, MDS transmission, restorative care, and medication error rate. Some deficiencies corrected after first visit but not corrected at second visit.
Deficiencies (9)
F0000 - INITIAL COMMENTS
F0550 - Resident Rights/Exercise of Rights
F0582 - Medicaid/Medicare Coverage/Liability Notice
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0640 - Encoding/Transmitting Resident Assessments
F0688 - Increase/Prevent Decrease in ROM/Mobility
F0759 - Free of Medication Error Rts 5 Prcnt or More
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Routine
Deficiencies: 5
Date: Oct 6, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, environment, MDS assessment transmissions, restorative therapy, and medication administration.
Findings
The facility was found deficient in ensuring resident dignity and privacy, maintaining safe and clean bathroom environments, timely transmission of MDS assessments, providing restorative therapy as ordered, and maintaining medication error rates below 5%. Several residents experienced privacy violations, environmental maintenance issues, delayed MDS transmissions, lack of restorative therapy, and medication administration errors.
Deficiencies (5)
F 0550: The facility failed to ensure residents were treated with dignity and respect, resulting in lack of privacy for Resident 13 during ADL care and bathroom use.
F 0584: The facility failed to maintain resident bathrooms in a safe, clean, and homelike condition, with issues such as non-functioning light bulbs, lint buildup, continuous running toilet, floor cracks, and rust stains.
F 0640: The facility failed to transmit Discharge and Quarterly MDS Assessments timely for 2 of 14 sampled residents, risking untimely and inaccurate records.
F 0688: The facility failed to provide restorative therapy as ordered for 3 of 3 sampled residents, placing them at risk for decline in range of motion and mobility.
F 0759: The facility failed to maintain medication error rates below 5%, with 3 errors in 27 opportunities (11.11% error rate) involving improper medication administration for Residents 2, 6, and 10.
Report Facts
Medication error rate: 11.11
Medication errors: 3
Medication administration opportunities: 27
Restorative therapy sessions missed: 30
Restorative therapy sessions received: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 2 | Director of Nursing Services (DNS) | Acknowledged privacy issues, MDS transmission delays, restorative therapy deficiencies, and medication administration expectations |
| Staff 3 | LPN/Resident Care Manager | Acknowledged privacy issues and restorative therapy deficiencies; confirmed medication administration instructions |
| Staff 9 | Certified Nursing Assistant (CNA) | Observed providing ADL care without privacy for Resident 13 |
| Staff 11 | Licensed Practical Nurse (LPN) | Observed medication administration error with alendronate sodium for Resident 2 |
| Staff 10 | Licensed Practical Nurse (LPN) | Observed medication administration error with metoprolol for Resident 6 |
| Staff 6 | Licensed Practical Nurse (LPN) | Observed medication administration error with Lantus insulin for Resident 10 |
| Staff 13 | Maintenance Director | Acknowledged bathroom repairs needed but was unaware of specific issues |
Inspection Report
Complaint Investigation
Capacity: 51
Deficiencies: 12
Date: Feb 21, 2023
Visit Reason
Survey with 9 deficiencies including abuse, reporting, activities, infection control, environment, supervision, and call system. Some deficiencies corrected after first visit but not corrected at second visit. Immediate jeopardy situation related to sexual abuse was abated.
Findings
Survey with 9 deficiencies including abuse, reporting, activities, infection control, environment, supervision, and call system. Some deficiencies corrected after first visit but not corrected at second visit. Immediate jeopardy situation related to sexual abuse was abated.
Deficiencies (12)
F0000 - INITIAL COMMENTS
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0600 - Free from Abuse and Neglect
F0609 - Reporting of Alleged Violations
F0610 - Investigate/Prevent/Correct Alleged Violation
F0679 - Activities Meet Interest/Needs Each Resident
F0680 - Qualifications of Activity Professional
F0740 - Behavioral Health Services
F0880 - Infection Prevention & Control
F0921 - Safe/Functional/Sanitary/Comfortable Environ
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Capacity: 51
Deficiencies: 1
Date: Nov 21, 2022
Visit Reason
Focused Infection Control survey with 1 deficiency related to failure to report complete COVID-19 information to CDC's NHSN during required period.
Findings
Focused Infection Control survey with 1 deficiency related to failure to report complete COVID-19 information to CDC's NHSN during required period.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Complaint Investigation
Capacity: 51
Deficiencies: 20
Date: Sep 27, 2022
Visit Reason
Survey with 20 deficiencies including resident rights, dignity, care planning, abuse, environment, infection control, staffing, nutrition, medication management, and call system. Some deficiencies corrected after first visit but not corrected at second visit.
Findings
Survey with 20 deficiencies including resident rights, dignity, care planning, abuse, environment, infection control, staffing, nutrition, medication management, and call system. Some deficiencies corrected after first visit but not corrected at second visit.
Deficiencies (20)
F0000 - INITIAL COMMENTS
F0550 - Resident Rights/Exercise of Rights
F0552 - Right to be Informed/Make Treatment Decisions
F0561 - Self-Determination
F0583 - Personal Privacy/Confidentiality of Records
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0640 - Encoding/Transmitting Resident Assessments
F0688 - Increase/Prevent Decrease in ROM/Mobility
F0689 - Free of Accident Hazards/Supervision/Devices
F0690 - Bowel/Bladder Incontinence, Catheter, UTI
F0692 - Nutrition/Hydration Status Maintenance
F0757 - Drug Regimen is Free from Unnecessary Drugs
F0758 - Free from Unnec Psychotropic Meds/PRN Use
F0804 - Nutritive Value/Appear, Palatable/Prefer Temp
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0842 - Resident Records - Identifiable Information
F0919 - Resident Call System
M0000 - Initial Comments
M0183 - Nursing Services: Minimum CNA Staffing
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Annual Inspection
Deficiencies: 17
Date: Sep 27, 2022
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care, including resident rights, medication management, care planning, environment, and food service.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity and respect, inadequate informed consent for psychotropic medications, failure to honor resident preferences, privacy violations, environmental maintenance issues, incomplete PASRR evaluations, incomplete and inaccurate care plans, medication administration errors, inadequate supervision to prevent accidents, improper catheter use, nutrition and food service deficiencies, and incomplete medical records.
Deficiencies (17)
F 0550: The facility failed to provide care and services in a manner that maintained and promoted dignity for 1 of 2 sampled residents, resulting in increased anxiety and lack of trust in staff communication.
F 0552: The facility failed to inform residents of treatment risks and obtain informed consent prior to psychotropic medication use for 2 of 8 sampled residents, placing them at risk for being uninformed.
F 0561: The facility failed to ensure resident shower preference, medication regimen, and care were provided per resident preference for 2 of 3 sampled residents, risking lack of personalized care.
F 0583: The facility failed to maintain privacy for 1 of 1 sampled resident by allowing incontinence briefs to be visible from the doorway.
F 0584: The facility failed to ensure resident rooms were in good repair and sinks had hot water for 5 of 32 rooms reviewed, risking dignity and homelike environment.
F 0646: The facility failed to ensure a resident with mental health disorder received a PASRR II evaluation after new onset of suicidal ideation for 1 of 2 sampled residents.
F 0657: The facility failed to update a care plan to reflect a resident's increased need for assistance with oral hygiene for 1 of 3 sampled residents, risking poor oral hygiene.
F 0677: The facility failed to ensure a resident was assisted to clean her partial denture for 1 of 3 sampled residents, risking poor oral hygiene.
F 0684: The facility failed to follow physician medication orders for 2 of 6 sampled residents, risking adverse medication consequences.
F 0689: The facility failed to provide adequate supervision to prevent accidents for 1 of 7 sampled residents, placing residents at risk for accidents.
F 0690: The facility failed to ensure clinical rationale for indwelling urinary catheter placement for 1 of 1 sampled resident, risking urinary tract infections.
F 0692: The facility failed to provide a resident with a diet per registered dietitian recommendations for 1 of 2 sampled residents, risking weight gain.
F 0757: The facility failed to ensure medications had indications for use for 1 of 5 sampled residents, risking unnecessary medications.
F 0758: The facility failed to discontinue a psychotropic medication as ordered for 1 of 5 sampled residents, risking adverse medication consequences.
F 0804: The facility failed to ensure food was palatable, attractive, and maintained appetizing temperature for food served, risking poor food quality.
F 0812: The facility failed to ensure food safety requirements were met in the kitchen, including undated and improperly sealed foods and unclean ice machine, risking foodborne illness.
F 0842: The facility failed to maintain complete and accurate medical records for 2 of 3 sampled residents, risking inaccurate medical records.
Report Facts
Resident refusals: 12
Resident refusals: 3
Resident refusals: 4
Resident refusals: 9
Resident refusals: 5
Resident refusals: 5
Resident refusals: 5
Facility visits: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Administrator | Confirmed failure to ensure resident dignity and respect; acknowledged failure to ensure adequate supervision to prevent accidents; informed of food service deficiencies |
| Staff 2 | DNS | Confirmed no PASRR II evaluation for Resident 6; confirmed no assessment for Resident 6's catheter; verified medication discontinuation failure for Resident 6; unable to provide insulin order implementation documentation |
| Staff 3 | LPN/Resident Care Manager Assistant | Acknowledged failure to discuss medication changes with Resident 2; acknowledged failure to honor Resident 2's choices; confirmed medication administration errors; verified Resident 27's death details; verified multiple medication indication issues |
| Staff 4 | Dietary Manager | Acknowledged food service complaints and kitchen deficiencies including ice machine and refrigerator issues |
| Staff 6 | CMA | Unaware if Resident 11 was an elopement risk |
| Staff 7 | LPN | Aware Resident 11 left facility unsupervised; unaware of elopement process |
| Staff 8 | CNA | Acknowledged Resident 13's need for assistance with denture care; confirmed Resident 13's shower schedule |
| Staff 9 | CNA | Acknowledged Resident 16's refusal of care; stated Resident 11 left facility unsupervised |
| Staff 10 | CNA | Clarified documentation practices for oral care |
| Staff 11 | LPN | Inserted indwelling Foley catheter for Resident 6 |
| Staff 12 | CNA | Reported Resident 11 left facility unsupervised |
| Staff 13 | Cook | Confirmed kitchen food safety issues |
| Staff 14 | Dietary Aid | Confirmed ice machine cleaning deficiencies |
| Witness 4 | POA | Reported Resident 2's concerns about staff communication and medication management |
Inspection Report
Capacity: 51
Deficiencies: 3
Date: Aug 4, 2022
Visit Reason
Focused Infection Control survey with 3 initial comments deficiencies not corrected at visit.
Findings
Focused Infection Control survey with 3 initial comments deficiencies not corrected at visit.
Deficiencies (3)
E0000 - Initial Comments
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Capacity: 51
Deficiencies: 1
Date: Dec 6, 2021
Visit Reason
Focused Infection Control survey with 1 deficiency related to failure to report complete COVID-19 information to CDC's NHSN during required period.
Findings
Focused Infection Control survey with 1 deficiency related to failure to report complete COVID-19 information to CDC's NHSN during required period.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
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