Rivercrest Post Acute, Oregon City, OR

The Essentials

Summary

Across 6 inspections from July 2023 to July 2026, state surveyors documented 35 findings at Rivercrest Post Acute; 35 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections: 6; 2023–2026, complaint and standard
Findings: 35; Deficiencies cited by state inspectors
Corrected: 35; Of 35 findings, with a recorded correction date
Penalties: 1; 1 fine; payment not published

Findings by Year

Findings
Of which, actual harm (level G or above)

* Partial year, through October 1, 2026.

Findings by year
Year	Inspections	Findings
2023	1	6
2024	1	10
2025	2	3
2026	2	16

What the Record Shows

35 of 35 findings have a recorded correction date.
CMS lists 1 enforcement action in the window: 1 fine of $18,075, its payment not published.
4 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
The latest standard inspection, February 13, 2026, recorded 15 findings (most serious: Level E).

What to Ask About

Accident Hazards and Supervision, Cited in Three Inspections
Care Plans, Cited in Two Inspections
Quality of Care, Cited in Two Inspections
Continence and Catheter Care, Cited in Two Inspections
Respiratory Care, Cited in Two Inspections
Citation F730, Cited in Two Inspections
Medication Labeling and Storage, Cited in Two Inspections
Infection Control, Cited in Two Inspections

Report at a Glance

Facility: Rivercrest Post Acute
Address: 148 Hood Street, Oregon City, OR 97045
CMS Certification Number: 385245
Provider Type: Skilled nursing facility and nursing facility
Certified Beds: 53
Ownership: For profit - Limited Liability company
Record Window: July 14, 2023 to October 1, 2026

Chronology

Inspection History

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

Jul 302026
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 31, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Feb 132026
Standard health inspection
15 findings
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Mar 25, 2026
- F578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.Level ENo actual harm, potential for moreCorrected Mar 25, 2026
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Level ENo actual harm, potential for moreCorrected Mar 25, 2026
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Mar 25, 2026
- F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Mar 25, 2026
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Mar 25, 2026
- F610Respond appropriately to all alleged violations.Level DNo actual harm, potential for moreCorrected Mar 25, 2026
- F641Ensure each resident receives an accurate assessment.Level DNo actual harm, potential for moreCorrected Mar 25, 2026
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Mar 25, 2026
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Mar 25, 2026
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Mar 25, 2026
- F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Level DNo actual harm, potential for moreCorrected Mar 25, 2026
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level DNo actual harm, potential for moreCorrected Mar 25, 2026
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Mar 25, 2026
- F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Level BPotential for minimal harmCorrected Mar 25, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Nov 192025
Complaint investigation
1 finding
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Dec 12, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Apr 182025
Complaint investigation
2 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected May 19, 2025
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected May 19, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oct 112024
Standard health inspection
10 findings
The same visit included a complaint investigation.
- F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyLevel FNo actual harm, potential for moreCorrected Nov 15, 2024
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Nov 15, 2024
- F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.Level DNo actual harm, potential for moreCorrected Nov 15, 2024
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Level DNo actual harm, potential for moreCorrected Nov 15, 2024
- F583Keep residents' personal and medical records private and confidential.Level DNo actual harm, potential for moreCorrected Nov 15, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Nov 15, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Nov 15, 2024
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Nov 15, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Nov 15, 2024
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Nov 15, 2024
Enforcement Action
Civil money penalty, $18,075 imposed November 22, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 11, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Jul 142023
Standard health inspection
6 findings
- F730Observe each nurse aide's job performance and give regular training.Level ENo actual harm, potential for moreCorrected Aug 15, 2023
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level ENo actual harm, potential for moreCorrected Aug 15, 2023
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Aug 15, 2023
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Aug 15, 2023
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Aug 15, 2023
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Aug 15, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

Context

Patterns Worth Examining

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1
Accident Hazards and Supervision, Cited in Three Inspections
Inspectors cited F689 in April 2025, February 2026 and July 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232425252626F689 across all 6 inspections, oldest to newest
2
Care Plans, Cited in Two Inspections
Inspectors cited F656 in October 2024 and February 2026. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232425252626F656 across all 6 inspections, oldest to newest
3
Quality of Care, Cited in Two Inspections
Inspectors cited F684 in July 2023 and November 2025. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232425252626F684 across all 6 inspections, oldest to newest
4
Continence and Catheter Care, Cited in Two Inspections
Inspectors cited F690 in October 2024 and February 2026. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232425252626F690 across all 6 inspections, oldest to newest
5
Respiratory Care, Cited in Two Inspections
Inspectors cited F695 in July 2023 and October 2024. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232425252626F695 across all 6 inspections, oldest to newest
6
Citation F730, Cited in Two Inspections
Inspectors cited F730 in July 2023 and February 2026. The agency describes it this way: Observe each nurse aide's job performance and give regular training. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232425252626F730 across all 6 inspections, oldest to newest
7
Medication Labeling and Storage, Cited in Two Inspections
Inspectors cited F761 in July 2023 and October 2024. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232425252626F761 across all 6 inspections, oldest to newest
8
Infection Control, Cited in Two Inspections
Inspectors cited F880 in April 2025 and February 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232425252626F880 across all 6 inspections, oldest to newest

For Your Next Visit

Questions to Ask on Your Visit

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

01
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in three inspections, most seriously at level E.
02
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in two inspections, most seriously at level D.
03
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in two inspections, most seriously at level D.
04
How is continence care scheduled, and how do you prevent urinary infections?
Continence and Catheter Care: cited in two inspections, most seriously at level D.
05
Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?
Respiratory Care: cited in two inspections, most seriously at level D.
06
What changed after F730 was cited, and how do you check it now?
Citation F730: cited in two inspections, most seriously at level E.
07
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in two inspections, most seriously at level D.
08
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in two inspections, most seriously at level D.
09
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
10
What led to the 2024 fine, and has it been paid?
An $18,075 civil money penalty was imposed November 22, 2024. CMS publishes the fine, not whether it has been paid.

The Evidence

Sources and Coverage

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Oregon state survey agency.

Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Jul 14, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Oct 11, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Apr 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Nov 19, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Feb 13, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Oregon state survey agency
Inspection Jul 30, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Penalties, Provider Data Catalog
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗
Provider Information, Provider Data Catalog
Centers for Medicare & Medicaid Services · 385245
Published Oct 1, 2026 · Retrieved Nov 1, 2026
View Dataset ↗

Coverage

Record windowJuly 14, 2023 – October 1, 2026

CMS publishes about three inspection cycles; inspections before July 2023 are not in this release.
CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.

What This Report Cannot Tell You

Complaints not investigated onsite: Allegations screened out by the state before an onsite visit are not published.
Complaint allegations: CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
Facility-reported incidents: Self-reported incidents appear only if they led to an inspection.
Follow-up visits: CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
Fire safety inspections: Published by CMS separately and not included in this record yet.
Staffing levels and ownership history: Published by CMS separately and not included in this record.
Whether fines were paid: CMS publishes the fines imposed, not whether or when they were paid.

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.