Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rivercrest Post Acute during CMS and state inspections, most recent first.
Lack of Privacy During Resident Council Meetings: A resident council meeting was held in the dining area near the therapy gym, where staff and other residents repeatedly passed through, causing interruptions. Conversations from the therapy room and hallway were heard during the meeting, and staff also entered the area for coffee and supplies, leaving the meeting without privacy.
Advance Directives Not Offered or Obtained for Multiple Residents: The facility failed to ask or obtain advance directive information for four sampled residents. One resident with liver failure and heart disease said an AD existed but staff never asked about it; another resident with acute respiratory failure and HF said no AD was offered and wanted to complete one. Two other residents, including one cognitively intact resident with a BIMS of 15, had no AD documentation in the record, and staff acknowledged the AD process was not completed or followed up.
Failure to Provide Discharge Recapitulation: The facility did not provide a written recapitulation of stay at discharge for 3 residents reviewed. Records showed residents discharged after treatment for conditions including sepsis, cellulitis, pneumonia, adult failure to thrive, diabetes, and muscle weakness, while staff stated only verbal education, physician orders, lab results as applicable, a progress note, and home health details were provided; staff confirmed no recapitulation was completed.
Failure to investigate resident falls and secure smoking supplies: The facility did not complete thorough fall investigations for multiple incidents involving a resident with seizures and dementia, with records lacking root cause analysis, evaluation of existing interventions, or new interventions after repeated falls. The facility also left a resident's lighter unsecured on a bedside table despite a care plan requiring smoking supplies to be stored at the nurse's station, and staff gave conflicting accounts about smoking supervision and storage requirements.
The facility failed to complete annual performance reviews for three CNAs reviewed for staffing competency. Record review showed the CNAs did not have completed evaluations, and the ADCS confirmed the missing reviews.
Failure to report resident-to-resident abuse allegations. A resident with anxiety and depression and another resident with TBI and depression were involved in verbal and physical altercations, including threats, raised hands, kicking, and reports that one resident was hit. The DNS acknowledged no investigation was completed for one incident and that it was not reported to the State Agency, and the RD of Clinical stated the incident should have been reported.
Failure to Investigate Resident-to-Resident Abuse Allegations: A resident-to-resident altercation involving two residents was not properly investigated, including an incident where one resident threatened another and a separate event where an LPN documented that one resident kicked the other. The DNS stated one incident had no investigation completed and another was ruled out as abuse and neglect without thorough review, while the Regional Director of Clinical stated the incident should have been investigated.
A resident with cancer of the larynx and lungs had an MDS that incorrectly indicated no O2 use and no suctioning needs, even though the MAR showed daily O2 and suctioning multiple times per day during the look-back period. The AD of Clinical acknowledged the MDS was coded incorrectly.
A resident receiving dialysis was admitted with ESRD and DM, but the baseline care plan was not completed within 48 hours. The care plan was not initiated until four days after admission and did not include dialysis-related instructions for no blood draws or BP on the access arm, emergency supplies at bedside, or routine weights, although it did note the resident’s fistula and need to check the dressing after dialysis.
The facility failed to develop comprehensive care plans for two residents reviewed for pain and nutrition. One resident had chronic back pain related to a lumbar compression fracture, frequent pain, and scheduled plus PRN pain meds, but no pain care plan with goals or interventions was implemented. Another resident with ESRD, dialysis, and malnutrition was identified as nutritionally at risk and in need of added protein, but no nutrition care plan with goals or interventions was developed.
A resident admitted with osteomyelitis and neurogenic bladder had an indwelling catheter in place, but the facility did not obtain physician orders for catheter care until later. The resident stated the facility did not provide required catheter care, and an RN and LPN acknowledged that orders were needed to direct flushing and changing of the catheter.
Unnecessary Concurrent Anticoagulant and Antiplatelet Use: A resident with ESRD and DVT received Eliquis and Plavix together despite transfer orders stating Plavix was not to be taken while on Eliquis. The MAR showed the antiplatelet was entered in error and administered with the anticoagulant for 12 days, and the resident later returned from dialysis with abnormal labs and low Hgb, prompting an ED evaluation.
Resident food was not stored in a sanitary manner in the dining room refrigerator. Surveyors found a container of brown sliced peppers labeled for a resident and dated, but kept far beyond the facility’s discard timeframe, along with brown residue on the refrigerator ceiling and door shelf. The Dietary Mgr confirmed the outdated food and dirty condition, and the Admin acknowledged the findings.
A resident with a urinary catheter and wounds was on enhanced barrier precautions, but a CNA transferred the resident into a wheelchair without wearing a gown. The CNA later acknowledged a gown should have been worn, and the IP/LPN stated staff were expected to wear gloves and a gown during direct care such as transfers.
Survey results from the prior year were not readily accessible in the facility's survey binder for resident council review. A resident reported that the binder contained results from two years ago, and surveyors later observed that the most recent survey report was missing. The Administrator acknowledged the current survey results were not included in the binder.
Two residents received medication in error due to staff failing to follow physician orders and proper identification procedures. One resident was administered more oxycodone than prescribed, while another received a roommate's antidepressant after an LPN used the wrong name and did not verify identity. Both incidents were acknowledged by facility leadership.
Two residents experienced falls that were not thoroughly evaluated, and there was no documentation to show that care plan interventions were followed. One resident with heart failure slid out of bed and sustained a skin tear, while another with failure to thrive had an unwitnessed fall with an incomplete investigation. Facility staff confirmed that comprehensive analyses were not completed for these incidents.
A resident with advanced pressure ulcers received a dressing change from an LPN who did not change gloves between handling soiled and clean dressings and improperly removed her PPE gown, coming into contact with the contaminated exterior. The LPN acknowledged awareness of proper procedures, and facility leadership confirmed expectations for correct glove and gown use.
The facility did not have the Medical Director attend the QAA/QAPI meetings from April to September 2024, as required. The Former Medical Director refused to participate in these meetings, either in person or via Skype, which posed a risk for unidentified resident needs.
The facility failed to ensure a safe and homelike environment, with observations of heavily stained carpets, a missing floor latch socket creating a hole, and damaged bathroom floors. Room doors were also found with rough, damaged surfaces. The Maintenance Director confirmed these issues, and the Facility Administrator acknowledged the need for a plan to address them.
A facility failed to develop a comprehensive care plan for a resident with diabetes, COPD, and other conditions. The care plan lacked interventions to reduce incontinence episodes and did not address a prescribed fluid restriction, despite the risk of dehydration. Additionally, the resident was offered an Advance Directive form but did not have one in place. The DNS confirmed the care plan was not accurate or individualized.
A resident admitted with a stroke required substantial assistance for showers but only received a bed bath without hair washing, resulting in greasy hair. Staff confirmed that residents were scheduled for showers or bed baths twice weekly, and all body parts, including hair, should be washed. The oversight was acknowledged by staff.
A resident with COPD, obstructive sleep apnea, and heart failure did not receive continuous humidified oxygen as ordered. Observations showed the resident's portable oxygen tank was often empty, and the oxygen was not humidified. Staff were unaware of the resident's continuous oxygen needs, leading to incidents where the resident was without oxygen, including nearly fainting during a bathroom visit.
A resident with anxiety and schizoaffective disorder was informed they would have to move from their long-term room to a shared space, causing significant distress. Despite being cognitively intact, the resident's preferences were not honored, leading to increased anxiety and sleep disturbances. Staff noted the resident's struggle with change and privacy needs, but the facility did not adequately support their right to self-determination.
A resident with lower extremity paraplegia was not informed in writing of changes in financial coverage after being discharged from Medicare Part A services, despite having 37 skilled days remaining. The facility failed to provide the necessary Notice of Medicare Non-coverage (NOMNC) or Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN), as confirmed by interviews with the Social Services Coordinator and Director.
A resident with an intracranial abscess had a private medical conversation with a Physician's Assistant in a dining room, which was overheard by surveyors due to inadequate privacy measures. The resident expressed discomfort with the lack of privacy in the facility, particularly in shared rooms. Interviews revealed a lack of private meeting spaces, with staff acknowledging the need for more appropriate areas for confidential discussions.
A facility failed to provide adequate support for a resident's continence management, leading to frequent incontinence episodes. The resident, with conditions like COPD and heart failure, required assistance with toileting. Despite a care plan addressing skin breakdown due to incontinence, it lacked specific strategies for managing the resident's mixed incontinence. Interviews revealed slow call light responses contributed to the issue, and staff confirmed the absence of interventions to reduce incontinence frequency.
The facility failed to ensure medication storage areas were free of expired medications, risking diminished treatment efficacy. Observations revealed expired tuberculin and acidophilus in the medication storage room refrigerator, and expired Bacitracin ointment on a treatment cart. Staff confirmed these findings, indicating a lapse in proper medication storage protocols.
Lack of Privacy During Resident Council Meetings
Penalty
Summary
The facility failed to provide a private space for resident council meetings for 1 of 1 resident council group reviewed for privacy. On 2/11/26 at 12:35 PM, a resident council meeting was held in the dining room with state surveyors and eleven residents. The dining room was located next to the therapy gym with only a thin plastic room divider between the two rooms, and the therapy gym had only one entrance and exit that required staff to pass through the dining area to get residents to and from therapy. During the meeting, staff and other residents repeatedly entered the dining area to get to the therapy gym, causing the resident council meeting to pause. Conversations from the therapy room and hallway were heard during the meeting, creating a disruptive environment and indicating a lack of privacy. Staff also entered the dining area to get coffee and supplies for residents who were not part of the resident council meeting. A resident stated resident council was held in the dining area monthly and privacy was always an issue, and the Activities Director and Administrator both acknowledged the lack of privacy during the meetings.
Advance Directives Not Offered or Obtained for Multiple Residents
Penalty
Summary
The facility failed to ensure advance directives were offered or obtained for 4 of 4 sampled residents reviewed for advance directives. Resident 4 was admitted with diagnoses including liver failure and heart disease, and the care plan indicated an advance directive, but the medical record contained no evidence of one. The resident stated that an advance directive existed but that no one in the facility had asked about it. Staff acknowledged the resident was not asked about an advance directive and stated the process was to ask on admission and offer one if the resident did not have one. Resident 26 was admitted with diagnoses including acute respiratory failure and heart failure, and the revised care plan indicated full code status with full treatment, but the medical record contained no evidence of an advance directive. The resident stated no advance directive had been offered and expressed interest in completing one. Resident 22’s record showed no indication that the resident was asked about an advance directive or offered a blank form, and the resident stated the facility never discussed wishes or offered an advance directive. Resident 25, who had a BIMS of 15 and was cognitively intact, had a care plan noting full code status, but the medical record contained no advance directive information; the resident stated paperwork was at home and the facility did not ask for it, while staff stated the care plan reference was to a POLST and were unaware the resident had an advance directive at home.
Failure to Provide Written Recapitulation of Stay at Discharge
Penalty
Summary
The facility failed to provide a written recapitulation of the resident's stay at discharge for 3 of 3 sampled residents reviewed for Beneficiary Notification Review. Resident 61 was admitted with diagnoses including sepsis and cellulitis and was discharged from the facility on 1/8/26, but the medical record showed no indication that a written recapitulation of the stay was completed and provided at discharge. Staff stated that verbal education, a printed copy of physician orders, lab results as applicable, a printed progress note, and home health details were provided, but also confirmed that a recapitulation was not completed for this resident. Resident 62 was admitted with diagnoses including pneumonia and adult failure to thrive and was discharged on 9/30/25, and Resident 63 was admitted with diagnoses including diabetes and muscle weakness and was discharged on 10/2/25. For both residents, the medical record showed no indication that a written recapitulation of the stay was completed and provided at discharge. Staff again stated that verbal education, physician orders, lab results as applicable, a printed progress note, and home health details were provided, and later confirmed that a recapitulation was not completed for either resident at discharge.
Failure to Investigate Falls and Secure Smoking Supplies
Penalty
Summary
The facility failed to investigate the root cause of resident falls for 8 of 10 sampled fall investigations. Resident 4, admitted with diagnoses including seizures and dementia, stated on 2/9/26 that he or she had a lot of falls due to self-transferring when tired of lying in bed. Facility investigations dated 12/27/25 and 2/3/26 documented multiple incidents in which Resident 4 was found on the floor in the dining room or in the room, or fell while standing using the urinal, but the investigations did not include an analysis of the root cause of the falls, whether care planned interventions were effective, or whether any additional interventions were put in place. On 2/13/26, the Regional Director of Clinical Services stated the fall investigations were not thorough and were missing root cause analysis and interventions to help prevent further falls or injuries from falls. The facility also failed to ensure safety interventions were in place to prevent smoking-related accidents for Resident 7, who was admitted with diagnoses including sepsis and was cognitively intact per the 1/8/26 Quarterly MDS. A 1/24/26 care plan indicated Resident 7 was assessed to be safe and independent while smoking and had to store smoking supplies at the nurse's station, but multiple observations from 2/9/26 through 2/13/26 showed the resident's lighter on the bedside table. Resident 7 stated he or she had passed the facility assessment, was allowed to smoke at any time, and was able to keep smoking supplies in the room, and also stated no lock box had been provided. Staff gave conflicting statements about whether smoking supplies were to be kept in a secured lock box at the nurse's station or could remain in the room, and the Administrator acknowledged the lighter was not stored in a secure manner.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure CNA annual performance reviews were completed for three CNAs reviewed for sufficient and competent nurse staffing. Personnel record review showed that Staff 15, hired on 4/9/22, did not have a performance review completed, Staff 16, hired on 1/17/22, did not have a performance review completed, and Staff 17, hired on 10/1/13, did not have a performance review completed. On 2/12/26 at 2:26 PM, Staff 3, the Assistant Director of Clinical Services, confirmed that the annual performance reviews for Staff 15, Staff 16, and Staff 17 were not completed.
Failure to Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to timely report allegations of abuse involving resident-to-resident altercations for 1 of 1 sampled resident reviewed for abuse. Resident 2 was admitted with diagnoses including anxiety and depression, and Resident 43 was admitted with diagnoses including traumatic brain injury and depression. On 11/8/25, a progress note documented that Resident 2 was involved in a verbal altercation with Resident 43, and Resident 43 threatened to hit Resident 2 with a hand and with a box of gloves. A CNA written statement indicated Resident 43 raised a hand toward Resident 2 and Resident 2 expressed fear; Resident 2 could not be interviewed about the incident due to cognitive impairment. The facility did not complete an investigation for the 11/8/25 altercation and did not report the incident to the State Agency. Staff 2, the DNS, acknowledged on 2/11/26 that no investigation had been completed and that the incident was not reported. Staff 5, the Regional Director of Clinical, later stated the resident-to-resident incident should have been reported. The report also identified a separate resident-to-resident altercation on 11/9/25 involving Resident 43 and Resident 2, where a progress note stated Resident 43 kicked Resident 2 when Resident 2 would not give Resident 43 a cigarette. Although an investigation later stated abuse and neglect were immediately ruled out and the incident was not reported, Staff 24 stated she saw the residents' wheelchairs bump into each other and heard Resident 2 say Resident 43 hit her/him, and the on-call nurse was notified.
Failure to Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to investigate an allegation of abuse involving Resident 2 and Resident 43. Resident 2 was admitted with diagnoses including anxiety and depression, and Resident 43 was admitted with diagnoses including traumatic brain injury and depression. A 11/8/25 progress note documented a verbal altercation in which Resident 43 threatened to hit Resident 2 with a hand and a box of gloves. A written statement from a CNA indicated Resident 43 raised a hand toward Resident 2 and Resident 2 expressed fear. Resident 2 could not be interviewed about the incident because of cognitive impairment, and the DNS stated there was no investigation completed for the altercation. Staff 23 later stated Resident 43 became upset with Resident 2, raised a hand at Resident 2, and Resident 2 flinched, while the Regional Director of Clinical stated the incident should have been investigated. The facility also did not thoroughly investigate a separate resident-to-resident altercation involving the same residents. A progress note written by an LPN indicated Resident 43 kicked Resident 2 when Resident 2 would not give Resident 43 a cigarette, but Resident 2's record contained no documentation of the altercation. The DNS provided an investigation stating abuse and neglect were immediately ruled out and the incident was not reported to the state agency. The investigation later indicated the LPN errantly documented that Resident 43 kicked Resident 2 and that the LPN witnessed Resident 43 kick at Resident 2 from a distance, but no physical contact was made. The LPN stated she saw the residents' wheelchairs bump into each other and heard Resident 2 say Resident 43 hit her/him, and the on-call nurse was notified. The Regional Director of Clinical stated the resident-to-resident incident was not investigated thoroughly.
Incorrect MDS Coding for Respiratory Care Needs
Penalty
Summary
The facility failed to accurately code an MDS assessment for one resident who was admitted with diagnoses including cancer of the larynx and lungs. Physician orders dated 12/10/25 directed oxygen as needed and monitoring for need for suctioning every four hours, and the MAR showed the resident received oxygen daily and required suctioning two to three times a day during December 2025. However, the 12/20/25 Significant Change MDS indicated the resident did not receive oxygen and did not need suctioning. During interview on 2/12/26, the Assistant Director of Clinical stated the resident received oxygen and suctioning during the look-back period for the MDS and acknowledged the assessment was coded incorrectly.
Baseline Care Plan Not Completed Timely for Resident Receiving Dialysis
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for one sampled resident who was receiving dialysis. Resident 28 was admitted with diagnoses including end-stage renal disease and diabetes, and the 1/24/26 nursing admission evaluation and assessment documented that the resident received dialysis treatments. The facility’s Baseline Plan of Care policy stated that direct caregivers must have accurate information available to properly care for residents, and that the licensed nurse completes the initial nursing database upon admission and makes interventions available on the plan of care for CNAs and other caregivers to review. The resident’s care plan was not initiated until 1/28/26, four days after admission, and the plan identified dialysis on Monday, Wednesday, and Friday at 6:00 AM with transportation arriving at 5:00 AM. The care plan addressed the resident’s fistula to the left forearm and noted risk for bleeding at the access site, edema, hypertension, and hypotension, with staff to check the fistula site dressing upon return from dialysis. However, it did not include instructions related to blood draws, blood pressure, the location of emergency supplies, or information about obtaining routine weights. On 2/13/26 at 9:43 AM, Staff 4 and Staff 2 acknowledged that the baseline care plan did not adequately address the resident’s dialysis-related care needs.
Incomplete Care Plans for Pain and Nutrition
Penalty
Summary
The facility failed to develop comprehensive care plans for 2 of 5 sampled residents reviewed for nutrition and pain. The facility’s policy stated that care plan interventions are to be based on a thorough analysis of assessment information, include measurable objectives and timeframes, describe services to be furnished, reflect resident goals and strengths, and be revised as resident conditions change. The report found that these expectations were not met for two residents whose assessments identified ongoing needs, but whose care plans did not contain corresponding goals or interventions. Resident 22 was admitted with diagnoses including a lumbar wedge compression fracture, pain in an unspecified joint, and opioid dependence. The admission MDS showed frequent pain with scheduled and PRN pain medication, and the Pain CAA stated the resident had chronic back pain that limited day-to-day activities, affected rehab participation, and disturbed sleep. Staff were to encourage turning and repositioning for comfort, and the care plan was to be developed to monitor pain management, but the care plan contained no indication that a pain care plan had been developed and no goals or interventions were implemented. Resident 28 was admitted with ESRD and malnutrition. The nursing admission evaluation showed dialysis treatments, and the nutritional risk assessment identified nutritional risk related to malnutrition, a therapeutic diet, potential decreased intake related to ESRD with dialysis, expected weight fluctuations with dialysis, and a need for additional protein with meals. The Nutritional Status CAA stated the nutrition care plan would be developed and updated as needed, but the care plan contained no indication that a nutrition care plan had been developed and no goals or interventions were implemented related to malnutrition.
Failure to Provide Ordered Catheter Care
Penalty
Summary
The facility failed to ensure appropriate treatment and care for an indwelling urinary catheter for Resident 25, who was admitted with diagnoses including osteomyelitis and neurogenic bladder and had a catheter in place on admission. The nursing admission assessment documented the catheter, and the MDS also identified an indwelling catheter, but the resident’s physician orders did not include catheter care instructions until 2/9/26. During observation on 2/9/26, Resident 25 was seen with the catheter and stated the facility did not provide the required catheter care. Staff later stated that physician orders were needed to direct catheter care, including when to flush and change the catheter, and acknowledged that Resident 25’s catheter had not been changed and that the facility did not obtain orders for catheter care until 2/9/26.
Unnecessary Concurrent Anticoagulant and Antiplatelet Use
Penalty
Summary
The facility failed to ensure Resident 28 was free from unnecessary antiplatelet medications. Resident 28 was admitted with diagnoses including end-stage renal disease (ESRD) and acute embolism and thrombosis of deep veins in the lower extremity. Hospital transfer orders dated 1/24/26 directed that Eliquis, an anticoagulant, be started on 1/24/26 and that Plavix, an antiplatelet, be started on 3/6/26, with special instructions not to take Plavix while on Eliquis. The January 2026 MAR showed Resident 28 received Eliquis from 1/24/26 through 2/9/26. The MAR also showed an order for Plavix was entered on 1/28/26 and administered starting 1/29/26 through 2/9/26, resulting in both medications being given together for 12 days. A 2/9/26 progress note stated the resident returned from dialysis with abnormal lab results and was sent to the ED for evaluation. A 2/10/26 progress note stated the resident returned from the ED with low hemoglobin lab results and was told not to take Eliquis and Plavix together. Staff later stated the Plavix order had been entered in error, and the medication error report noted the ED discharge orders indicated Plavix should have been held until Eliquis was completed, but it was not held.
Resident Food Refrigerator Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to store resident food in a sanitary manner for 1 of 1 resident refrigerator reviewed for food safety. During observation of the resident refrigerator located in the dining room, surveyors found one clear plastic container with what appeared to be sliced peppers that were brown in color, labeled with a resident's name and dated 1/6/26, and stored for 37 days. Surveyors also observed a clump of thick brown creamy substance on the ceiling of the refrigerator and sticky brown residue on the shelf of the door. The facility policy for resident food from outside sources stated refrigerated items should be stored with the date received, product type, and resident name/room number, and that certain refrigerated items are discarded on day three. Staff stated the refrigerator was cleaned weekly and as needed, that kitchen staff were responsible for cleaning and discarding outdated food items, and confirmed the condition of the refrigerator and the outdated food items. The Administrator acknowledged the findings and stated he expected the resident refrigerator to remain clean.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to follow transmission-based precautions for one resident reviewed for infection control. Resident 25, who was admitted in 12/2025 with diagnoses including diabetes, had a urinary catheter in place and was on enhanced barrier precautions because of the catheter and wounds. On 2/9/26 at 11:47 AM, Resident 25 was observed being transferred into a wheelchair by Staff 20, a CNA, without a gown on. When interviewed shortly afterward, Staff 20 stated that Resident 25 was on enhanced barrier precautions and that she should have worn a gown when transferring the resident out of bed. Staff 4, an LPN and the Infection Preventionist/Assistant Director of Nursing, later stated that when residents are on enhanced barrier precautions, staff are expected to wear gloves and a gown when providing direct patient care such as transferring residents out of bed.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure that survey results from the previous year were readily accessible in the survey binder for resident council review. During the resident council meeting, a resident stated that the survey results binder contained survey results from two years ago. Later that morning, the survey binder was observed near the facility entrance, and the report from the facility's most recent survey was not found. The Administrator acknowledged that the most recent survey results were not included in the facility survey binder.
Failure to Follow Physician Orders and Proper Resident Identification in Medication Administration
Penalty
Summary
The facility failed to follow physician orders for two residents in relation to medication administration. One resident, admitted with depression and adjustment disorder and experiencing pain from recent surgery and multiple fractures, had a physician order for oxycodone not to exceed 40 mg per day. On one occasion, the resident received 50 mg of oxycodone in a single day, exceeding the prescribed limit. Documentation showed that the medication was signed out and administered by an LPN, and the error was later acknowledged by the Director of Nursing Services. Another resident, admitted with depression, was given the wrong medication after an LPN addressed the resident by the incorrect name and administered the roommate's morning medication, which included 60 mg of duloxetine. The resident did not notice the error at the time and took the medication. The LPN, who was working through a staffing agency and unfamiliar with the residents, realized the mistake only after attempting to give medication to the correct resident. The error was acknowledged by both the LPN and the facility administrator.
Failure to Evaluate Falls and Follow Care Plan Interventions
Penalty
Summary
The facility failed to ensure that falls were properly evaluated and that care plan interventions were followed for two residents. One resident, admitted with heart failure, slid out of bed and sustained a skin tear, after which there was no documentation indicating whether the fall was witnessed or unwitnessed, nor evidence that the fall was evaluated or that care plan interventions were reviewed. The resident was sent to the hospital at their request and did not return. Another resident, admitted with failure to thrive, experienced an unwitnessed fall, but the fall investigation was incomplete, lacking analysis and documentation to show the incident was evaluated or that care plan interventions were followed. This resident had a history of previous falls in the facility. Facility staff confirmed that thorough and complete analyses were not conducted for either incident.
Failure to Follow Contact Precautions During Wound Care
Penalty
Summary
Staff failed to follow proper infection control procedures during a dressing change for a resident with stage 3 and stage 4 pressure ulcers. During the dressing change, the LPN did not change gloves between handling soiled and clean dressings, and improperly removed her PPE gown by coming into contact with the exterior side. The LPN acknowledged awareness of the correct procedures for glove changes and gown removal. The Director of Nursing Services and RN consultant confirmed that the facility's expectation was for gloves to be changed between dirty and clean portions of the procedure and for gowns to be removed properly.
Medical Director's Absence from QAA/QAPI Meetings
Penalty
Summary
The facility failed to ensure the Medical Director's attendance at the Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committee meetings, which is a requirement. Documentation of the QAA/QAPI meeting minutes from April 2024 through September 2024 showed that the Former Medical Director did not attend any of these meetings. Interviews with the Administrator revealed that the Former Medical Director refused to attend the meetings either in person or via Skype. This absence placed residents at risk for unidentified needs.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of damaged and worn surfaces. The hall carpet throughout the facility was heavily stained and worn, despite regular steam cleaning. A metal floor latch socket was missing below the fire doors, creating a hole in the flooring that posed a risk for canes and walkers to catch on. Additionally, the floor covering surrounding the base of the toilet in certain rooms was damaged, exposing an uncleanable surface. The bathroom floor was also worn with patches of gray discoloration. Further observations revealed that the doors to several rooms had rough, damaged surfaces, with one door having a deeply gouged and splintered surface with sharp edges. The Maintenance Director confirmed the condition of the carpet and acknowledged the need to fill the hole in the floor and repair the damaged doors. However, he was not specifically aware of the damage to the bathroom floor. The Facility Administrator was informed of these findings and acknowledged that the facility was working on a plan to address the flooring and door issues.
Incomplete Care Plan for Resident with Multiple Health Conditions
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a recently admitted resident with multiple health conditions, including diabetes, chronic obstructive pulmonary disease, a history of lung cancer, heart failure, and generalized weakness. The resident was frequently incontinent of urine due to weakness and diuretic medication use, requiring staff assistance with toileting. The care plan identified bladder incontinence related to diuretic use and impaired mobility, directing staff to check and change frequently. However, it lacked interventions to reduce incontinent episodes. Additionally, the care plan did not address the resident's prescribed 2000 ml per day fluid restriction, despite the risk for dehydration or electrolyte imbalance due to diabetes and diuretic use. The care plan included an intervention to encourage increased oral fluids, which contradicted the fluid restriction order. Furthermore, the resident was offered a blank Advance Directive form upon admission but did not have one in place. The Director of Nursing Services confirmed that the care plan was not completely accurate or individualized.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADL) for a resident who required substantial/maximal assistance due to a stroke. The resident was admitted in October 2024 and was noted to need help with showers. However, the resident only received a bed bath since admission, and their hair was not washed, leading to greasy hair. Observations over several days confirmed the resident's hair remained greasy, and the resident expressed a desire for their hair to be washed. Staff interviews revealed that residents were scheduled for showers or bed baths twice weekly, and it was expected that all body parts, including hair, would be washed during a bed bath. Staff acknowledged that the resident's hair was not washed as required.
Failure to Provide Continuous Humidified Oxygen
Penalty
Summary
The facility failed to adhere to physician's orders for continuous humidified oxygen for a resident with chronic respiratory conditions, including COPD, obstructive sleep apnea, and heart failure. The resident was admitted for rehabilitation and required continuous humidified oxygen at 6 liters per minute to maintain oxygen saturation between 89 and 92%. However, observations revealed that the resident's portable oxygen tank was frequently empty, and the oxygen was not humidified as ordered. On multiple occasions, the resident was found without adequate oxygen supply, including an incident where the resident was assisted to the toilet without oxygen and nearly fainted. Staff interviews confirmed a lack of awareness and understanding of the resident's oxygen needs. A CNA admitted to not knowing the resident required continuous oxygen, and staff sometimes forgot to turn off the oxygen tank when switching to the in-room concentrator, leading to depletion of the portable tank. Additionally, the resident reported dryness due to the lack of humidification, and staff confirmed the absence of a humidifier on the oxygen concentrator. These oversights placed the resident at risk for complications related to their chronic respiratory disease.
Failure to Promote Resident Self-Determination
Penalty
Summary
The facility failed to promote self-determination for a resident who was cognitively intact, as evidenced by a BIMS score of 15. The resident, diagnosed with anxiety and schizoaffective disorder, was informed by management that they would have to move from their current room, where they had resided for two years, to a shared room with three other female residents. This information caused the resident significant distress, as they expressed dissatisfaction with the move and reported difficulty sleeping since the conversation. Staff members, including an LPN and CNAs, observed an increase in the resident's anxiousness and noted that the resident was very private, did not like their room touched, and struggled with change. The Social Service Director and Social Services staff confirmed that the resident had mentioned the impending room change, which contributed to their anxiety. The Director of Nursing Services (DNS) stated that the facility was considering converting a therapy room into a four-person space for long-term care female residents, including the resident in question. The DNS acknowledged the resident's suspicion of new situations and their tendency to hoard, which further complicated the situation. Despite the resident's concerns and the lack of a set timeline for the move, the facility's actions did not adequately support the resident's right to self-determination and choice regarding their living arrangements.
Failure to Provide Required Medicare Non-coverage Notices
Penalty
Summary
The facility failed to inform residents in writing of changes in financial coverage, specifically for one resident who was reviewed for advance beneficiary notification. This deficiency was identified through interviews and record reviews, which revealed that the facility did not provide the necessary Notice of Medicare Non-coverage (NOMNC) or Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) to the resident. The resident, who was admitted with lower extremity paraplegia, was discharged from Medicare Part A services while still having 37 skilled days remaining. Despite this, there was no documentation in the resident's electronic health record indicating that they received the required notices. Interviews with facility staff, including the Social Services Coordinator and the Social Services Director, confirmed the absence of these notifications. The Social Services Coordinator was unable to locate the NOMNC or SNF ABN for the resident, and the Social Services Director acknowledged that the facility did not provide these notices. This oversight placed the resident at risk for unknown financial liabilities and a lack of knowledge regarding their right to appeal the decision.
Privacy Breach During Medical Consultation
Penalty
Summary
The facility failed to ensure personal privacy for a resident, identified as Resident 187, who was admitted with an intracranial abscess. During an observation, the resident was seen having a medical conversation with a Physician's Assistant, Staff 27, in a corner of the main dining room. This conversation, which included private health information such as diagnoses, symptoms, medications, and prognosis, was overheard by the survey team in an adjacent room separated only by a curtain. The resident expressed discomfort with the lack of privacy, particularly due to sharing a room with three roommates, and mentioned a desire to leave the facility because of this issue. Interviews conducted with Staff 27, Resident 187, the Social Services Director (Staff 3), and the Administrator (Staff 1) revealed a lack of adequate private meeting spaces within the facility. Staff 27 acknowledged that the conversation should have been held in a more private area and was unaware of any private meeting areas. Resident 187 confirmed the difficulty in finding private spaces for conversations or phone calls. Staff 3 mentioned using the Social Services office or outdoor areas for privacy but expressed concerns about future changes affecting privacy. Staff 1 stated that residents could request to use staff offices for private meetings, although Resident 187 did not make such a request for the meeting with Staff 27.
Inadequate Support for Continence Management
Penalty
Summary
The facility failed to provide adequate support to maintain continence for a resident who was frequently incontinent of urine. The resident, admitted with diagnoses including chronic obstructive pulmonary disease, heart failure, and generalized weakness, required staff assistance with toileting. The resident's care plan identified moisture-associated skin breakdown due to incontinence and directed staff to keep the resident's skin clean and dry. However, the care plan did not address the specific type of incontinence or include strategies to reduce the frequency of incontinent episodes. Interviews with the resident and staff revealed that the resident experienced slow call light response times, leading to incontinence. The resident expressed that waiting five to ten minutes was too long, especially due to the urgency caused by diuretic medication. Staff confirmed that interventions to reduce incontinence frequency were not in place, and the resident's preference to avoid using briefs was not addressed. This lack of timely assistance and specific interventions placed the resident at risk for skin breakdown and loss of dignity.
Expired Medications Found in Storage Areas
Penalty
Summary
The facility failed to ensure that medication storage areas were free of expired medications and biologicals, which placed residents at risk for diminished treatment efficacy. During an observation of the medication storage room refrigerator, a vial of tuberculin used for tuberculosis screening was found to be opened and not discarded after 30 days, as confirmed by Staff 2 (DNS). Additionally, a bottle of acidophilus with an expired date was located in the refrigerator's door compartment, which Staff 2 also confirmed as expired. Further observations of one of the facility's treatment carts revealed a vial of Bacitracin ointment with an expired date. Staff 2 confirmed that the used tube of Bacitracin was expired. These findings indicate a failure to adhere to proper medication storage protocols, potentially compromising the efficacy of treatments provided to residents.
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What surveyors actually found near you
We read the 500 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oregon City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marquis Oregon City Post Acute Rehab | 0.6 mi | ★★★★★ | 5 | 0 |
| Avamere Rehabilitation Of Oregon City | 1.2 mi | ★★★★★ | 1 | 0 |
| Rose Linn Care Center | 3.1 mi | ★★★★★ | 12 | 0 |
| Avamere Rehabilitation Of Clackamas | 3.1 mi | ★★★★★ | 6 | 0 |
| Fernwood Supportive Living At Madrona Grove | 6.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.