Rivercrest Post Acute
Inspection Findings
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review it was determined the facility failed to follow physician orders for 2 of 6 sampled residents (#s 2 and 22) reviewed for medication. This placed residents at risk for adverse side effects.
Findings include:1. Resident 2 admitted to the facility in 2025 with diagnoses including depression and adjustment disorder.The 1/29/25 Care Plan indicated Resident 2 experienced pain due to a recent surgery and motor vehicle accident with multiple fractures. Interventions included to administer medications as ordered.A 4/8/25 physician order indicate Resident 2 was to receive oxycodone 5 mg every four hours as needed for pain and 10 mg every four hours as needed for pain. The medication was not to exceed more than 40 mg daily.A 4/24/25 progress note indicated Staff 5 (LPN) signed out a dose of oxycodone and noted Resident 2 received 50 mg of Oxycodone on 4/23/25. The medication was to not exceed 40 mg per day. Resident 2 was notified and the on call provider was notified. Resident 2 was placed on alert.A 4/24/25 Medication Error report indicated Staff 5 signed out a dose of oxycodone and noted Resident 2 received 50 mg on 4/23/25. The order indicated not to exceed 40 mg per day.On 11/13/25 at 12:41 PM Staff 5 stated
she recalled Resident 2 had an odd order related to pain medication. Staff 5 stated she could not recall the identified medication error and was unable to provide additional information.On 11/14/25 at 11:55 AM Staff 2 (DNS) acknowledged the findings of the medication error related to Resident 2 receiving excessive oxycodone.2. Resident 22 admitted to the facility in 2023 with diagnoses including depression.A 12/20/24 progress note indicated Resident 22 was approached with medications. Staff 15 (LPN) said the incorrect name to the resident. Resident 22 did not hear the wrong name and took the medication. Resident 22 was administered the medication in error. The provider was notified, and the resident was placed on alert for adverse side effects.The 12/20/24 Medication Error report indicated Resident 22 received her/his roommate's morning medication including 60 mg of duloxetine (antidepressant). Resident 22 indicated she/he felt fine.On 11/18/25 at 12:00 PM Staff 22 stated she was worked for a staffing agency and only worked in the facility for one or two shifts. Staff 22 stated on the day of the incident she asked Resident 22 if
this was her/his name [roommate's name], and she/he stated yes. Staff 22 stated she told the resident she had her/his medication and the resident stated okay and took the medication. Staff 22 stated when she went to give medication to the roommate, she realized she gave Resident 22 the wrong medication. Staff 22 stated if she was not familiar with a resident and a picture was not available; she asked other staff where
she could find the resident. Staff 22 acknowledged the identified medication error.On 11/18/25 at 11:18 AM Staff 1 (Administrator) acknowledged the identified medication error that occurred related to Resident 22.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
RIVERCREST POST ACUTE in OREGON CITY, OR inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in OREGON CITY, OR, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from RIVERCREST POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.