The Esther at Riverbend Assisted Living

Last inspection

March 4, 2026

Inspections

3, 3 deficiencies cited

Substantiated abuse

0

Substantiated licensing violations

8

Regulatory actions

1

Current owner since

January 9, 2024

License conditions and other regulatory actions

• March 13, 2026 to May 26, 2026: License Condition, Failed to assure resident was safe ALFCD26-00116; incident: CALMS - 00104386
  Based on preliminary information, received on or about March 9, 2026, a License complaint investigation was received. ODHS concludes that Respondents acts or omissions create a situation where the residents of the facility and future residents are at risk of immediate jeopardy. Facility failure to comply with Oregon Administrative Rules constitutes a threat to the health, safety, and welfare of its residents.
  Rules: 411-054-0025 (Facility Administration); 411-054-0034 (Resident Move-In and Evaluation); 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0040 (Change of Condition and Monitoring)

Inspections

• March 4, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• May 9, 2025: Complaint Investig., 2 deficiencies cited report
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0363: Acuity Based Staffing Tool - Updates & Plan severity level 2, scope L2 Widespread
• July 22, 2024: Initial Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0

Substantiated licensing violations

• March 12, 2026: Failed to provide safe environment Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  The facility allegedly failed to provide reasonable precautions against conditions that may threaten the health, safety, or welfare of residents. There was no documented evidence that the facility completed the required hourly safety checks as directed in the temporary service plans dated 02/26/26 and 02/28/26, following the resident’s fall with injury. The facility’s failure to exercise reasonable precautions against conditions that may threaten the health, safety, or welfare of residents was substantiated. The investigation determined this constitutes a violation of Oregon Administrative Rules.

• March 3, 2026: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

• March 3, 2026: Failed to properly plan care Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0034 (Resident Move-In and Evaluation)
  State’s findings

  The facility allegedly failed to properly develop and implement a service plan for the Alleged Victim. The facility did not complete the required evaluations at move-in, nor did it obtain sufficient information to develop an initial service plan that met the resident’s needs. The investigation determined this constitutes a violation of Oregon Administrative Rules.

• March 3, 2026: Failed to provide oversight and monitoring of change of condition Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The facility allegedly failed to provide required oversight and monitoring. There was no documented evidence that the facility completed the required hourly safety checks as specified in the temporary service plans dated 02/26/26 and 02/28/26 following the resident’s fall with injury. The facility failed to monitor the Alleged Victim in accordance with his or her evaluated needs and service plan. The investigation determined this constitutes a violation of Oregon Administrative Rules.

• March 3, 2026: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  The facility allegedly failed to follow the service plan for the Alleged Victim. There was no documented evidence that the facility completed the required hourly safety checks as outlined in the temporary service plans dated 02/26/26 and 02/28/26, following the resident’s fall with injury. The facility’s failure to ensure the implementation of required services was substantiated. The investigation determined this constitutes a violation of Oregon Administrative Rules.

Read the full record on the state’s site →

ODHS lists only substantiated violations: “either a substantiated instance of abuse or a licensing violation. Open investigations and complaints that are being appealed by the provider are not listed.” Oregon counts neglect as a form of abuse; see the state’s definitions of abuse. Each violation shows the level ODHS gives it, in the state’s words (for example “2 - Minor harm or potential for moderate harm”), and any fine ODHS assessed. Inspection citations show the state’s severity level and scope, and the date ODHS recorded the problem as corrected when it lists one. Rule names come from the Oregon Administrative Rules. ODHS: “Formal regulatory actions can range from a condition placed upon a license due to non-compliance or a notice to revoke a license.” This community is licensed for 115 residents; larger communities are inspected and reported on more often, so read counts with size in mind. Source: Oregon Department of Human Services, Long-Term Care Licensing, data as of October 15, 2026, showing the last five years. Always visit in person and ask the community about anything listed here.