Inspection Reports for The Rawlin at Riverbend Memory Care
3491 Game Farm Rd, Springfield, OR 97477, United States, OR, 97477
Back to Facility ProfileDeficiencies per Year
28
21
14
7
0
Unclassified
Inspection Report
Complaint Investigation
Capacity: 72
Deficiencies: 26
Apr 17, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022-2025 with deficiency history and enforcement actions
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited numerous deficiencies including failure to promptly report and investigate abuse, incomplete resident evaluations and service plans, inadequate monitoring of changes of condition, medication administration errors, insufficient staff training, and issues with the call system and kitchen sanitation. Several deficiencies were repeated or related to licensing and health care compliance.
Complaint Details
Multiple complaint investigations documented failures in abuse reporting, medication administration, resident care plans, staffing, and other regulatory compliance issues across inspections dated 2023-2025.
Deficiencies (26)
| Description |
|---|
| C0231 - Reporting & Investigating Abuse-Other Action: Failed to immediately notify local SPD office of abuse or suspected abuse and failed to promptly investigate incidents for multiple residents |
| C0252 - Resident Move-in & Evaluation: Res Evaluation: Failed to ensure resident evaluations described physical health, mental status, and environmental factors relevant to needs for 5 of 7 residents |
| C0260 - Service Plan: General: Failed to ensure service plans reflected residents’ needs and provided clear directions for 5 of 7 residents |
| C0270 - Change of Condition and Monitoring: Failed to determine, communicate, and monitor resident-specific interventions for short-term changes of condition for multiple residents |
| C0362 - Acuity Based Staffing Tool - ABST Time: Failed to accurately capture care time and care elements for 5 of 7 residents |
| Z0142 - Administration Compliance: Failed to follow licensing rules for Residential Care and Assisted Living Facilities; referenced other citations |
| Z0162 - Compliance with Rules Health Care: Failed to provide health care services in accordance with licensing rules; referenced other citations |
| C0000 - Comment: Kitchen inspections documented substantial compliance or deficiencies related to food sanitation rules |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to maintain kitchen in good repair and sanitary manner with multiple specific issues noted |
| C0300 - Systems: Medications and Treatments: Findings documented during complaint investigation |
| C0450 - Inspections and Investigations: Findings documented during complaint investigation |
| C0303 - Systems: Treatment Orders: Failed to ensure physician orders were carried out as prescribed for multiple residents |
| C0310 - Systems: Medication Administration: Failed to ensure resident MARs included specific parameters and instructions for PRN medications |
| C0330 - Systems: Psychotropic Medication: Failed to ensure staff knew reasons for use and documented non-pharmacological interventions prior to PRN psychotropic medication administration |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure newly hired direct care staff had documented first aid and abdominal thrust training within 30 days |
| C0455 - Inspections and Investigation: Insp Interval: Failed to ensure re-licensure survey plan of correction was implemented and satisfied the Department |
| C0555 - Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable: Failed to provide a call system that consistently connected resident units to care staff center or staff pagers |
| Z0163 - Nutrition and Hydration: Failed to ensure individualized nutrition and hydration plans were developed and included in service plans for 2 of 5 residents |
| Z0164 - Activities: Failed to evaluate and develop individualized activity plans for all sampled residents |
| Z0165 - Behavior: Failed to provide individualized service plan for behavioral symptoms for 1 of 2 sampled residents |
| C0010 - Licensing Complaint Investigation: Findings documented during complaint investigations on multiple dates |
| C0243 - Resident Services: Adls: Findings documented during complaint investigation |
| C0280 - Resident Health Services: Findings documented during complaint investigation |
| C0360 - Staffing Requirements and Training: Staffing: Findings documented during complaint investigation |
| C0361 - Acuity-Based Staffing Tool: Findings documented during complaint investigation |
| C0302 - Systems: Tracking Control Substances: Failed to have system in place to track controlled substances; narcotic discrepancies not reported timely |
Report Facts
Inspections on page: 10
Total deficiencies: 34
Licensing violations: 10
Notices: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director | Named in multiple findings related to abuse reporting, resident evaluations, service plans, medication administration, and call system issues |
| Staff 2 | Registered Nurse | Named in findings related to abuse investigations, medication administration, and resident care monitoring |
| Staff 3 | Resident Care Coordinator | Named in findings related to abuse reporting, resident evaluations, service plans, and care monitoring |
| Staff 6 | Business Office Director | Named in findings related to staff training deficiencies |
| Staff 7 | Caregiver | Named in staff training deficiency finding |
| Staff 8 | Caregiver | Named in staff training deficiency finding |
| Staff 9 | Caregiver | Named in staff training deficiency finding |
| Staff 10 | Caregiver | Named in staff training deficiency finding |
| Staff 11 | Resident Care Coordinator | Named in medication administration and care monitoring findings |
| Staff 12 | Resident Care Coordinator / Licensed Practical Nurse | Named in medication administration and care monitoring findings |
| Staff 16 | Named in call system deficiency finding |
Loading inspection reports...
