Regency Village at Bend

The findings of the re-licensure survey, conducted 07/29/24 through 08/01/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 08/01/24, conducted on 11/13/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004

Based on observation, interview, and record review, it was determined the facility failed to notify SPD related to suspected abuse for 1 of 1 sampled resident (#5) reviewed with an allegation of abuse. Findings include, but are not limited to:Resident 5 was admitted to the facility in 12/2023 with diagnoses including bipolar disorder and major depressive disorder recurrent.During an observation and interview with Resident 5 on 07/30/24 at 11:40 am, the following was noted:During an interview with Resident 5 on 07/30/24 at 11:40 am, s/he was observed sitting in a recliner with his/her feet elevated. The resident reported s/he was having a difficult time talking about incidents that had occurred with an employee, which s/he wanted to share with the surveyor. The resident was observed to be tearful and had to take several deep breaths before s/he could continue. The following was revealed by the resident:* A staff member started visiting the resident frequently, entering his/her apartment and sitting on the bed to visit without permission.* Resident 5 began receiving gifts from the staff member every day, as well as receiving frequent hugs.* The staff member was calling every day, even on their days off, to inquire about the status of the resident.* The staff member was sharing personal information about other staff members with the resident.* The staff member started saying, "I love you," upon departure from the resident's room.Resident 5 stated s/he felt "abused" by the staff member and had reported the incidents to the administrator.In an interview with Staff 1 (ED) on 07/30/24 at 3:15 pm, he acknowledged the resident had made a complaint regarding suspected abuse. Although an internal investigation had been completed and a formal write-up had been documented, there was no documented evidence the allegation of suspected abuse had been reported to the local SPD office.Staff 1 documented a thorough investigation and reported the incident to SPD on 07/30/24 at approximately 5:30 pm. Staff 1 verified the staff member had received a formal write-up and was directed to not have any contact with the resident, including visiting, phone calls, and/or text messages.The need to notify SPD immediately of any incident of abuse or suspected abuse was discussed with Staff 1 on 07/30/24 at 3:15 pm. Staff acknowledged SPD had not been notified of the situation.

Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) to have an accurate number of minutes for 2 of 6 sampled residents (#s 3 and 4) whose ABST was reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 06/2019 with diagnoses including anxiety and multiple sclerosis.The resident's 06/25/24 service plan, progress notes dated 04/01/24 through 07/29/24, and Resident 3's ABST data was reviewed. Staff were interviewed and observations were made of the resident.The following areas were not reflective of the resident's current ADL assistance:* How much time was spent monitoring behavioral conditions or symptoms;* How much time was spent monitoring physical conditions or symptoms;* How much time was spent cueing or redirecting due to cognitive impairment or dementia; and* How much time was spent with bathing.The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), and Staff 12 (Regional VP) on 08/01/24 at 10:30 am. They acknowledged the findings.2. Resident 4 was admitted to the facility in 01/2021 with diagnoses including alcohol dependence and osteoarthritis.The resident's 07/23/24 service plan, progress notes from 04/01/24 through 07/25/24, and Resident 4's ABST data was reviewed. Staff were interviewed and observations were made of the resident.The following areas were not reflective of the resident's current ADL assistance:* How much time was spent responding to call lights;* How much time was spent monitoring behavioral conditions or symptoms; and* How much time was spent cueing or redirecting due to cognitive impairment or dementia.The need to ensure the ABST tool addressed the amount of staff time needed to provide care was discussed with Staff 1 (ED), Staff 2 (Health Services Administrator), and Staff 12 (Regional VP) on 08/01/24 at 10:30 am. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:The facility was toured throughout the survey from 07/29/24 to 08/01/24. The following issues were identified:* There were gouges and scratches to the wood paneling in the elevator. The laminate on the elevator walls was chipped and broken in multiple areas;* There were spots and stains on the rugs in the hallway near room 112; and* All the settees on the first, second, and third floors had stains on them.On 07/31/24 at 1:30 pm, the areas needing cleaned or repaired were reviewed with Staff 1 (ED) and Staff 3 (Maintenance Director). They acknowledged the areas needing cleaning and repair.

The findings of the kitchen inspection, conducted 07/21/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 07/21/22, conducted on 08/31/22, are documented in this report. The facility was found in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the main facility kitchen, food storage areas, food preparation, and food service on 07/21/22 revealed:* Splatters, spills, drips, and debris noted on: - Stainless steel and wire rack shelving throughout kitchen; - Garbage can by the bread rack; - Warming drawers; - Walls throughout the kitchen; - Interior of the oven; and - Exterior of food bins and bin handles. * Undated and unlabeled food items were noted in the reach in refrigerator.* A small diameter probe thermometer was not used to measure thin foods.* Missing laminate on the shelving below the pass through and toaster, creating an uncleanable surface.* Damage to the wall beside the range and the wall by the bread rack, creating uncleanable surfaces.* Staff were observed to not change gloves between tasks during the preparation and plating of breakfast.* Liquid Scrambled eggs prepared for breakfast were not monitored to ensure they reached the required temperature. The eggs were noted to be fully cooked on the griddle and placed in the steam tray. * There was no evidence the operation of the low temperature dish sanitizer or the sanitizer buckets were being monitored. Test strips were available. Staff 2 (Dietary Manager) and the surveyor toured the kitchen. Staff 2 acknowledged the above findings.The areas in need of cleaning and repair, food storage, and hand hygiene concerns were reviewed with Staff 1 (Executive Director). She acknowledged the findings.

The findings of the re-licensure survey, conducted 12/14/21 through 12/15/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 12/15/2021, conducted on 1/24/2022, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OAR's 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:The building was toured on 12/14/21 with Staff 1 (ED). Staff 1 confirmed the doors residents exited the facility did not have a working alarm or other acceptable system to alert staff when residents left the building.The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 on 12/14/21. No other information was provided.