Regency Care Of Rogue Valley

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined the facility failed to provide required communication and documentation for 2 of 3 sampled residents (#s 49 and 51) reviewed for hospitalization and discharge. This placed residents at risk for unsafe discharge. Findings include: The 8/2024 Facilities Bed Hold Policy and Agreement Form indicated a resident who was temporarily absent from the facility because of a Break in Services (defined under Oregon law as a hospitalization or leave of absence) may apply for a bed hold to ensure her/his bed was preserved for her/his anticipated return. The policy indicated at the time of discharge to the hospital; the discharging nurse would give the residents and representatives a copy of the Bed Hold Policy and Agreement.1.Resident 51 was admitted to the facility on [DATE] with diagnoses including muscle weakness and stroke.On 1/18/26, Resident 51 left for a physician appointment. After the appointment, Resident 51 went home with Witness 1 (Family Member). On 1/18/26…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to maintain water temperatures for 2 of 6 sampled residents (#s 27 and 88) reviewed for environment and accidents. This placed residents at risk for burns. Findings include: 1. Resident 27 admitted to the facility 10/2024 with a diagnosis of a wedge compression fracture. An 10/2024 admission MDS revealed Resident 27 was cognitively intact. Resident 27 resided in Birch Hall. On 11/19/24 at 10:54 AM Resident 27 stated on one occassion she/he used the sink to wet her/his hair. On 11/19/24 at 10:56 AM Staff 6 (Maintenance Director) used a digital thermometer to test the hot water temperature at the tap of the sink in Resident 27's room. The thermometer indicated the hot water temperature was 125 degrees F. Staff 6 acknowledged the temperature of the hot water in Resident 27's room needed to be dialed down. 2. Resident 88 admitted to the facility 11/2024 with a diagnosis of hip surgery. A 11/14/24 admission MDS revealed Resident 88 was cognitively intact. Resident 88 resided in Cedar Hall. On 11/18/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to ensure concerns regarding proper food temperatures were addressed for Resident Council and 2 of 5 sampled residents (#s 9 and 25) reviewed for food. This placed residents at risk for food that was not palatable. Findings include: A 9/9/24 computer dashboard communication revealed CNAs were provided a reminder to not reheat anything for a resident in a microwave oven because resident safety and staff licenses were at risk. Staff were given the following direction: Coffee-offer to get them a new cup. Food-ask the kitchen to reheat the food. 1. On 11/20/24 at 11:00 AM nine residents attended a Resident Council meeting. A majority of the residents in attendance agreed staff were not allowed to warm or address cold food concerns when a resident stated she/he was concerned about cold food. On 11/20/24 at 8:04 AM Staff 11 (Dietary Manager) stated the kitchen had one additional meal available if a resident requested warmer food during a meal service. Staff 11 stated food handled by a resident could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to notify a resident prior to change of administration of medication for 1 of 1 sampled resident (#139) reviewed for informed consent. This placed residents at risk for lack of informed consent. Findings include: Resident 139 admitted to the facility in 2024 with diagnoses including depression. A 3/26/24 admission MDS indicated Resident 139 was cognitively intact. admission orders signed 3/28/24 revealed Citalopram (an anti-depressant) 60mg at bedtime and Imipramine (an anti-depressant) 50mg at bedtime for depression. An 4/9/24 provider order specified Citalopram 20mg at bedtime and Imipramine 25mg at bedtime for depression. An 4/18/24 provider note indicated the provider spoke with Resident 139 and she/he had no unaddressed concerns. A review of Resident 139's chart revealed no documentation to indicate Resident 139 was notified of the changes to her/his medications. On 11/18/24 at 2:49 PM Resident 139 stated she/he was taking Citalopram 60mg and Imipramine 50mg at bedtime as a successful depression…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to provide a meaningful activity program for 1 of 1 sampled resident (#3) reviewed for activities. This placed residents at risk for lack of social engagement. Findings include: Resident 3 admitted to the facility in 8/2023 with a diagnosis of paralysis. A 7/23/24 annual MDS revealed Resident 3 was cognitively impaired, preferred to stay in bed, and required assistance with ADLs. When interviewed, Resident 3 indicated choosing activities was very important. Activities important to Resident 3 included interaction with pets and reading. A care plan initiated on 8/23/23 and revised on 10/7/24 indicated Resident 3 was at risk for little activity involvement related to physical mobility, decreased ROM, impaired motor skills, and deficits in judgement. Activities to offer included to invite Resident 3 to group activities, provide 1:1 visits, and to provide reading material. An 10/23/24 Activities Quarterly Participation Review form indicated Resident 3 preferred to self-direct her/his own activities,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to properly assess a pressure ulcer and revise treatments for 1 of 1 sampled resident (#5) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: Resident 5 admitted to the facility in 3/2017 with diagnoses including dementia and failure to thrive. An 4/11/24 Annual Pressure Ulcer CAA indicated Resident 5 was at risk for pressure ulcers, was unable to make position changes independently, and had recurrent MASD (Moisture Associated Skin Damage). A 7/4/24 Unavoidable Pressure Injury Evaluation indicated Resident 5 had MASD which resulted in a pressure injury due to fragile skin and impaired skin integrity despite pressure injury interventions. An 10/2/24 Quarterly MDS indicated Resident 5 had a facility acquired Stage 3 (full thickness tissue loss) pressure ulcer. An 10/12/24 physician order indicated Resident 5 was to receive wound care to her/his coccyx (tailbone) every evening which included to cover the wound bed with calcium alginate (dressing to treat…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure a resident was provided an RA program for 1 of 1 sampled resident (#3) reviewed for mobility. This placed residents at risk for increased weakness. Findings include: Resident 3 admitted to the facility in 8/2023 with a diagnosis of paralysis. A 7/23/24 annual MDS indicated Resident 3 had impaired cognition, was bed bound, required a mechanical lift for transfers, and assistance with ADLs. An 8/3/24 PT Discharge Summary revealed Resident 3 was provided therapy services to assist her/him with increased independence with bed mobility, sitting balance while in a wheelchair, and improve ROM to her/his legs. The benefit of therapy was to prevent contractures and muscle wasting. Discharge recommendation included a RA program. The RA program was for ROM for feet mobility and leg rotation. The RA program was also to assist in maintaining the resident's ability to sit at the side of the bed, transfer to the wheelchair, and participate in bed mobility. A care plan revised on 10/30/24 revealed Resident 3 had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure respiratory treatments were implemented timely and diagnostic results were available in the medical record timely for 1 of 1 sampled resident (#1) reviewed for respiratory care. This placed residents at risk for respiratory complications. Findings include: Resident 1 admitted to the facility in 8/2021 with a diagnosis of a stroke. Progress Notes revealed: -10/8/24 Resident 1 was assessed by her/his NP for shortness of breath and orders were placed for a PRN nebulizer (machine which turns liquid medicine into a mist that can be inhaled to treat lung conditions). The note was not signed by the NP as completed until 10/26/24. -10/10/24 Resident 1 had shortness of breath, wheezing, and the physician was faxed to obtain an order for a nebulizer. -10/11/24 Resident 1 had chest pain with deep breaths, an order for a chest x-ray was obtained, and staff were waiting for results. -10/17/24 staff called radiology for x-rays obtained on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to monitor a resident's thyroid hormone level for 1 of 5 sampled residents (#1) reviewed for medications. This placed residents at risk for a non-therapeutic medication regimen. Findings include: Resident 1 admitted to the facility in 8/2021 with a diagnosis of obesity. A 9/20/24 Order Summary Report revealed Resident 1 was administered Synthroid (hormone to increase thyroid levels). The start date was 10/9/21. Resident 1's clinical record revealed her/his last TSH (thyroid stimulating hormone; monitors thyroid function) test was obtained on 11/20/22 and the results were within therapeutic range. No additional TSH test results were in the clinical record. On 11/19/24 at 2:00 PM Staff 10 (LPN IP) stated TSH levels were usually checked annually. A request was made to Staff 10 to provide documentation a TSH level was obtained yearly after 2022 or a rationale was in the resident's record indicating it was not required. No additional information was provided. On 11/19/24 at 5:00 PM in interview with Staff 4 (RN…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview it was determined the facility failed to provide dignity during dining for 1 of 1 sampled dining rooms observed for dining assistance. This placed residents at risk for an undignified dining experience. Findings include: On 1/13/20 at 6:10 PM Staff 10 (CNA) was observed standing and assisting two residents with dining during the evening meal. On 1/14/20 at 12:30 PM and 1/15/20 at 12:23 PM Staff 6 (CNA) was observed standing while assisting two residents with dining during the afternoon meal. On 1/15/20 at 4:12 PM Staff 2 (DNS) stated she expected staff to interact with residents during meals and not stand over them.

Based on interview and record review it was determined the facility failed to ensure narcotic drug records were in order and an account of all controlled drugs was maintained for 3 of 4 medication carts reviewed for medication storage. This placed residents at risk for drug diversion. Findings include: On 1/14/20 at 9:45 AM the D hall medication cart Narcotic log book revealed 24 times out of 107 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 1/14/20 at 10:30 AM the A hall medication cart Narcotic log book revealed 27 times out of 107 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 1/14/20 at 11:00 AM the B hall medication cart Narcotic log book revealed 17 times out of 109 counting opportunities the facility staff did not sign verification the narcotic count was accurate. On 1/14/20 at 10:22 AM Staff 2 (DNS) verified the missing signatures in the Narcotic books. Staff 2 acknowledged the Narcotic book always needed to be signed by two nurses to verify the count was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to provide therapeutic heart healthy diets for 1 of 1 kitchens reviewed for dining. This placed residents at risk for worsening health conditions. Findings include: On 1/15/20 at 7:22 AM Staff 5 (Cook) was observed during the breakfast meal portioning hot food according to a typed document posted on the wall near the kitchen steam table titled Portion Sizes and Diets. The document included the following statements: -CCHO (Controlled Carbohydrate) diets-regular protein, regular vegetables, half serving starch, half serving desserts or diabetic dessert. -Heart Healthy-Regular Portions??? Small serving of desserts. On 1/15/20 at 8:10 AM Staff 4 (Dietary Manager) indicated she was not aware of the Portion Sizes and Diet document posted on the kitchen wall. Staff 4 confirmed staff were to follow therapeutic diets as order by the physician for each resident and provide portion sizes and food restriction of therapeutic diets according spreadsheets provided by the Registered Dietitian. Staff 4 also…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.