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Regency Florence

1951 E. 21st Street, Florence, OR 97439 · For profit - Corporation · 72 certified beds · (541) 997-8436 Medicare & Medicaid certified

Call the home — (541) 997-8436 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Aug 20231 actual-harm citation$7,443 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Aug 2023
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $7,443 in federal fines (most recent 2023-08-25)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2002 Highway 101 · (541) 997-8422 · Call to confirm hours
Pharmacy
2935 Highway 101 · (541) 902-9966 · Call to confirm hours
Grocery
2066 US-101 · (541) 997-0343 · Call to confirm hours
Park
Honeyman State Park Florence Oregon · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased25.5%14.9%15.4%worse
Long-stay residents who lose too much weight2.7%4.7%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.4%0.9%better
Long-stay residents with a urinary tract infection1.6%2.0%2.0%better
Long-stay residents with depressive symptoms0.8%4.9%6.5%better
Long-stay residents who were physically restrained1.6%0.1%0.1%worse
Long-stay residents with falls causing major injury2.3%2.4%3.3%better
Long-stay residents whose ability to walk worsened39.3%20.6%16.1%worse
Long-stay residents on antianxiety or hypnotic medication3.5%12.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.2%95.3%typical
Long-stay residents with pressure ulcers7.5%5.8%4.7%worse
Long-stay residents with worsening bladder/bowel control22.5%21.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table1.0%13.9%17.1%better
Short-stay residents who newly got an antipsychotic medication1.5%1.4%1.4%typical
Short-stay residents given the seasonal flu vaccine75.9%81.2%79.4%typical
Short-stay residents rehospitalized after admission29.0%21.4%22.6%worse
Short-stay residents with an outpatient ER visit25.1%16.1%12.0%worse

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

56.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 91 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

56.3%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
55.0%U.S. median 56.6%
Met the expected recovery
0.47U.S. median 0.31
Therapy hours / resident / day
0.31hours / resident / day
Physical therapy
0.15hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Met the expected recovery: 55.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 40 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF56.3%CMS range 44.8–64.751.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.5–14.910.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge55.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge37.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge60.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.1%CMS range 3.3–10.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.001.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.73
RN hours/ resident / day
1.08
LPN hours/ resident / day
3.27
Aide hours/ resident / day
5.08
Total nurse hours/ resident / day
0.38
RN hoursweekends
51.4%
Total nursing turnover
44.4%
RN turnover

How full it usually is: this home is certified for 72 beds and averages 43.0 residents a day — about 60% occupied, or roughly 29 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.73 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.27 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.43 hrs/resident/day on weekends vs 5.35 on weekdays — 17% thinner on weekends. RN hours go from 0.87 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

3
deficiencies at the latest standard inspection (2026-04-24)
10
at the previous standard inspection (2024-12-06)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.

  • Actual harm · Gcited before2023-08-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure staff provided a safe mechanical lift transfer during care for 1 of 3 sampled residents (#11) reviewed for accidents. Resident 11 sustained a pelvic fracture and bilateral leg fractures. Findings include: Resident 11 admitted to the facility in 7/2015 and readmitted on 8/2023 with diagnoses including a pelvic fracture and bilateral leg fractures. An 8/9/23 Fall Incident Report revealed the following: -Resident 11 fell out of a mechanical lift during a two-person transfer. -Staff 8 (CNA) and Staff 24 (CNA) were getting Resident 11 ready for her/his smoke break, the bottom left side of the sling came off the hook. Resident 11 hit her/his head on the bottom of the bed, Staff 8 ran out of the room for help, and Staff 24 stayed with the resident. -Resident 11 was alert and talking and stated, I fell out and hit my head on the bed, but it is my legs and lower back that are hurting. Staff were unable to move Resident 11 due to her/his yelling out in pain and waited for the paramedics to arrive. -Resident…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to develop a comprehensive person-centered care plan for 2 of 7 sampled residents (#s 6 and 7) reviewed for unnecessary medications and skin conditions. This placed residents at risk for unmet needs. Findings include: 1. Resident 6 admitted to the facility in 2/2026 with diagnoses including surgical wound infection and adjustment disorder with depressed mood. Resident 6's 2/27/26 admission MDS revealed Resident 6 had a history of depression, took medication for anxiety, and had a wound VAC (a non-surgical treatment that applies controlled suction to a wound to accelerate healing). A review of Resident 6's physician orders revealed orders for care for a wound VAC, hydroxyzine (an antianxiety medication), and duloxetine (an antidepressant). Resident 6's comprehensive care plan revealed no interventions related to her/his wound VAC. Resident 6's comprehensive care plan also did not have target behaviors or interventions for mood or anxiety related to her/his use of hydroxyzine and duloxetine. On 4/22/26 at 2:31…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-04-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to follow physician orders for 1 of 2 sampled residents (#38) reviewed for skin conditions. This placed residents at risk for re-opening of closed wounds. Findings include: Resident 38 was admitted to the facility in 12/2025 with diagnoses including multiple sclerosis and a history of cellulitis of the right lower leg.A 12/22/25 Initial Non-Pressure Skin Condition Evaluation indicated the presence of a four centimeter by four centimeter right lower leg venous ulcer on admission with a small amount of serosanguineous exudate (blood-tinged fluid drainage).A 1/5/26 Weekly Non-Pressure Skin Condition Evaluation indicated the right lower leg ulcer had resolved. Treatment continued for the right lower leg skin.On 4/21/26 at 2:04 PM, Resident 38 stated she/he was concerned about the condition of her/his right lower leg. The 4/22/26 physician order for treatment of Resident 38's right lower leg stated right lower extremity dressing changes-Primary Treatment: Cleanse with wound cleanser. Apply Xeroform,…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-24 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure staff followed infection control procedures for wound care for 1 of 3 sampled residents (#7) reviewed for pressure wounds and 1 of 1 facility reviewed for medication administration. This placed residents at risk for cross contamination and worsening wounds. Findings include: Based on a medication administration observation on 4/22/26 at 8:05 AM, Staff 11(RN) prepared medications for a resident in room [ROOM NUMBER]. Staff 11 entered the room without performing hand hygiene. Staff 11 grasped the resident's water cup and handed it to her/him. Staff 11 provided eye drops and nasal spray to her/him. Staff 11 moved multiple cups on the overbed table and handled the medication cup, eye drops, and nasal spray. Staff 11 failed to sanitize the bottles after usage. Staff 11 returned to the medication cart and logged onto the computer without performing hand hygiene. Staff 11 stated she should perform hand hygiene before…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to follow physician orders for therapy, failed to provide incontinence care and failed to ensure a call light was accessible for 2 of 3 sampled residents (#s 102 and 104) reviewed for quality of care and treatment. This placed residents at risk for unmet care needs. Findings include: 1. Resident 102 was admitted to the facility in 2024, with diagnoses including stroke and diabetes. Resident 102's admission Orders dated 9/12/24 included orders for Physical and Occupational Therapy. On 3/25/25 at 1:34 PM, Staff 15 (OT/Therapy Manager) stated the resident was not seen for therapy as they had not received therapy orders. On 3/26/25 at 3:40 PM, Witness 1 (Family Member) stated the resident was admitted to the nursing facility for Respite Care (temporary relief for caregivers of individuals with chronic illness, disabilities, or special needs) in 9/2024. The resident's PCP included orders for PT and OT but the resident did not receive any therapy while at the facility. On 3/27/25 at 3:36 PM, Staff 1 (Administrator)…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review it was determined the facility failed to obtain consent prior to administration of a vaccine for 1 of 5 sampled residents (#1) reviewed for immunizations. This placed residents at risk for lack of informed consent. Findings include: Resident 1 admitted to the facility in 4/2024 with diagnoses including depression. A 12/4/24 review of immunizations revealed Resident 1 received a COVID-19 vaccine on 5/9/24. A 12/4/24 review of Resident 1's medical record revealed no evidence of a COVID-19 vaccine consent. On 12/6/24 at 10:46 AM Staff 2 (DNS) stated she was unable to locate a signed consent for the COVID-19 vaccine Resident 1 received on 5/9/24.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to obtain information related to advance directives and health care decisions for 1 of 3 sampled residents (#30) reviewed for advance directives. This placed residents at risk for not having health care decisions honored. Findings include: Resident 30 admitted to the facility in 10/2021 with diagnoses including stroke. 5/23/23, 2/8/24, 2/22/24, 5/23/24 and 8/22/24 Interdisciplinary Care Conference notes revealed Resident 30 did not have an advance directive, but wanted one offered. Review of Resident 30's electronic record revealed no advance directive. On 12/3/24 at 9:43 AM Resident 30 stated she/he attended Care Conferences, but was not offered an advance directive. On 12/4/24 at 9:47 AM Staff 3 (Social Service Director) stated she offered advance directives at care conferences, and had the resident sign an admission Assessment document to verify they received the advance directive. Staff 3 stated she did not conduct follow up related to provision of advance directives. On 12/5/24 at Staff 1 (Administrator)…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-06 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to thoroughly investigate allegations of abuse for 1 of 7 sampled residents (#94) reviewed for abuse. This placed residents at risk for abuse. Findings include: Resident 94 admitted to the facility in 3/2024 with diagnoses including failure to thrive. On 9/23/24 a public complaint was received which alleged on 9/12/24 Resident 94 stated Staff 17 (Former Agency LPN) indicated she was going to administer her/him an extra dose of oxycodone beyond what was prescribed, laughed and walked out of the resident's room. Resident 94 stated she/he felt threatened, verbally abused, and the incident caused her/him increased anxiety. Resident 94 stated Staff 17 came to her/his room later and indicated she gave the resident an extra dose of oxycodone. Resident 94 stated she/he was extremely upset and scared. Resident 94 stated a couple hours later Staff 17 came back to her/his room and explained she administered an extra dose of oxycodone to another resident and not her/him, laughed, and walked out of her/his room. 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to follow doctor's orders for 1 of 5 sampled residents (#24) reviewed for unnecessary medications. This placed residents at risk for receiving unnecessary medications. Findings include: Resident 24 admitted on [DATE] with diagnoses including heart disease. A review of Resident 24's medication orders revealed orders for Ipratropium-Albuterol Inhalation Solution (a medication to treat shortness of breath) for five days beginning 11/22/24. A review of Resident 24's 11/2024 and 12/2024 MARs also revealed the medication should be discontinued after five days on 11/27/24, however the MAR indicated the medication was administered through 12/4/24. In an interview on 12/4/24 at 4:00 PM Staff 2 (DNS) acknowledged the record showed Resident 24 continued to be given doses of Ipratropium-Albuterol Inhalation Solution for seven days past the date the medication was ordered to be discontinued.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0685 — isolated
    Assist a resident in gaining access to vision and hearing services.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review it was determined the facility failed to address orders for corrective lenses for 1 of 2 sampled residents (#1) reviewed for vision. This placed residents at risk for unmet vision needs. Findings include: Resident 1 admitted to the facility in 4/2024 with diagnoses including depression. A 6/3/24 Encounter Summary revealed Resident 1 saw an optometrist on 6/3/24 and a prescription was written for glasses. On 12/2/24 at 2:51 PM Resident 1 stated she/he went to an eye exam about six months previously and was supposed to get glasses, but did not. On 12/4/24 at 8:48 AM Staff 3 (Social Service Director) stated Resident 1 had her/his eyes checked on 6/3/24 but was unaware of the order for new glasses. On 12/4/24 at 2:04 PM Staff 2 (DNS) stated Resident 1 had an order for glasses but did not receive new glasses. Staff 2 acknowledged Resident 1 did not receive timely follow up for new glasses.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-06 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to assess and monitor pressure ulcers for 2 of 2 sampled residents (#s 11 and 94) reviewed for pressure ulcers. This placed residents at risk for unassessed and unmet treatment needs. Findings include: 1. Resident 11 admitted to the facility in 1/2017 with diagnoses including dementia. a. An 10/18/24 New Pressure Injury Incident Report indicated Staff 15 (LPN) was completing wound care for Resident 11 and noticed a new pressure injury to the left heel. The heel tissue was purple in color, soft to the touch, and the skin was intact. Staff 15 stated Resident 11 did not have her/his feet elevated with a pillow. Staff 11 (NA) reported the resident was upset and kicked the pillow off the bed. An 8/28/24 Care Plan revealed staff were to float Resident 11's heels with pillows while she/he was in bed as she/he allowed. A review of Resident 11's medical record revealed a left heel facility-acquired pressure ulcer. There was no documentation in the resident's medical record the left heel wound 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 19 citations
  • Potential for harm · Dcited before2024-12-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to monitor residents at risk for elopement and follow care plans related to safety for 2 of 6 sampled residents (#s 8 and 93) reviewed for accidents. This placed residents at risk for accidents. Findings include: 1. Resident 8 admitted to the facility in 2/2019 with diagnoses including dementia. A 3/24/24 Quarterly MDS indicated Resident 8 had severe cognitive deficits. A 3/28/24 Elopement Evaluation indicated Resident 8 was at risk for elopement. A 5/5/24 Progress Note indicated Resident 8 attempted to leave the facility four times in the evening before eloping at approximately 5:30 PM. Resident 8 was found outside, on the side of the road near the facility. Resident 8 fell out of her/his wheelchair and was assisted by individuals that were passing by. On 12/5/24 at 1:13 PM Staff 6 (CNA) stated Resident 8 was an active exit seeker prior to her/his elopement on 5/5/24. Staff 6 stated Resident 8 figured out the door code and attempted to leave the facility by entering in the door code. On 12/5/24 at 2:00 PM…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0699 — isolated
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure provision of trauma-informed care for 2 of 2 sampled residents (#s 11 and 30) reviewed for behavioral needs. This placed residents at risk for unmet trauma needs and a decreased quality of life. Findings include: 1. Resident 11 admitted to the facility in 1/2017 with diagnoses including bipolar disorder, mood disturbance, communication deficit and post-traumatic stress disorder (PTSD). An 10/21/24 Annual MDS revealed Resident 11's BIMS score was five which indicated she/he had severe cognitive impairment. Resident 11 had little interest or pleasure in doing things, felt down, depressed, or hopeless, had trouble with sleep, felt tired, had eating difficulties, felt bad about herself/himself, trouble concentrating and moving and spoke slowly. A review of Resident 11's 11/8/24 care plan revealed areas which discussed trauma. All areas listed a history of trauma from the Vietnam War with history of a gunshot wound. There were no specific triggers related to Resident 11's PTSD or interventions included…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to address pharmacy recommendations for 2 of 5 sampled residents (#s 1 and 24) reviewed for unnecessary medications. This placed residents at risk for adverse medication reactions and unnecessary medications. Findings include: 1. Resident 1 admitted to the facility in 4/2024 with diagnoses including depression. A review of Resident 1's pharmacy consultation reports revealed a 9/3/24 recommendation to attempt a gradual dose reduction on citalopram (an antidepressant medication). A review of Resident 1's medical record revealed no evidence of a signed physician order to attempt a gradual dose reduction on citalopram in 9/2024. A review of Resident 1's pharmacy consultation reports revealed a 10/1/24 recommendation to attempt a gradual dose reduction on citalopram. A review of Resident 1's medical record revealed a 10/8/24 order to decrease citalopram from 20 mg to 10 mg. On 12/4/24 at 1:47 PM Staff 8 (LPN Resident Care Manager) stated…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to process physician laboratory orders timely for 2 of 5 sampled residents (#s 1 and 20) reviewed for unnecessary medications. This placed residents at risk for unnecessary medications. Findings include: 1. Resident 1 admitted to the facility in 4/2024 with diagnoses including depression. A review of Resident 1's orders revealed a 5/7/24 order for a comprehensive metabolic panel (laboratory test) to be completed on the next lab day and every six months. A review of Resident 1's laboratory test results revealed a comprehensive metabolic panel completed on 9/7/24. On 12/4/24 at 2:05 PM Staff 2 (DNS) acknowledged Resident 1's comprehensive metabolic panel was ordered on 5/7/24 but not completed until 9/7/24. Staff 2 stated the test was not completed timely. 2. Resident 20 admitted to the facility in 8/2024 with diagnoses including depression. A review of Resident 20's orders revealed an 8/9/24 order for a lipid panel (laboratory test) to be completed the next lab day and every 12 months. A review of Resident…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-06 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each resident.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review it was determined the facility failed to make a dental appointment for 1 of 2 sampled residents (#1) reviewed for dental needs. This placed residents at risk for unmet dental needs. Findings include: Resident 1 admitted to the facility in 4/2024 with diagnoses including depression. On 12/2/24 at 2:48 PM Resident 1 stated the facility informed her/him they were going to make a dental appointment for new dentures at her/his last care conference approximately two to three months ago, but no dental appointment was scheduled. On 12/4/24 at 2:19 PM Staff 8 (LPN Resident Care Manager) stated during the 10/17/24 Care Conference Resident 1 indicated she/he needed to see the dentist and Staff 8 stated the appointment was not scheduled. Staff 8 acknowledged Resident 1 did not have timely follow up for her/his dental appointment needs.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to provide incontinence care for 3 of 3 dependent residents (#s 101, 102 and 103) reviewed for incontinence care. This placed residents at risk for unmet care needs. Findings include: 1. Resident 101 was admitted to the facility in 2020, with diagnoses including dementia and Traumatic Brain Injury (TBI). Resident 101's 2/2/24 Annual MDS CAA for Urinary Incontinence revealed Resident 101 was frequently incontinent of urine and required extensive assistance for toilet use and total dependence for transfers. Resident 101 was dependent on staff for toileting hygiene and was always incontinent of bladder. The resident had mixed incontinence (urge and functional). The resident has a terminal illness. Staff were directed to maintain pride and dignity while giving personal care. Resident 101's care plan indicated the resident was at risk for ADL deficits related to weakness, decreased mobility, impulse disorder, dementia with behaviors and traumatic brain injury. Resident 101 was on a Check and Change…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-11-07 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to complete a thorough investigation within five working days related to potential narcotic medication misappropriation for 1 of 4 sampled residents (#2) reviewed for medications. This placed residents at risk for misappropriation of property. Findings include: Resident 2 was admitted to the facility in 3/2021 with diagnoses including a stroke. Review of a physician order dated 3/21/21 the resident was to receive morphine(narcotic pain medication) 0.25 ml as needed for pain. A physician order dated 9/22/21 revealed the resident was to receive morphine 0.25 ml daily. Review of a narcotic log dated 10/9/23 revealed the last dose of morphine was administered to the resident on 10/20/23 and indicated 4 ml remaining. The unused quantity in the bottle was 0.25 ml and was verified by Staff 2 (DNS) and Staff 3 (DNS/RNCM) on 10/24/23. A note on the log indicated the bottle was greater than five months old and some is likely evaporated/stuck in bottle neck. Review of an incident report dated 10/24/23 at 11:07 AM…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-09 · tag F0658 — failed to meet professional standards of care — pattern
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure Staff 2 (DNS), Staff 3 (RNCM), Staff 9 (LPN), Staff 15 (CMA) and Staff 19 (LPN) adhered to standards of practice regarding medication administration for 1 of 1 sampled residents (# 4) reviewed for significant medication error. Findings include: OAR 8510450040 Scope of Practice Standards for All Licensed Nurses indicated the following: (1) Standards related to the licensed nurse's responsibilities for client advocacy. The licensed nurse: (b) Intervenes on behalf of the client to identify changes in health status, to protect, promote and optimize health, and to alleviate suffering. OAR 8510450050 Scope of Practice Standards for Licensed Practical Nurses indicated the following: (B) Distinguishing abnormal from normal data, sorting, selecting, recording, and reporting the data; (C) Selecting appropriate nursing interventions and strategies; (d) Implement the plan of care by: (A) Implementing treatments and therapy, appropriate to…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-09 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure medications were available per physician orders for 6 of 6 sampled residents (#s 2, 3, 4, 9, 13 and 14) reviewed for medications. This placed residents at risk for medication-related adverse consequences. Findings include: The facility's 8/2023 Medication Administration Audit Report revealed the following sample of residents with missed medications: -Resident 3's 8/26/23 physician order for Carbidopa-Levodopa, two tablets, three times a day for Parkinson's Disease. The Medication Administration Audit Report revealed the resident did not receive the scheduled dose on 8/26/23 at 10:00 AM. -Resident 14's 8/17/23 physician order for a scheduled dose of Warfarin Sodium (blood clot prevention). The Medication Administration Audit Report revealed the resident did not receive the dose on 8/17/23 at 7:00 AM. On 9/18/23 at 3:12 PM Witness 13 stated there was an Azithromycin (antibiotic) medication error for Resident 9. There was no pharmacy satellite available and no medication was pulled from the Omnicell.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-10-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to ensure weekly skin and wound assessments were completed and completed timely and appropriate wound care treatment was provided for residents with wound vacuum systems for 2 of 2 residents (#s 5 and 6) reviewed for appropriate wound care and assessments. This placed residents at risk for delayed wound healing. Findings include: 1. Resident 5 was admitted to the facility in 8/2023 with diagnoses including Fournier's gangrene (rare but deadly infection of the genital and perineum) and Vacuum Assisted Closure wound therapy (wound vac) for a perirectal abscess wound. A hospital Wound Consult note dated 8/22/23 indicated a recommendation for wound vac therapy to encourage granulation tissue formation (development of new tissue and blood vessels), to increase the rate of healing, and to decrease the chance of complications including infection. There was enough skin between the wound edges and the anus to seal the wound vac dressing and withstand the presence of stool if loose stools occurred. There…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-09 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to ensure policies and procedures were in place for the safe and secure handling of controlled medications and other drugs subject to abuse, and to adhere to best practices for ordering, refilling, receiving, documenting and disposition of medications for 1 of 1 facility reviewed for safe medication systems. This placed residents at risk for unmet care, medication needs and drug diversion. Findings include: The facility's 8/2023 Medication Administration Audit Report revealed the following sample of residents with missed medications: -Resident 3 had an 8/26/23 physician order for Carbidopa-Levodopa, two tablets, three times a day for Parkinson's Disease. The Medication Administration Audit Report revealed the resident did not receive the scheduled dose on 8/26/23 at 10:00 AM. -Resident 14 had an 8/17/23 physician order for a scheduled dose of Warfarin Sodium (blood thinner). The Medication Administration Audit Report revealed the resident did not receive the dose on 8/17/23 at 7:00 AM. 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-10-09 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview it was determined the facility failed to store milk-based nutritional supplements correctly for 2 of 2 medication carts observed for medications. This placed residents at risk of food-borne illness. Findings include: On 9/26/23 at 11:17 AM an observation with Staff 2 (DNS) was conducted and revealed the Hi Cal Oral (nutritional) Supplement (milk-based) to be in a metal container on the long term hall medication cart. Staff 2 checked the temperature of the supplement which was 52.4 degrees F. On 9/26/23 at 11:20 AM an observation with Staff 2 (DNS) was conducted and revealed the Hi Cal Oral Supplement to be in an empty metal container on the skilled hall medication cart. Staff 2 checked the temperature of the supplement which was 58 degrees F. On 9/26/23 at 11:19 AM Staff 2 stated she did not know what the safe temperature zone was for the nutritional supplements.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-09 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to administer medication for prevention of blood clots as ordered by the physician which resulted in a significant medication error for 1 of 1 sampled resident (#4) reviewed for medications. This placed resident at risk for development of blood clots, heart attack, stroke, or other damage to the cardiovascular system. Findings include: Resident 4 was admitted to the facility in 9/2023 with diagnoses including STEMI (heart attack) with stent (tube inserted to promote blood flow) placement and ischemic cardiomyopathy (reduced blood flow to the heart). A Progress Alert Note dated 9/4/23 indicated the resident with no bleeding issues and no indications of clotting related to no administration of Plavix (blood thinner) for the past three days. A Progress Alert Note dated 9/5/23 indicated the resident was on alert charting for bleeding abnormalities related to no Plavix for three days. On Monday 9/4/23 at 4:46 PM Witness 11 indicated Resident 4's order for Plavix was transcribed incorrectly. The correct dosage 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-09 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review it was determined the facility failed to ensure controlled drugs listed in Scheduled II-V of the Controlled Drug Abuse Prevention and Control Act and other drugs subject to abuse were accurately identified, correctly counted, and stored in separately locked, permanently affixed compartments with mechanisms in place to minimize loss or diversion for 1 of 1 facility reviewed for safe medication system. This placed residents' medications at risk for drug diversion. Findings include: A review of facility records indicated the facility with a recent significant drug diversion case in 3/2023. A 9/18/23 at 1:30 PM an observation of the facility's medication room revealed the room with one single lock on the door. The room also contained an Omnicell (locked storage for narcotic and high-risk medications). On 9/18/23 at 9:58 AM Witness 8 indicated the facility with a resident with medications from home. Resident 9 had a duffle bag of medications including narcotics which were brought from home. The facility took the medications per their…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-10-09 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to ensure medical records for each resident were complete and accurately documented for 1 of 1 facility reviewed for medical record documentation. This placed residents at risk for medical complications. Findings include: On 9/18/23 at 3:15 PM Witness 13 said Staff 9 (LPN) copied and pasted notes word for word with no changes from other nurses' documentation into the electronic health records. If she did not do her own documenting, she did not do the tasks. Witness 13 indicated she told Staff 2 (DNS) about the copied and pasted notes which was false documentation. On 9/19/23 at 7:06 AM Witness 20 stated Staff 9 copied and pasted notes. She also said to copy and paste someone else's notes was not okay, sections of others' notes could be used but documentation should be individualized and reflect the tasks which were completed by the nurse. On 9/20/23 at 11:09 AM Witness 7 said on 7/5/23 both she and Witness 8 saw Staff 9 copy and paste notes into the electronic record and sign them. Witness 7 and Witness 8…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-25 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to protect the resident's right to be free from verbal abuse by Staff 19 (Former RN) for 1 of 2 sampled residents (#242) reviewed for abuse. This placed residents at risk for psychosocial harm. Findings include: Resident 242 was admitted to the facility in 2023 with diagnoses including colostomy (diversion of the colon through an opening in the abdomen). The facility's 9/2022 Abuse/Neglect/Misappropriation/Exploitation Policy revealed the facility was to protect residents from abuse. Verbal abuse was defined as the use of oral language that willfully included disparaging and derogatory terms to residents. A 6/3/23 FRI revealed Resident 242 asked Staff 19 (Former RN) to leave her/his room due to care issues. Staff 19 became upset and said to the resident, shut the [profanity] up. Resident 242 reported a previous incident when Staff 19 pressed too hard on her/his abdomen while replacing a colostomy bag. Since that occurrence Staff 19 no longer provided colostomy care to the resident. Staff 16 (Agency CNA)…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Potential for harm · D2023-08-25 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review it was determined the facility failed to report allegations of abuse and serious bodily injury to the State Survey Agency for 1 of 3 sampled residents (#11) reviewed for accidents. This placed residents at risk for abuse and neglect. Findings include: Resident 11 admitted to the facility in 7/2015 and readmitted in 8/2023 with diagnoses including bilateral leg fractures and a pelvic fracture. A Fall Incident Report dated 8/9/23 revealed Resident 3 had a fall from a mechanical lift during a two-person transfer when the bottom left side loop of the sling came undone and the resident fell to the floor. Resident 3 was transported to the hospital and it was determined the resident sustained a pelvic fracture and bilateral leg fractures due to the fall. No evidence was found to indicate this incident was reported to the State Survey Agency. In an interview on 8/23/23 at 10:08 AM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged the 8/9/23 incident was not reported to the State Survey Agency.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-25 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to thoroughly investigate an injury of unknown origin for 1 of 2 sampled residents (#21) reviewed for abuse. This placed residents at risk for abuse and neglect. Findings include: Resident 21 admitted to the facility in 2018 with diagnoses including anxiety. Resident 21's undated care plan indicated she/he used a wheelchair for mobility. Resident 9 admitted to the facility in 2019 with diagnoses including dementia. Resident 9's 3/24/23 MDS indicated she/he use a wheelchair for mobility. A progress note dated 6/9/23 indicated Staff 20 (Social Services) heard Resident 21 yelling at Resident 9. Resident 9 wanted Resident 21 to move and hit Resident 21 in the shoulder. Resident 21 was upset and hit Resident 9 back. Staff 20 and Staff 1 (Administrator) removed Resident 21 from the situation. Resident 21 understood Resident 9's behavior was not directed towards her/him as Resident 9 had dementia. Resident 21 was calmed down and both residents were to stay away from each other moving forward. A review of Resident…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review it was determined the facility failed to follow physician orders for bowel care for 1 of 5 sampled residents (#8) reviewed for medications. This placed residents at risk for medical complications from constipation. Findings include: Resident 8 was admitted to the facility in 2023 with diagnoses including dementia. The facility's Bowel Care Protocol indicated: - PRN bowel medication was to be administered after no BM (bowel movement) for three days. - PRN bowel medications (laxatives) order of administration was (Milk of Magnesia, Dulcolax tablet/suppository, Fleet enema). - If no bowel movement after all three PRN medications a digital exam was to be completed, the medical provider notified, and the resident placed on alert charting until resolved. Resident 8's Physician Order Summary Report as of 8/25/23 indicated the following PRN bowel medication orders: - Milk of Magnesia 30 ml every 24 hours as needed for constipation. - Dulcolax tablet 10 mg every 24 hours as needed for constipation. - Dulcolax suppository 10 mg every 24 hours as needed for…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$7,443 in federal fines across 1 penalty.

  • $7,443 — penalty dated 2023-08-25

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to REGENCY PACIFIC MANAGEMENT — 27 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 4 of 53.9+0.1 vs chain
Health inspection 4 of 53.7+0.3 vs chain
Staffing 4 of 54.0≈ chain avg
Quality measures 2 of 53.6-1.6 vs chain
The other 26 homes this chain runs (chain average 3.9★, per CMS)
1 of 5Pilot Butte Rehabilitation CenterBend, OR 1 of 5Puyallup Post AcutePuyallup, WA 2 of 5Park Rose Care CenterTacoma, WA 2 of 5Regency AlbanyAlbany, OR 2 of 5Regency Coupeville Rehab And Nursing CenterCoupeville, WA 3 of 5Kauai Care CenterWaimea, HI 3 of 5Laurel Hill Nursing CenterGrants Pass, OR 3 of 5Regency Hermiston Nursing & Rehab CenterHermiston, OR 3 of 5Sharon Care CenterCentralia, WA 3 of 5View Ridge Care CenterEverett, WA 4 of 5Arlington Health And RehabilitationArlington, WA 4 of 5Regency Care Center At MonroeMonroe, WA 5 of 5Good Samaritan Health Care CtrYakima, WA 5 of 5Mt Baker Care CenterBellingham, WA 5 of 5Regency At NorthpointeSpokane, WA 5 of 5Regency At The ParkCollege Place, WA 5 of 5Regency Canyon Lakes Rehab And Nursing CenterKennewick, WA 5 of 5Regency Care Of Central OregonBend, OR 5 of 5Regency Care Of Rogue ValleyGrants Pass, OR 5 of 5Regency Gresham Nursing & Rehabilitation CenterGresham, OR 5 of 5Regency Harmony House Rehab & NursingBrewster, WA 5 of 5Regency Olympia Rehabilitation And Nursing CenterOlympia, WA 5 of 5Regency OmakOmak, WA 5 of 5Regency Prineville Rehabilitation and Nursing CentPrineville, OR 5 of 5Regency Redmond Rehabilitation And Nursing CenterRedmond, OR 5 of 5Regency Wenatchee Rehabiliation & Nursing CenterWenatchee, WA

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
LEHNER, TIMOTHYIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF20%since 02/16/2006
PEACEHEALTHOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2005
REGENCY PACIFIC MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2010
BEDDOE, MARVINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/16/2006
KERNER, STEPHENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2005
RAPP, ANDREWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/08/2016
RYAN, PAIGEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/16/2022
CBL PROPERTIES II LLCOrganizationADP OF THE SNFsince 12/27/2005
OMNICARE LLCOrganizationADP OF THE SNFsince 09/01/2013
CLAY, JAMESIndividualADP OF THE SNFsince 02/16/2006

CMS files one row per role, so the 17 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

4 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$7.4M
Net patient revenuemost recent cost report
-0.6%
Operating marginrevenue minus expenses
$1.2M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 53%Medicare 16%Other / private 31%

This home reported $1.2M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$527per resident / day
operating cost
$16,021per month
≈ monthly operating cost
$524per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in OR

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Oregon Medicaid page.

Typical monthly cost in Oregon
$16,760/mo
Nursing home (semi-private)
$18,448/mo
Nursing home (private)
$6,875/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 385142. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-24, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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