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Regency Hermiston Nursing & Rehab Center

970 W Juniper Avenue, Hermiston, OR 97838 · For profit - Corporation · 105 certified beds · (541) 567-8337 Medicare & Medicaid certified

Call the home — (541) 567-8337 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Apr 20251 actual-harm citation$46,907 in federal fines
Insights

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

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • 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 Apr 2025
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $46,907 in federal fines (most recent 2023-11-17)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
589 NW 11th St · (541) 567-1717 · Call to confirm hours
Pharmacy
600 NW 11th St Ste e04 · (541) 667-3652 · Call to confirm hours
Grocery
292 W Hermiston Ave · (541) 701-0471 · Call to confirm hours
Park
225 SW 10th St · (541) 667-5018 · Typically dawn to dusk
Place of worship
555 SW 11th St · (541) 567-9497

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 3 of 5
Long-stay residentspeople who live here 3 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 improved from 1 to 3 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 rating3★
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 increased2.5%14.9%15.4%better
Long-stay residents who lose too much weight6.7%4.7%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%1.4%0.9%better
Long-stay residents with a urinary tract infection1.3%2.0%2.0%better
Long-stay residents with depressive symptoms4.0%4.9%6.5%better
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.1%2.4%3.3%better
Long-stay residents whose ability to walk worsened7.2%20.6%16.1%better
Long-stay residents on antianxiety or hypnotic medication15.7%12.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%95.2%95.3%typical
Long-stay residents with pressure ulcers9.2%5.8%4.7%worse
Long-stay residents with worsening bladder/bowel control11.3%21.8%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table20.1%13.9%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.7%1.4%1.4%worse
Short-stay residents given the seasonal flu vaccine90.0%81.2%79.4%better
Short-stay residents rehospitalized after admission20.1%21.4%22.6%better
Short-stay residents with an outpatient ER visit17.1%16.1%12.0%worse
Long-stay hospitalizations per 1,000 resident days2.341.481.67worse
Long-stay outpatient ER visits per 1,000 resident days5.302.351.80worse

§ 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.

37.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 204 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

37.1%U.S. median 51.5%
Got home and stayed home
12.2%U.S. median 10.7%
Went back to hospital
74.6%U.S. median 56.6%
Met the expected recovery
0.62U.S. median 0.31
Therapy hours / resident / day
0.30hours / resident / day
Physical therapy
0.24hours / resident / day
Occupational therapy
0.09hours / resident / day
Speech therapy

Met the expected recovery: 74.6% 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 138 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 0.62 therapist hours per resident per day in 2026Q1 — more than 89% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 27% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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 SNF37.1%CMS range 29.2–43.851.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.2%CMS range 9.2–15.510.7%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 discharge74.6%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 discharge68.1%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 discharge65.2%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 identified98.5%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 setting96.3%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 discharge84.5%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 stay0.5%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 worsened5.6%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 hospitalization7.2%CMS range 4.6–10.37.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.171.02Oct 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

0.60
RN hours/ resident / day
0.60
LPN hours/ resident / day
3.72
Aide hours/ resident / day
4.91
Total nurse hours/ resident / day
0.28
RN hoursweekends
44.7%
Total nursing turnover
30.0%
RN turnover

How full it usually is: this home is certified for 105 beds and averages 78.5 residents a day — about 75% occupied, or roughly 26 beds typically open. It usually has some room. 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 4.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.72 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 4.09 hrs/resident/day on weekends vs 5.25 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.72 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% 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

6
deficiencies at the latest standard inspection (2025-04-11)
12
at the previous standard inspection (2023-11-17)

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.

26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.

  • Actual harm · Gcited before2023-11-17 · 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

    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 the environment remained free from accident hazards related to mechanical lift transfers for 3 of 3 sampled residents (#s 4, 15 and 18) reviewed for accidents. This failure resulted in Resident 15 sustaining a hip fracture which required surgical intervention. Findings include: Resident 15 was admitted to the facility in 2018 with diagnoses including pain in her/his lower legs. Resident 15's [DATE] Annual MDS indicated the resident had no cognitive impairment. Resident 15 required the assistance of two-persons using a mechanical lift for transfers. An [DATE] 7:21 AM Fall Investigation revealed Resident 15 fell during a mechanical lift transfer because staff were unable to turn the mechanical lift which resulted in the mechanical lift tipping over and the resident landing on her/his right side. Resident 15 complained of pain to her/his right leg and shoulder and was sent to the hospital. A witness statement…

    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 · E2025-04-11 · tag F0759 — failed to keep medication error rate low — pattern
    Ensure medication error rates are not 5 percent or greater.
    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 maintain a medication administration error rate of less than five percent. There were 4 errors in 29 opportunities resulting in a 13.79 percent error rate. This placed residents at risk for adverse medication side effects. Findings include: 1. Resident 3 admitted to the facility in 11/2019 with diagnoses including seizures and multiple sclerosis. A 2/22/2025 quarterly MDS revealed Resident 3 had a BIMS score of three which indicated the resident had severe cognitive impairment. Resident 3's 2/2025 provider orders indicated Metoprolol Tartrate 25mg (a blood pressure medication) was to be given as 12.5mg twice daily with instructions to hold the medication for systolic blood pressure (top number in a blood pressure reading) below 110. Resident 3's provider orders indicated potassium chloride extended release 20meq (a supplement) was to be given one time a day with instructions to swallow whole, do not crush or chew, and do not allow to dissolve in the mouth. During an observation of medication…

    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 · E2025-04-11 · tag F0761 — failed to label and store drugs safely — pattern
    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 resident medications were not expired for 2 of 2 medication storage rooms and 2 of 3 medication carts reviewed for medication storage. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications. Findings include: The facility Medication Storage In The Facility policy, revised July 2021, indicated expiration dates on all medications were to be checked prior to administration, no expired medications were to be administered, and all expired medications were to be removed from the active supply and destroyed in the facility. During an observation of the 400-hall medication cart on 4/8/25 at 3:52 PM, the following were found: - One bottle of Geri Dryl 25mg tablets with an expiration date of 9/2024. - One bottle of ASA 81mg tablets with an expiration date of 8/2024. - One bottle of calcium 500mg + D 500mg tablets with an expiration date of 12/2024. - One bottle of melatonin 1mg tablets with an expiration date of 3/2025. - One bottle of acid…

    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 · Ecited before2025-04-11 · 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 — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to store food in a manner to prevent spoilage in 1 of 1 kitchen reviewed for sanitary practices. This placed residents at risk for foodborne illness. Findings include: The facility's Food Safety and Sanitation Policy and Procedure dated 2023 indicates: -All time and temperature control for safety foods should be labeled, covered and dated when stored; and -Perishable foods should be used prior to the use by date on the package. On 4/7/25 at 10:06 AM during a tour of the facility's Kitchen, the following was observed in the walk-in refrigerator: -a plastic container labeled, chicken noodle - use by 4/5; -a plastic container labeled, rice prep - use by 4/6; -a one-quart container of sauerkraut labeled, expires 4/4; and -two unlabeled and undated trays containing multiple prepared beverage cups: 28 cups of milk and 6 cups of apple juice. On 4/7/25 at 10:06 AM Staff 5 (Dietary Manager) acknowledged the items should not be in the refrigerator past their use by dates and should be thrown away. Staff 5…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-11 · 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 observation, interview, and record review it was determined the facility failed to develop comprehensive care plans for 1 of 1 sampled resident (#40) reviewed for vision. This placed resident at risk for lack of visual care needs. Findings include: Resident 12 admitted to the facility in 2020 with a diagnoses including dementia with behavioral disturbance. Resident 12's 1/6/25 Quarterly MDS revealed the resident had vision impairment and her/his BIMS score was 5 which indicated a severe cognitive impairment. The resident's required substantial/maximal assistance with a helper completing more than half of the effort. On 4/7/25 at 11:55 AM Resident 12 was observed without eyeglasses, in bed coloring. Resident 12 stated she/he was worried about her/his eyeglasses and said they were missing. The surveyor looked around on Resident 12's bed and bedside table and no eyeglasses were visible. Resident 12 was observed to not have worn eyeglasses on the following dates and times: -4/7/25 at 10:28 AM and 11:55 AM; -4/8/25 at 8:08 AM, 9:26 AM, 12:39 PM and 2:23 PM; -4/9/25 at 7:41 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-11 · 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 skin assessments and monitoring for 2 of 2 residents (#s 27 and 40) reviewed for non-pressure skin conditions. This placed residents at risk for delayed treatment and skin breakdown. Findings include: The facility's revised 4/2018 Skin at Risk Program Overview Policy indicated the Skin at Risk Program was based on the nursing process and included identification of residents at risk for skin breakdown, care plan developed to prevent skin breakdown, implementation of care plan interventions, to evaluate and monitor interventions for skin. 1. Resident 27 admitted to the facility in 2019 with diagnoses chronic pain and depression. Resident 27's physician order, start date on 10/21/23, directed staff to check her/his skin and indicate if a new condition was present. If a new condition was present staff were to document a progress note and initiate a skin documentation form. Resident 27's 2/25/25 Quarterly MDS revealed the resident had a BIMS score of 11 which indicated 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-11 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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 accurate communication occurred between the facility and the dialysis provider, ensure the residents care plan and physician orders were followed for fluid restriction for 1 of 1 sampled resident (#69) reviewed for dialysis. This paced residents at risk for lack of communication with the dialysis center and fluid overload. Findings include: Resident 69 admitted to the facility in 3/2025 with diagnoses including heart failure and ESRD (end stage kidney disease). The facility's Dialysis Policy revised on 3/2024 indicated the following: -Licensed nurses were to complete the Pre and Post-dialysis assessments with each dialysis visit. -The licensed nurse are to ensure the Dialysis Communication form were completed and special instructions/orders were implemented. a. A 3/3/25 physician order indicated staff were to follow the dialysis flow sheet protocol every day shift every Tuesday, Thursday and Saturday. A review of the Dialysis Communication form revealed the following: The 3/4/25,…

    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 · D2025-04-11 · 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 observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from sexual and physical abuse by other residents for 4 of 5 sampled residents (#s 12, 29, 128 and 279) reviewed for abuse. This placed residents at risk for mental anguish and abuse. Findings include: Review of the facility's revised 10/2022 Abuse/Neglect/Misappropriation/Exploitation Policy and Procedures revealed the purpose of the policy was to define how the facility will prevent, identify, report and investigate abuse. Sexual abuse was defined as any form of non-consensual contact including unwanted or inappropriate touching. The facility must evaluate whether the resident has the capacity to consent to sexual activity. Physical abuse included hitting, slapping, pinching, striking with an object and shoving. 1. Resident 12 admitted to the facility in 2020 with a diagnoses including dementia with behavioral disturbance. Resident 12's 7/6/24 Quarterly MDS revealed, Resident 12 had a BIMS score of 3, which indicated the resident had severe cognitive…

    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 · D2025-04-11 · 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 ensure dependent residents received required assistance with ADLs for 2 of 4 sampled residents (#s 11 and 40) reviewed for ADLs. This placed residents at risk for a lack of personal hygiene and loss of dignity. Findings include: 1. Resident 11 admitted to the facility in 12/2024 with diagnoses including weakness and kidney disease. A 4/4/25 quarterly MDS revealed Resident 11 had a BIMS score of three which indicated severe cognitive impairment and was dependent on staff for grooming. A review of Resident 11's 3/13/25 through 4/10/25 health record revealed CNA staff documented grooming was completed daily, a shower was provided six times, and the resident refused a shower two times. Random observations from 4/7/25 through 4/11/25 revealed Resident 11 had long white hairs hanging approximately two inches from her/his chin in multiple locations. On 4/10/25 at 2:42 PM, Staff 28 (CNA) stated she was not sure if Resident 11 had long chin hairs. She stated grooming for residents occurred at least…

    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 · D2024-06-05 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    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 narcotics were administered according to physician's orders for 1 of 4 sampled residents (#1) reviewed for medication errors. This placed residents at risk for adverse medication consequences. Findings include: On 3/21/24 a concern was received by the State Survey Agency (SSA) which alleged Resident 1 was given an additional dose of the narcotic Oxycodone. Resident 1 was admitted to the facility in 2022, with diagnoses including a fractured leg and dementia. Resident 1's 3/2024 signed physician orders revealed she/he was to be administered an Oxycodone 5 mg tablet by mouth every eight hours for pain. A review of Resident 1's 3/2024 MAR revealed on 3/20/24 Resident 1 was given Oxycodone 5 mg at 6:00 AM, 2:00 PM and 10:00 PM. On 3/20/24 at 9:00 PM, Staff 9 (CMA) and Staff 10 (CMA/CNA) counted the narcotics for Resident 1 and discovered there was a missing Oxycodone tablet. Staff 9 stated she had accidentally given Resident 1 an extra dose of 5 mg Oxycodone. Staff 9 and Staff 10 informed the charge…

    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 · Fcited before2023-11-17 · tag F0812 — failed to store, cook, and serve food safely — widespread
    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 — an excerpt from the official record, may be distressing

    Based on observation and interview it was determined the facility failed to ensure food was labeled and stored in a manner to minimize spoilage and proper food handling practices were followed to prevent cross contamination in 1 of 1 kitchen reviewed for food safety. This placed residents at risk for foodborne illness and unappetizing meals. Findings include: 1. On 11/13/23 at 10:56 AM the following observations were made regarding dry food storage: -Three undated containers of pasta; -One undated container of croutons; and -One undated container of rice. On 11/13/23 at 11:13 AM Staff 33 (Cook) stated dry food containers were not dated. When questioned, Staff 33 was unable to say specifically how long they have had the dry foods. On 11/15/23 at 12:05 PM Staff 35 (Dietary Manager) confirmed all food should be dated. 2. On 11/15/23 at 11:39 AM Staff 34 (Cook) was observed preparing and plating lunch with no hairnet. On 11/15/23 at 12:05 PM Staff 35 (Dietary Manager) stated staff were to wear hairnets anytime they were in the kitchen area. Staff 35 confirmed Staff 34 was not wearing 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · F2023-11-17 · tag F0947 — failed to train nurse aides adequately — widespread
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    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 have a system in place to track annual nurse aide training (required 12-hour minimum every year) for 5 of 5 randomly sampled CNAs (#s 7, 8, 12, 30 and 31) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff. Findings include: On 11/16/23 at 12:02 PM the following CNA staff training logs were requested and received from Staff 2 (DNS): -Staff 7 (CNA): received 0 hours of annual training; -Staff 8 (CNA): received 0 hours of annual training; -Staff 12 (CNA): received 0 hours of annual training; -Staff 30 (CNA): received 0 hours of annual training and -Staff 31 (CNA): received 0 hours of annual training. On 11/16/23 at 12:26 PM Staff 2 acknowledged the required 12 hours of annual in-service training was not completed for Staff 7, Staff 8, Staff 12, Staff 30 and Staff 31.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-17 · tag F0575 — pattern
    Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview it was determined the facility failed to ensure contact information for pertinent State agencies was posted and available to residents for 1 of 1 facility observed for required postings. This failure placed residents at risk for lack of information about how to file a complaint. Findings include: Review of the facility's required postings on 11/16/23 revealed a poster with State agency information on reporting a complaint was not posted in the facility. On 11/16/23 at 10:16 AM Staff 2 (DNS) stated the facility previously had a poster up with contact information for the pertinent State agencies, but the poster was removed a week ago. Staff 2 acknowledged no contact information for the pertinent State agencies was currently posted.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-17 · tag F0577 — pattern
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview it was determined the facility failed to ensure survey results were readily accessible for 1 of 1 facility reviewed for resident rights. This placed residents and the public at risk for not being informed of the facility's survey history. Findings include: On 11/14/23 at 10:30 AM a binder containing the facility's survey results was observed lying flat on the counter adjacent to a closed roll-up window on the south side of the building. The binder was oriented away from the room and the label of the binder was not visible when observed from wheelchair height. A sign was observed on the outside of the door which read, PUBLIC ACCESS TO FACILITY IS LOCATED ON THE [north] SIDE OF THE BUILDING. On 11/14/23 at 10:33 AM Staff 9 (Activities Director) stated the south side of the building was the facility's back door. She stated the main entrance was located on the north side of building and residents and guests entered and exited through the north side doors. On 11/17/23 at 11:05 AM Staff 5 (RN) reported she knew the binder existed but did not know where…

    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 · Ecited before2023-11-17 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 and interview it was determined the facility failed to maintain a homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for living in an unkempt environment. Findings include: Observations of the facility's general environment and residents' rooms from 11/13/23 through 11/17/23 identified the following issues: -The 100 hall shower room was missing the threshold from the shower room to the hallway and was not cleanable. The tiles in the shower stall were worn down and chipped. The flooring was discolored. The overhead light was dirty and had a cracked plastic covering. -The skilled floor dining room had black marks along the wall under the window and black shoe prints on the wall near the sink. -room [ROOM NUMBER] had gouges in the wall above the bed and along the wall next to the bathroom. The heater was also gouged and had areas of missing paint. -room [ROOM NUMBER]'s bathroom light covering had come off and was on the floor by the toilet. In the…

    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 · E2023-11-17 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    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 sufficient staffing to meet resident care needs for 1 of 1 facility reviewed for sufficient and competent staffing. This placed residents at risk for unmet care needs and lengthy call light response times. Findings include: On 11/13/23 the facility had a census of 72 residents. On 11/15/23 Staff 2 (DNS) provided a list of residents who: -Required two-person mechanical lift transfers: 24. -Were considered to be bariatric (obese) with a body mass index over 40: 9. -Had behavioral healthcare needs: 13. -Required frequent checks: 3. -Were determined to be at a high fall risk: 26. -Were dependent on staff for showers: 57. -Were dependent on staff for toileting: 44. -Required one-to-one assistance with eating: 6. The 1/2023 through 11/2023 Resident Council Meeting notes revealed residents' voiced concerns regarding long call light response times during every Resident Council meeting this year. Observations from 11/13/23…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-17 · tag F0730 — pattern
    Observe each nurse aide's job performance and give regular training.
    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 ensure CNA staff annual performance reviews were completed for 2 of 5 sampled CNA staff (#s 7 and 31) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include: On 11/16/23 at 12:10 PM a review of the facility staff training records for CNAs employed over one year revealed the following: -Staff 7 (CNA), hire date 7/17/22; had no annual performance review documentation on file. -Staff 31 (CNA), hire date 10/1/21; had no annual performance review documentation on file. On 11/16/23 at 1:09 PM Staff 2 (DNS) confirmed she was unable to provide annual performance review documentation for Staff 7 and Staff 31.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-11-17 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview it was determined the facility failed to ensure the garbage area dumpsters were covered and free from debris for 3 of 3 facility dumpsters reviewed for sanitation. This placed residents at risk for exposure to pests and rodents. Findings include: On 11/15/23 at 12:06 PM three dumpsters were observed, all with lids open. Two used medical gloves and one wet-wipe were observed around the two south dumpsters. On 11/16/23 at 9:25 AM three dumpsters were observed, all with lids open. Three used medical gloves were observed on the ground around the outside of the south dumpsters. Two medical gloves were observed on the ground around the outside of the north dumpster. On 11/16/23 at 10:10 AM the north and south dumpster areas were reviewed with Staff 11 (Maintenance Director). Staff 11 confirmed the dumpster lids were to be closed and used medical equipment was to be in the containers, not on the ground around the containers.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-11-17 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    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 dignity for 1 of 2 sampled residents (#40) reviewed for dignity. This placed residents at risk for lack of dignity. Findings include: Resident 40 was admitted to the facility in 2021 with diagnoses including stroke. A review of Resident 40's 9/27/23 Annual MDS Assessment revealed she/he had moderate cognitive impairment. Resident 40's Care Plan revised on 10/8/21 revealed she/he required extensive assistance from one staff member twice a week and as necessary to complete bathing tasks. Resident 37 was admitted to the facility in 2022 with diagnoses including muscle wasting and atrophy. A review of Resident 37's 10/7/23 Quarterly MDS Assessment revealed she/he had moderate cognitive impairment. On 11/14/23 at 1:42 PM Resident 40 was observed in a shower chair and partially covered by a bath blanket while Staff 17 (CNA) transported her/him to the 400 hall shower room. Resident 40's left buttock and left leg were completely exposed. On 11/14/23 at 1:44 PM Resident 37 was observed sitting…

    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 before2023-11-17 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 a resident for safe self-administration of medication for 1 of 2 sampled residents (#41) reviewed for medication self-administration. This placed residents at risk for unsafe medication administration. Findings include: Resident 41 was admitted to the facility in 2022 with diagnoses including asthma. A Physician Order from 3/17/23 instructed Resident 41 to inhale 2 puffs of albuterol 90 mcg for shortness of breath. The order included instructions the medication was to be administered by a clinician. On 11/13/23 at 3:38 PM an albuterol inhaler was observed on the residents bedside table. Resident 41 stated she/he had been assessed and approved to use the inhaler independently. On 11/15/23 at 8:43 AM Staff 32 (RNCM) stated a resident must have physician orders and an assessment for safety with self-administration of any medication. Review of Resident 41's orders with Staff 32 revealed Resident 41's albuterol medication was to be administered by a clinician and should not be left in…

    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 · D2023-11-17 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 oxygen was administered as ordered for 1 of 1 sampled resident (#31) reviewed for respiratory care. This placed residents at risk for adverse respiratory effects and discomfort. Findings include: Resident 31 was admitted to the facility in 2021 with diagnoses including chronic respiratory failure with hypoxia (an absence of enough oxygen), pneumonia and chronic obstructive pulmonary disease (a lung disease that makes it difficult to breathe). The facility's 6/2023 Oxygen Administration Policy indicated the following: -It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until order can be obtained. Resident 31's 8/12/21 Physician Order indicated the resident received two liters of oxygen per minute (LPM) via nasal cannula (a medical device to provide supplemental oxygen therapy to people with low oxygen levels). An 8/22/23 Annual MDS indicated Resident 31 received oxygen therapy. An observation on 11/16/23 at 10:59…

    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 before2022-11-04 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    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 and interview, it was determined the facility faileded to ensure the building was clean and kept in good repair for 5 of 5 rooms (#s 109, 505, 506, 510, 515) reviewed for environment. This placed residents at risk of living in an unkept and unhomelike environment. Findings include: On 10/31/22 at 1:14 PM large holes and chipped paint was observed in room [ROOM NUMBER] near Resident 22's bed. On 10/31/22 at 1:18 PM large gouges and chipped paint was observed on the wall in room [ROOM NUMBER] behind Resident 12's bed. On 10/31/22 at 1:45 PM holes and chipped paint was observed underneath the soap dispenser in room [ROOM NUMBER]. On 10/31/22 at 4:11 PM large gouges and chipped paint was observed in room [ROOM NUMBER] near Resident 40's bed. On 10/31/22 at 4:16 PM major damage including large gouges, exposed drywall and exposed pipes were observed in room [ROOM NUMBER] near Resident 23's bed. On 11/2/22 at 3:35 PM Staff 9 (CNA) stated she reported the wall damage in room [ROOM NUMBER] in August…

    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 before2022-11-04 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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 a resident's ability to safely self-administer medications for 1 of 1 sampled resident (#13) reviewed for self-administration of medications. This placed the residents at risk for unsafe medication administration. Findings include: Resident 13 was admitted to the facility 2021 with diagnoses including diabetes. The 8/14/22 quarterly MDS indicated the resident was cognitively intact. A review of Resident 13's clinical record revealed no medication self-administration assessment or physician orders the resident could self-administer medication. On 11/1/22 at 11:41 AM during a random observation in Resident 13's room, a medicated nasal spray was observed on Resident 13's counter. On 11/1/22 at 11:41 AM Resident 13 stated she/he used the nasal spray for their runny nose. On 11/1/22 at 12:10 PM Staff 11 (RN) stated residents can self-administer their medications after a self-administration assessment. An assessment ensures the residents ability to self-administer medications safely. All…

    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 before2022-11-04 · 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 administer medications according to physician's orders for 2 of 5 sampled residents (# 13 and 35) reviewed for unnecessary medications. This placed residents at risk for adverse medication consequences. Findings include: 1. Resident 35 was admitted to the facility in 2022 with diagnoses including heart failure, presence of a pacemaker and hypertension (high blood pressure). Resident 35's current physician's orders included: - metoprolol 25 mg evry morning for hypertension. Do not administer the medication if the systolic blood pressure (the top number in a blood pressure reading) was less than 110, the diastolic blood pressure (the bottom number in a blood pressure reading) was less than 60 or if the heart rate was less than 55. - hydralazine 50 mg for hypertension. Do not administer the medication if the systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. Resident 35's 10/2022 MAR revealed the following: - The metoprolol was administered to Resident 35 on 10/8/22,…

    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 before2022-11-04 · 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 observation, interview and record review it was determined the facility failed to implement care planned interventions related to transferring of a resident for 1 of 1 sampled residents (#51) reviewed for accidents. This placed the resident at risk for falls. Findings include: Resident 51 was re-admitted to the facility 2022 with diagnoses including left femur fracture, dementia and a colostomy (an opening on the resident's abdomen used to expel waste products). The 8/2022 Quarterly MDS indicated Resident 51 was severely cognitively impaired; required two staff persons assistance with transfers and one staff person assistance with wheelchair mobility. Resident 51's care plan dated 6/2022 indicated the resident had a history of falls and the interventions implemented included a two person assist with transfers. On 11/2/22 at 1:56 PM Staff 13 (CMA/CNA) was observed to assist Resident 51 from the wheelchair to the resident's bed. Staff 13 stated the resident was a one-person extensive assist and the resident could bear weight. The amount of weight was dependent on 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 · D2022-11-04 · 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 Silva, [NAME] L. Based on observation and interview it was determined the facility failed to follow proper infection control practices for 1 of 1 staff (# 15) reviewed for infection control. This placed the residents at risk of developing an infection. Findings include: On 11/2/22 at 11:49 AM Staff 15 (CNA) was observed to assist Resident 13 with sitting up in bed. While assisting the resident, Staff 15 noticed an issue with the residents colostomy bag (on opening on the residents abdomen used to expel waste products). With gloved hands, Staff 15 repositioned the resident's full colostomy bag and stated she needed to get the nurse to look at the residents colostomy bag. Staff 15 assisted the resident back to laying down, doffed (removed) her gloves without performing hand hygiene afterwards, touched the doorknob in the resident's room, walked down the hall and touched the counter at the nurse's station. Staff 15 stated I know I should have washed my hands after doffing (removing) my gloves, but I didn't. 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.

    Infection Control 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

$46,907 in federal fines across 1 penalty.

  • $46,907 — penalty dated 2023-11-17

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 3 of 53.9-0.9 vs chain
Health inspection 3 of 53.7-0.7 vs chain
Staffing 4 of 54.0≈ chain avg
Quality measures 3 of 53.6-0.6 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 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 4 of 5Regency FlorenceFlorence, OR 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
STROUD, DAVIDIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF33%since 03/14/2007
BEDDOE, MARVINIndividualMANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/14/2007
REGENCY PACIFIC MANAGEMENT LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2010
BAKE, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/27/2014
RAPP, ANDREWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/08/2016
SUAREZ, YOLANDAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/01/2026
CBDS HERMISTON PROPERTIES LLCOrganizationADP OF THE SNFsince 07/01/2007
TIETON VILLAGE DRUG INC.OrganizationADP OF THE SNFsince 11/01/2021
CLAY, JAMESIndividualADP OF THE SNFsince 03/14/2007

CMS files one row per role, so the 17 rows in the source record cover these 9 parties — each is shown once here with every role it holds. Nothing is omitted.

3 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.

$13.2M
Net patient revenuemost recent cost report
+12.0%
Operating marginrevenue minus expenses
$1.7M
Related-party expense15% of expenses
Who pays — share of resident-days
Medicaid 66%Medicare 22%Other / private 12%

This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 15% 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

$477per resident / day
operating cost
$14,512per month
≈ monthly operating cost
$543per 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 385263. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-11, 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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