Regency Redmond Rehabilitation And Nursing Center
3025 SW Reservoir Drive, Redmond, OR 97756 · For profit - Limited Liability company · 50 certified beds · (541) 548-5066 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 2 actual-harm citations
- 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
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 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 3 to 5 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 7.0% | 14.9% | 15.4% | better |
| Long-stay residents who lose too much weight | 1.2% | 4.7% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.1% | 2.0% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 2.4% | 4.9% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 2.4% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents whose ability to walk worsened | 10.0% | 20.6% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 9.6% | 12.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 11.5% | 5.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 7.5% | 21.8% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 0.0% | 13.9% | 17.1% | check this* — see note marked star below the table |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 1.4% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 98.6% | 81.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 14.1% | 21.4% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 23.4% | 16.1% | 12.0% | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
§ 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.
61.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 124 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 86.0% 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 57 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 0.70 therapist hours per resident per day in 2026Q1 — more than 92% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 16% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.1%CMS range 51.4–69.5 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.2%CMS range 6.4–13.4 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 86.0% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 84.2% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 84.2% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | 98.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 1.6% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.6% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 6.4%CMS range 3.2–11.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.98 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 50 beds and averages 35.0 residents a day — about 70% occupied, or roughly 15 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 5.72 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.48 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.68 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 4.69 hrs/resident/day on weekends vs 6.15 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 1.70 to 0.93 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% 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
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.
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 12 most serious are shown; the remaining 18 are one tap away and print in full.
- Actual harm · G2023-04-07 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 15 (CMA) administered medications per the current standard of practice. This resulted in Resident 131 experiencing adverse medication consequences and being sent to the hospital for treatment and observation. Findings include: Resident 131 was admitted to the facility on [DATE] with diagnoses including femur fracture and respiratory failure. The 3/30/22 hospital physician orders indicated Resident 131 was to receive the following: -morphine 10 mg/5 ml take 2 ml in the morning and 1 ml in the afternoon; -morphine concentrate 10 mg/0.5 ml concentrated solution take 0.1 ml (2 mg total) PO TID PRN air hunger for up to three days. The Omnicell (automated medication dispensing system used when medication is not otherwise available) indicated on 3/30/22 at 6:42 PM Staff 6 (LPN) and Staff 18 (Former Staff/LPN) pulled one bottle of morphine sulfate 20 mg/ml solution 30 ml for Resident 131. The 3/31/22 Medication Administration…
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.
- Actual harm · G2023-04-07 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
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 residents were free from significant medications errors for 1 of 6 sampled residents (#131) reviewed for medication. Resident 131 received an excessive dose of morphine (opioid pain medication) which resulted in hospitalization. Findings include: Resident 131 was admitted to the facility on [DATE] with diagnoses including femur fracture and respiratory failure. The 3/30/22 hospital physician orders indicated Resident 131 was to receive the following: -morphine 10 mg/5 ml take 2 ml in the morning and 1 ml in the afternoon; -morphine concentrate 10 mg/0.5 ml concentrated solution take 0.1 ml (2 mg total) PO TID PRN air hunger for up to three days. The Omnicell (automated medication dispensing system used when medication is not otherwise available) indicated on 3/30/22 at 6:42 PM Staff 6 (LPN) and Staff 18 (Former Staff/LPN) pulled one bottle of morphine sulfate 20 mg/ml solution 30 ml for Resident 131. The 3/31/22 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.
- Potential for harm · D2026-01-16 · tag F0604 — failed to not use physical restraints improperly — isolatedEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 a resident was assessed prior to use of a potential restraint for 1 of 1 sampled resident (#17) reviewed for hospice. This placed residents at risk for limited mobility. Findings include: Resident 17 was admitted to the facility in 8/2024 with a diagnosis of dementia. The facility's Enabler Restraint Policy and Procedure revised 10/2022 revealed the facility was to evaluate and routinely review residents prior to the use of enablers or restraints to ensure less restrictive measures were attempted and how the device(s) enabled the resident to function at their highest practical level. An Enabler/Restraint Evaluation and Consent was to be completed prior to implementation of a device to ensure less restrictive measures were attempted and the device enabled a resident to function at their highest practical level. Resident 17's 8/12/25 Annual MDS revealed she/he had severe dementia and was a severe fall risk. The assessment indicated Resident 17's behaviors and memory were becoming worse.…
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.
- Potential for harm · Dcited before2026-01-16 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 a resident was assisted to with grooming for 1 of 2 sampled residents (#5) reviewed for ADLs. This placed residents at risk for unmet grooming care needs. Findings include: Resident 5 was admitted to the facility in 11/2022 with a diagnosis of pain. Resident 5's 11/14/25 Annual MDS revealed she/he had severe dementia; it was important to her/him to make choices about bathing and required extensive assistance of one staff for hygiene. Resident 5's current Care Plan indicated she/he required extensive assistance by one staff with personal hygiene. The facility's 11/21/25 shower schedule revealed Resident 5 was to be showered on Mondays and Thursdays. Resident 5's 1/12/26 Skin Monitoring: Comprehensive CNA Shower Review Sheet revealed Staff 9 (CNA) assisted the resident with a shower on 1/12/26. On 1/12/26 at 1:33 PM and 1/13/26 at 12:56 PM, Resident 5 was observed to have long facial hair. Resident 5 stated she /he preferred to shave daily but staff did not offer to assist her/him. 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.
- Potential for harm · D2026-01-16 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
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 assessed and preferred activities were provided for 2 of 2 sampled residents (#s 2 and 17) reviewed for activities. This placed residents at risk for decreased quality of life. Findings include: 1. Resident 2 was admitted to the facility in 12/2025 with diagnoses including orthopedic surgery aftercare, PTSD (Post-Traumatic Stress Disorder), and depressive episodes. Resident 2's Activities Initial Review dated 12/8/25 indicated Resident 2 played games on her/his phone and it was very important for the resident to get outside and get fresh air when the weather was good. The 12/9/25 admission MDS indicated Resident 2 had a BIMS assessment score of 14 (cognitively intact) and the resident required extensive assistance by staff to maneuver in her/his wheelchair due to weakness and poor coordination. The 1/12/26 revised Care Plan indicated Resident 2 was at risk for little or no activity due to her/his right rotator cuff repair and staff was to provide in-room visits and one on one…
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.
- Potential for harm · Dcited before2026-01-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 ensure fall interventions were followed and ensured medications were not left at a resident's bedside for 3 of 5 sampled residents (#s 5, 8, and 17) reviewed for accidents, hospice and ADLs. Findings include: 1. Resident 17 was admitted to the facility in 8/2024 with a diagnosis of dementia. Resident 17's 8/10/25 Annual MDS revealed she/he had severe dementia, received hospice services, required extensive assistance with propelling a wheelchair, and was assessed to be a severe fall risk. Resident 17 had falls while residing in the facility. Resident 17's Care Plan revised on 9/20/24 revealed she/he was not to be left unattended while in a wheelchair related to elopement risk and high risk for falls related to self-transferring. Resident 17's 12/2025 MAR revealed she/he had PRN orders for the following pain medications: -Tylenol (over the counter pain medication) and was administered zero doses. -Morphine Sulfate (narcotic pain medication) and was administered zero doses. -Oxycodone (narcotic…
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.
- Potential for harm · D2026-01-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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 observation, interview, and record review it was determined the facility failed administer oxygen for 1 of 1 sampled resident (# 26) reviewed for respiratory care. This placed residents at risk for respiratory distress. Findings include: Resident 26 admitted to the facility in 6/2025 with diagnoses including hypoxemia (low levels of oxygen), acute respiratory distress (severe difficulty breathing due to lack of oxygen) and was on hospice. The 10/28/25 Care Plan revealed Resident 26 required 2-3 litters of continuous oxygen. The 11/18/25 Physician Order instructed staff to deliver 2 litters of oxygen per minute for comfort. On 1/12/26 at 11:02 AM, Resident 26 was observed seated in her/his wheelchair and was not interviewable. Resident 26's oxygen tubing was positioned along the side of the resident's face. Resident 26's portable oxygen tank gauge was observed in the red, indicating the tank was empty. On 1/12/26 at 12:37 PM, Resident 26's portable oxygen tank gauge was observed in the red, indicating the tank was empty. On 1/12/26 at 1:32 PM, Resident 26 remained seated 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.
- Potential for harm · Dcited before2026-01-16 · tag F0699 — isolatedProvide 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 implement trauma informed care interventions for 1 of 5 sampled residents (#2) reviewed for medications. This place residents at risk for re-traumatization. Findings include:Resident 2 was admitted to the facility in 12/2025 with diagnoses including PTSD (Post-Traumatic Stress Disorder) and depressive episodes. The 12/9/25 admission MDS indicated Resident 2 had a BIMS assessment score of 14 (cognitively intact) and she/he received an antidepressant for mood and sleep. A 12/26/25 Encounter Note indicated Resident 2 recently had an episode of nightmares when she/he was choking a person and woke up from sleep acting out the dream. Resident 2 was concerned about the nightmare because she/he received medication for sleep. Review of Resident 2's clinical record revealed no assessment or care plan interventions related to her/his PTSD. On 1/14/26 at 8:38 AM, Resident 2 acknowledged there was danger for staff if she/he was woken from sleep because of her/his PTSD. On 1/14/26 at 11:35 PM, Staff 6 (RN) stated he 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.
- Potential for harm · E2024-08-16 · tag F0727 — failed to provide required RN coverage — patternHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
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 staff a registered nurse for eight consecutive hours per day seven days per week for nine out of 60 days reviewed for staffing. This placed residents at risk for unmet assessment needs. Findings include: A review of the Direct Care Staff Daily Reports and payroll records dated 2/1/24 through 3/31/24 revealed nine days without eight consecutive hours of registered nurse coverage on any shift in a 24 hour period. On 8/15/24 at 12:04 PM and 8/16/24 at 10:32 AM Staff 1 (Administrator) confirmed on the dates of 2/3/24, 2/10/24, 2/17/24, 2/24/24, 3/2/24, 3/9/24, 3/16/24, 3/23/24 and 3/30/24 there were no RNs in the building as required and a corrective action plan was in place since 4/1/24 to address RN staffing. On 8/19/24 at 3:24 PM Staff 1 provided the following written documentation of the corrective action: an 4/1/24 short-term action plan was implemented to ensure RNs reallocated their hours to ensure the requirements for RN coverage was met until new RNs were hired and trained. The committee…
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.
- Potential for harm · E2024-08-16 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview review it was determined the facility failed to follow therapeutic diets for 1 of 1 kitchen. This placed residents at risk for lack of nutritional interventions. Findings include: On 8/15/24 at 11:06 AM Staff 14 (Cook) was observed to prepare lunch for residents and did not utilize recipes or therapeutic diet spread sheets for portion control or meal substitution for any resident who received a therapeutic diet. Staff 14 stated she had no training on the use of diet spread sheets since she was hired almost a year ago. Staff 14 also stated when a NEM (Nutritionally Enhanced Meal) was ordered for a resident, their foods were not nutritionally enhanced but rather nutritional supplements were ordered by the RD and provided. Staff 13 (Dietary Manager) stated any recipe used in the kitchen was obtained through a generic search of the Internet since no recipes were provided by the facility. On 8/15/24 at 11:16 AM and 12:16 PM Staff 15 (RD) stated her audits of the facility kitchen did not include verification that diet spread sheets and system recipes…
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.
- Potential for harm · D2024-08-16 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
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 call lights were in reach for 1 of 3 sampled residents (#287) reviewed for environment. This placed residents at risk for unaddressed individual needs. Findings include: Resident 287 was admitted to the facility in 8/2024 with diagnoses including palliative care and diabetes. A 8/5/24 care plan indicated staff were to respond immediately to Resident 287's need for pain relief. On 8/13/24 at 1:45 PM Resident 287 was observed in bed and her/his call light was not within reach. On 8/13/24 at 2:11 PM Staff 35 (CNA) stated she neglected to ensure Resident 287's call light was within reach after she provided her/his care around noon. On 8/14/24 11:37 AM Staff 4 (RNCM) stated Resident 287 was able to use her/his call light and expected the resident's call light would be within reach when she/he was alone in her/his room. Staff 4 stated staff would be re-educated to ensure Resident 287's call light was within reach. On 8/15/24 at 2:09 PM Resident 287 was observed in bed and her/his call light was not within…
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.
- Potential for harm · D2024-08-16 · tag F0585 — failed to handle grievances — isolatedHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 address a grievance for 1 of 4 sampled residents (#20) reviewed for ADLs. This placed residents at risk for unresolved grievances. Findings include: Resident 20 admitted to the facility in 6/2021 with a diagnosis of a stroke. A 11/20/23 Interdisciplinary Conference form revealed Resident 20 reported she/he requested assistance from a CNA and the CNA refused to assist. The form indicated the resident care manager was to follow up with the concern. On 8/15/24 at 8:35 AM Staff 9 (Social Services Director) stated if a resident voiced a concern at a care conference staff were to follow-up with the concern. Staff 9 stated Staff 28 (Staffing) was to review the schedule and determine the CNA who worked with the resident. Staff 9 stated she maintained all the grievances and she did not have a grievance for Resident 20's 11/20/23 concern. On 8/15/24 at 9:47 AM Staff 28 stated if a resident voiced a concern a grievance was to be initiated. Depending on the situation, she or nursing staff would address the 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.
Show the remaining 18 citations
- Potential for harm · Dcited before2024-08-16 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 allegations of abuse were reported to administration for 1 of 5 sampled residents (#85) reviewed for accidents. This placed residents at risk for abuse. Findings include: Resident 85 admitted to the facility in 1/2013 with a diagnosis of stroke. A 7/31/23 Progress Noted by Staff 20 (Agency LPN) revealed the nurse on the previous shift (not identified) reported she may have placed the suction tip too far into the resident's throat to suction secretions and blood was observed in the suction tubing. On 9/23/24 Witness 2 (Complainant) reported to the state agency facility staff were aware of an incident when a CNA held Resident 85's hands down in order for the nurse to suction the resident's secretions. On 8/13/24 at 5:40 PM Staff 32 (Former CNA) stated she heard another CNA held down Resident 85's hand while the nurse suctioned the resident. On 8/13/24 at 6:07 PM Witness 4 (Anonymous Staff) stated she was aware of a situation when the night nurse had a CNA hold down Resident 85's hand so the nurse…
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.
- Potential for harm · D2024-08-16 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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 person-centered care plan for 1 of 1 sampled resident (#30) reviewed for tube feeding. This placed residents at risk for lack of identified needs. Findings include: Resident 30 admitted to the facility in 3/15/24 with diagnoses including brain damage, quadriplegia (paralysis of all four extremities), and a feeding tube. An 3/15/24 Care Plan indicated the following for Resident 30: -Toilet use: the resident was independent or had toileting deficits due to quadriplegia and brain damage. The interventions included toilet use, dependant on one staff. Resident 30 was incontinent and did not use the toilet. -Bowel incontinence: the resident will have less than two episodes of incontinence per day. Assess pattern of incontinence and indicate toileting schedule if indicated. -Transfers: the resident was independent or had transferring performance deficits due to quadriplegia and brain damage. Interventions were three or more staff assistance with slide transfer to bed and wheelchair. Resident 30 used 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.
- Potential for harm · Dcited before2024-08-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 suction a resident safely, and failed to follow diabetic orders for 2 of 9 sampled residents (#s 7 and 85) reviewed for accidents and medications. This placed residents at risk for injury and delayed treatment. Findings include: 1. Resident 7 admitted to the facility in 7/2020 with a diagnosis of diabetes. A 7/2024 Diabetic Administration Record (DAR) revealed staff were to implement the hypoglycemic protocol (provide juice, sugar or medication to increase a resident's low blood sugar level) if Resident 7's CBG level was less than 60. The DAR revealed on 7/16/24 at 7:00 AM Resident 7's CBG was 48. The Diabetic Administration Record did not indicate the hypoglycemic protocol was implemented. A 7/16/23 Progress Note contained no information staff provided interventions when Resident 7's CBG level was 48. On 8/1/24 at 9:09 AM Staff 4 (RNCM) stated if a CBG level was less than 60 staff should have provided interventions, re-checked the CBG level after interventions were provided, and documented 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.
- Potential for harm · Dcited before2024-08-16 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 accurately assess, investigate, and care plan pressure ulcers for 3 of 4 sampled residents (#s 15, 27 and 28) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers. Findings include: A Skin at Risk Program Overview Policy revised on 4/2018 revealed the following: -Residents who enter the facility without a significant wound do not develop wounds unless their clinical condition demonstrates the wound was unavoidable. -The initial ulcer assessment will be initiated for each new ulcer (pressure, venous stasis, arterial or diabetic) identified, and wound monitoring order added to the resident treatment record as appropriate. -Pressure ulcers will be reviewed weekly during wound rounds. -Weekly measurements for pressure ulcers will be documented on the weekly ulcer evaluation following completion of the initial ulcer assessment. Documentation includes length, width, depth, undermining,…
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.
- Potential for harm · Dcited before2024-08-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 followed the care plan related to fall safety and ascertain post-fall injuries for 2 of 4 sampled residents (#s 10 and 26) reviewed for accidents. This placed resident placed at risk for lack of supervision and falls. Findings include: 1. Resident 26 admitted to the facility in 9/2022 with a diagnosis of a stroke. a. A Fall investigation dated 5/14/24 revealed Resident 26 had an unwitnessed fall on 5/14/24 at 12:35 AM. Progress Notes from 5/14/24 to 6/4/24 revealed the following: -5/14/24 Resident 26 fell and neurological assessments were initiated. -5/15/24 Resident 26 was assessed to not have an injury from her/his fall. There were no additional post fall assessments after 5/15/24. A Neurological Check form (assessment for head injury) initiated 5/14/24 revealed staff were to assess Resident 26 every 15 minutes for one hour, every one hour for four hours, every four hours for 16 hours, and every eight hours for 24 hours, a total of 19 assessments. The assessment included vital signs, pupil…
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.
- Potential for harm · Dcited before2024-08-16 · tag F0699 — isolatedProvide 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 observation, interview and record review it was determined the facility failed to assess and implement trauma informed care interventions for 1 of 5 sampled residents (#15) reviewed for medications. This placed residents at risk for re-traumatization. Findings include: Resident 15 admitted to the facility in 12/2023 with diagnoses including PTSD (Post Traumatic Stress Disorder) and anxiety. A 12/22/23 Psychosocial History and Discharge Plan assessment indicated Resident 15 had no trauma, mood or behavior issues. A 7/18/24 revised care plan indicated staff were to notify Staff 9 (Social Services Director) with changes in mood or behaviors and Resident 15's psychosocial well-being problem was related to a recent hospitalization (in 2023). No focus or interventions related to Resident 15's PTSD were found. On 8/12/24 11:30 AM and 1:18 PM Resident 15 was observed in bed sleeping with the door open and no blankets or clothing were observed to cover her/him. On 8/13/24 at 9:34 AM Resident 15 was observed in bed sleeping. Staff 6 (RN) stated Resident 15 usually was awake most of…
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.
- Potential for harm · D2024-08-16 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 side effects of psychotropic medications for 1 of 5 sampled residents (#7) reviewed for medications. This placed residents at risk for adverse medication reactions. Findings include: Resident 7 was admitted to the facility in 5/2017 with chronic mental health diagnoses. Resident 7's 7/2024 and 8/2024 MARs and TARs revealed she/he was administered scheduled olanzapine (antipsychotic), valproic acid (mood stabilizer), and clonazepam (treats anxiety). There was no indication the side effects of the psychotropic medications were monitored. On 8/14/24 at 10:01 AM Staff 3 (LPN) stated staff were to document on the TAR if a resident had side effects of psychotropic medications. If there were side effects staff were also to document in the Progress Notes. On 8/14/24 at 2:15 PM Staff 4 (RNCM) stated the psychotropic medication side effects were to be entered as a scheduled nursing task. Staff 4 stated the order was entered as PRN and therefore the system did not alert staff to monitor and document if 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.
- Potential for harm · D2024-08-16 · tag F0883 — failed to offer flu and pneumonia vaccines — isolatedDevelop and implement policies and procedures for flu and pneumonia vaccinations.
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 flu and pneumonia vaccines were provided for 2 of 5 sampled residents (#s 7 and 15) reviewed for immunizations. This placed residents at risk for respiratory infections. Findings include: 1. Resident 7 admitted to the facility in 4/2017 with a diagnosis of diabetes. A Consent For Annual Flu, Pneumonia, and Covid Vaccines form revealed on 5/4/24 Resident 7 consented to have a pneumonia vaccine administered. Resident 7's record did not have documentation to indicate she/he received the vaccine. On 8/14/24 at 2:33 PM Staff 30 (IP) verified Resident 7 consented to the pneumonia vaccine but staff did not administer it. 2. Resident 15 admitted to the facility in 12/19/23 with a diagnosis of diabetes. A Consent For Annual Flu, Pneumonia, and Covid Vaccines form revealed on 12/19/23 Resident 15 consented to have a flu vaccine administered. Resident 15's record did not have documentation to indicate she/he received the vaccine. On 8/14/24 at 2:33 PM Staff 30 (IP) verified Resident 15 consented to the flu…
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.
- Potential for harm · E2023-04-07 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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 interview and record review it was determined the facility failed to store food in accordance with professional standards for food service safety and maintain the ice machine for 1 of 1 kitchen reviewed for kitchen safety and cleanliness. This placed residents at risk for contamination. Findings include: 1. On 4/3/23 at 12:35 PM during the initial tour of the facility's kitchen, the refrigerator was observed to contain the following: - an undated bag of shredded lettuce - an undated bag of carrots - two packages of undated wrapped swiss cheese - a container four cooked chicken thighs, undated - a bag of undated raw broccoli - a container of strawberries, undated - a container of pineapple spears, undated - a large container of homemade red Jell-O, undated On 4/3/23 at 12:44 PM Staff 16 (Dietary Manager) confirmed the identified items were undated and/or opened to air. 2. On 4/3/23 at 12:30 PM and 4/7/23 at 8:55 AM the inside of the ice machine was observed to have a black mildew substance across the trim of the plastic ice dispenser. The ice was observed to be filled to 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.
- Potential for harm · E2023-04-07 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
1. Based on observation, interview, and record review, it was determined the facility failed to ensure staff followed proper infection control guidelines when using common use glucometers (a device used to obtain blood glucose levels) for 1 of 1 observation during CBG tests. This placed residents at risk for infection. Findings include: The undated cleaning and disinfecting procedure for the glucometer indicated it should be cleaned and disinfected between each patient with EPA approved wipes. On 4/6/23 at 12:01 PM Staff 12 (LPN) was observed to complete a CBG on Resident 26. On 4/6/23 at 12:03 PM Staff 12 returned to the medication cart and cleaned the glucometer with an alcohol wipe. Staff 12 did not complete additional CBGs. Staff 12 stated she used alcohol wipes or bleach wipes on the glucometer, whichever was available at the time. Staff 12 was unaware she needed to use EPA approved wipes on the glucometer. On 4/6/23 at 12:54 PM Staff 2 (DNS) acknowledged alcohol wipes were not an approved EPA wipe to clean the glucometer and acknowledged Staff 12 did not use an EPA approved…
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.
- Potential for harm · D2023-04-07 · tag F0553 — failed to let residents help plan their care — isolatedAllow resident to participate in the development and implementation of his or her person-centered plan of care.
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 offer residents and representatives the opportunity to participate in the care planning process for 1 of 1 sampled resident (#2) reviewed for care planning. This placed residents at risk for unmet needs. Findings include: Resident 2 was admitted to the facility in 10/2022 with diagnoses including stroke and dementia. On 4/3/23 at 2:27 PM Witness 4 (Family Member) stated she had not been invited to a care conference recently. On 4/4/23 Resident 2's medical record was reviewed and revealed a care conference was completed on 10/20/22. There was no indication an additional care conference was held between 10/20/22 and 4/4/23. On 4/4/23 at 1:09 PM Staff 3 (Social Services Director) stated Resident 2 did not have a care conference since October of 2022. She stated the resident was discharged from therapy, currently received hospice services and did not trigger for a care conference. On 4/4/23 at 2:06 PM Staff 2 (DNS) acknowledged 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.
- Potential for harm · Dcited before2023-04-07 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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 report allegations of neglect to the State Agency within the required timeframe for 2 of 7 sampled residents (#s 82 and 131) reviewed for resident safety and medications. This placed residents at risk for abuse. Findings include: 1. Resident 82 admitted to the facility in 2021 with diagnoses including quadriplegia and critical illness myopathy (severe slowing of the muscles). A 7/8/22 facility investigation for alleged neglect indicated Resident 82 called Staff 9 (Resident Care Manager LPN) on her personal phone and was gagging. Staff 9 drove to the facility and found Staff 8 (Former LPN) sleeping at the nurses station. Resident 82 was found to be vomiting due to a side effect of an IV (intravenous) infusion. Staff 8 was alleged to have failed to administer Resident 82 with medication due to vomiting. The FRI was received by the State Survey Agency on 7/25/22 at 5:37 PM (17 days after the incident occurred). On 4/6/23 at 10:13 AM Staff…
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.
- Potential for harm · D2023-04-07 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
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 complete a thorough investigation for 2 of 7 sampled residents (#s 82 and 131) reviewed for resident safety and medications. This placed residents at risk for abuse. Findings include: 1. Resident 131 admitted to the facility on [DATE] with diagnoses including femur fracture. A 4/13/22 facility investigation and FRI indicated on 3/30/22 an incorrect dosage of morphine concentrate liquid (opioid pain medication) was administered to Resident 131 which resulted in a higher than prescribed dose. The provider was contacted and the resident was transferred the emergency department via EMS. Emergency department records indicated the resident became drowsy in the ambulance and 2 mg of Narcan (opioid antidote) was administered. The root cause indicated two nurses removed the morphine from the emergency medication machine but the order was not updated in the record. The investigation indicated the following staff were involved or were witnesses…
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.
- Potential for harm · Dcited before2023-04-07 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide 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 interview and record review it was determined the facility failed to provide bathing assistance for 1 of 4 sampled residents (#19) reviewed for ADLs. This placed residents at risk for lack of cleaniness. Findings include: Resident 19 admitted to the facility in 2022 with diagnoses including weakness and heart failure. The 11/1/22 care plan indicated Resident 19 required assistance with showers. Resident 19's shower records indicated showers were scheduled every Monday and Thursday evening. The shower records revealed the following: - From 11/11/22 through 11/19/22 not applicable was documented with no further documentation noted. The resident did not receive a shower until 11/22/22 (14 days since last documented shower on 11/7/22). - From 1/3/23 through 1/10/23 not applicable was documented with no further documentation noted. - From 1/18/23 through 1/25/23 not applicable was documented with no further documentation noted. - From 2/11/23 through 2/16/23 not applicable was documented with no further documentation noted. The next scheduled shower day on 2/20/23 was not…
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.
- Potential for harm · Dcited before2023-04-07 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 1 sampled resident (#82) reviewed for resident safety. This placed residents at risk for not receiving medications as ordered. Findings include: Resident 82 admitted to the facility in 2021 and discharged [DATE] with diagnoses including quadriplegia and critical illness myopathy (severe slowing of the muscles). A 7/7/22 physician progress note indicated Resident 82 was experiencing nausea and vomiting following a IVIG infusion (therapy treatment used for antibody deficiencies). A 7/7/22 physician order indicated the resident was to receive Zofran (anti-nausea medication) every four hours as needed for nausea/vomiting. The 7/2022 MAR indicated Resident 82 received Zofran on 7/7/22 at 8:28 PM. The next dose was not documented as administered until 7/8/22 at 7:49 AM. A facility incident report indicated on early morning of 7/8/22 Resident 82 who is alert and oriented, called Staff 9 (Resident Care Manager…
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.
- Potential for harm · Dcited before2023-04-07 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 obtain treatment orders for a pressure ulcer for 1 of 1 sampled resident (#83) reviewed for pressure ulcers. This placed residents at risk for delayed wound treatment. Findings include: Resident 83 admitted to the facility on [DATE] with diagnoses including heart failure, respiratory failure and depression. Review of Resident 83's skin assessments revealed the following: -3/27/23 admission assessment indicated Resident admitted with a 2.5 cm x 1 cm stage 2 pressure ulcer on the lower back area. The wound was cleaned well and Optifoam was placed. - 3/29/23 stage 2 wound on lower back measured 2 cm x 1 cm x 2 cm. Wound was cleansed with wound cleanser, dried and Opifoam was placed. -4/3/23 wound measured 2 cm x 1 cm. Wound was cleaned well and placed Optifoam to cover. Review of Resident 83's progress notes revealed the following: - 3/27/23 pressure ulcer to lower back measured 2 cm x 1 cm, cleaned well and Optifoam was placed. - 3/28/23…
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.
- Potential for harm · D2023-04-07 · tag F0730 — isolatedObserve 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 3 sampled CNA staff (#s 13 and 14) reviewed for staffing. This placed residents at risk for a lack of competent staff. Findings include: On 4/6/23 at 10:18 AM Staff 1 (Administrator) was asked for the annual performance reviews for Staff 13 (CNA) and Staff 14 (CNA). Employee performance reviews indicated the following: -Staff 13 was hired 10/2006 and the last performance review was completed in 10/2020; -Staff 14 was hired 7/2013 and the last performance review was completed in 7/2020. On 4/6/23 at 2:41 PM Staff 2 (DNS) acknowledged the last performance review for Staff 13 was completed in 10/2020, the last performance review for Staff 14 was completed in 7/2020 and annual performance reviews were not completed.
- Potential for harm · D2023-04-07 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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 — the official record, unedited, may be distressing
Based on interview and record review it was determined the facility failed to respond to pharmacy recommendations timely for 1 of 6 sampled residents (#2) reviewed for medications. This placed residents at risk for adverse medication side effects. Findings include: Resident 2 was admitted to the facility in 10/2022 with diagnoses including stroke and dementia. The 3/15/23 pharmacy recommendation indicated Resident 2 received haloperidol (antipsychotic medication) 0.5 mg QID (four times daily) and the IDT (Interdisciplinary Team) stated the resident currently had no behavior and to reduce her/his haloperidol to 0.5 mg TID. On 4/6/23 there was no indication in the clinical record to indicate the pharmacy recommendation was reviewed or signed by the physician. On 4/6/23 at 9:31 AM and 9:44 AM Staff 11 (LPN Resident Care Manager) stated the recommendation for Resident 2's haloperidol was faxed to the hospice physician and the facility did not receive a response. On 4/6/23 at 1:17 PM Staff 2 (DNS) acknowledged follow up for the 3/15/23 pharmacy recommendation was not received timely.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.9 | +1.1 vs chain |
| Health inspection | 4 of 5 | 3.7 | +0.3 vs chain |
| Staffing | 5 of 5 | 4.0 | +1.0 vs chain |
| Quality measures | 5 of 5 | 3.6 | +1.4 vs chain |
The other 26 homes this chain runs (chain average 3.9★, per CMS)
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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BD FACILITIES LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 03/01/2019 |
| REGENCY PACIFIC MANAGEMENT LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/01/2010 |
| BEDDOE, MARVIN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2016 |
| RAPP, ANDREW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 03/08/2016 |
| STAUFFER, GRETCHEN | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/16/2022 |
| SUAREZ, YOLANDA | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 02/01/2026 |
| OMNICARE LLC | Organization | ADP OF THE SNF | — | since 09/01/2013 |
| BEDDOE, SANDRA | Individual | ADP OF THE SNF | — | since 06/01/2016 |
CMS files one row per role, so the 14 rows in the source record cover these 8 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.
This home reported $386K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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
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
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.
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 385230. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-16, 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.