Deficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% worse than Oregon average
Oregon average: 6.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 5
Dec 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication management, food safety, immunizations, and COVID-19 vaccination status at Regency Care of Central Oregon.
Findings
The facility was found deficient in documenting stop dates and clinical rationale for psychotropic medications, timely physician response to pharmacy recommendations, sanitary food handling practices, adherence to CDC pneumococcal vaccination guidelines, and offering COVID-19 vaccinations to eligible residents. These deficiencies placed residents at risk for overmedication, adverse medication regimens, foodborne illness, immunization side effects, and COVID-19 infection.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to document a stop date for PRN psychotropic medication beyond 14 days and failed to document clinical rationale for continuation without dose reduction for 2 of 5 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident's physician acted upon pharmacy recommendations timely for 1 of 5 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to handle and serve food in a sanitary manner in 1 of 1 kitchen, including improper glove use and handling of dropped food thermometer. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow CDC guidelines for pneumococcal immunizations for 1 of 5 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to offer the COVID-19 vaccination 2025 booster to 4 of 5 sampled residents and properly document vaccination status. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled for medication review: 5
Residents affected by psychotropic medication deficiency: 2
Residents affected by pharmacy consultation deficiency: 1
Residents affected by food handling deficiency: 1
Residents affected by pneumococcal immunization deficiency: 1
Residents affected by COVID-19 vaccination deficiency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 2 | Director of Nursing Services (DNS) | Confirmed medication administration issues and acknowledged lack of clinical rationale and timely response to pharmacy recommendations |
| Staff 4 | Dietary Manager | Observed failing to change gloves and perform hand hygiene during food service and acknowledged improper handling of dropped thermometer |
| Staff IP | LPN Infection Preventionist | Acknowledged failures in following CDC vaccination guidelines and offering COVID-19 vaccinations |
Inspection Report
Annual Inspection
Deficiencies: 2
Sep 13, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to the facility environment and respiratory care for residents.
Findings
The facility was found to have deficiencies including failure to maintain a homelike environment due to broken blinds in 15 of 32 resident rooms, and failure to ensure respiratory equipment maintenance for one resident, specifically an oxygen concentrator missing its external filter.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to provide a homelike environment for 15 of 32 sampled resident rooms due to blinds with bent or missing slats. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure respiratory equipment was maintained for 1 of 2 sampled residents; oxygen concentrator filter was missing. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 15
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 8 | Maintenance Director | Confirmed blinds in disrepair and ongoing budget issues for replacement |
| Staff 1 | Administrator | Confirmed window blinds in disrepair resulting in unhomelike environment |
| Staff 6 | RN | Stated night nurse was responsible for cleaning oxygen concentrator filter weekly |
| Staff 3 | RNCM | Observed oxygen concentrator missing filter and acknowledged the issue |
Inspection Report
Complaint Investigation
Deficiencies: 8
May 5, 2023
Visit Reason
The inspection was conducted to investigate complaints related to physical abuse, medication errors, failure to provide nail care, fall prevention, feeding tube care, and call light system functionality at Regency Care of Central Oregon.
Findings
The facility was found to have failed in protecting residents from physical abuse, maintaining professional nursing standards, ensuring safe medication administration, providing nail care, preventing falls, administering feeding tube nutrition according to orders, and maintaining a working call light system. Several incidents of abuse and medication errors were substantiated, and care plans were not consistently followed.
Complaint Details
The complaint investigation substantiated incidents of physical abuse involving Staff 13 and Staff 23, medication errors by Staff 9, Staff 24, and Staff 25, failure to provide nail care, failure to follow fall prevention care plans, failure to administer feeding tube nutrition properly, and issues with call light system functionality. Abuse was substantiated for Resident 25 by Staff 23. Medication errors included administration of medication despite high INR levels and administration of wrong medications to Resident 8.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to protect residents from physical abuse by staff or other residents for 2 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain professional nursing standards related to abuse and medication errors for 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide nail care as required for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure care planned interventions were followed to prevent falls for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer enteral feeding according to physician orders for 1 sampled resident with a feeding tube. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were free from unnecessary drugs for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were free from significant medication errors for 1 sampled resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure call lights and call light cords were in good repair and operative for 3 sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Medication dose: 12
INR value: 4.2
BIMS score: 6
BIMS score: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 13 | Named in physical abuse finding involving residents 25 and 34 | |
| Staff 23 | LPN | Gave Resident 25 a suppository without consent; substantiated abuse |
| Staff 9 | LPN | Failed to hold warfarin medication despite high INR |
| Staff 24 | RN | Involved in medication errors with Resident 8 |
| Staff 25 | RN | Involved in medication errors with Resident 8 |
| Staff 16 | CNA | Witnessed physical abuse incident between Residents 4 and 34 |
| Staff 4 | Social Service Director | Recalled and described physical abuse incident between Residents 4 and 34 |
| Staff 1 | Administrator | Acknowledged substantiation of abuse and medication errors |
| Staff 2 | DNS | Acknowledged substantiation of abuse and medication errors; discussed failed communication |
| Staff 5 | Maintenance Director | Reported call light system issues and repairs |
| Staff 17 | Agency CNA | Fed Resident 18 orally against care plan |
| Staff 18 | Former CNA | Failed to elevate head of bed during feeding tube care |
| Staff 11 | CNA | Reported call light issues and resident assistance needs |
| Staff 19 | Former Maintenance Director | Informed Resident 16 about call light repair needs |
Inspection Report
Routine
Deficiencies: 15
May 5, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, safety, medication administration, environment, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain a homelike environment, protect residents from abuse, accurately assess residents, ensure professional nursing standards, maintain functional abilities, provide adequate nail care, prevent falls, ensure safe medication administration, maintain food quality, ensure call light functionality, and maintain a safe and sanitary environment.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to maintain a homelike environment with multiple areas of damage and wear in resident rooms and hallways. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to protect residents from physical abuse by staff and other residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately assess the presence of a colostomy for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain professional nursing standards related to abuse and medication errors. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain or improve functional ability for a resident due to incomplete restorative therapy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide nail care for a resident as required by care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide services to prevent further decrease in range of motion and mobility for a resident with contractures. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure care planned interventions were followed to prevent falls for a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident was free from unnecessary drugs related to anticoagulant medication management. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident was free from significant medication errors related to administration of muscle relaxants to the wrong resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure meals were palatable and attractive, with complaints of bland, cold, and unappetizing food. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly store resident food in snack refrigerators, including expired and spoiled items. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate medical records for bowel care, with inconsistent and inaccurate documentation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure call lights and call light cords were in good repair and operative, placing residents at risk for unmet needs. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain the laundry room floor in a safe and sanitary condition, with missing flooring and an uncovered hole. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Black scuff marks: 20
INR value: 4.2
Medication dose: 12
BIMS score: 6
BIMS score: 5
BIMS score: 15
Dates with no bowel movement: 21
Number of residents with ROM limitation not receiving services: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 5 | Maintenance Director | Acknowledged repairs needed and call light issues |
| Staff 2 | Director of Nursing (DNS) | Acknowledged multiple deficiencies including medication errors and care plan issues |
| Staff 4 | Social Service Director | Interviewed regarding resident abuse incident |
| Staff 9 | Licensed Practical Nurse (LPN) | Involved in medication error with warfarin |
| Staff 23 | Licensed Practical Nurse (LPN) | Substantiated for abuse related to administering suppository without consent |
| Staff 24 | Registered Nurse (RN) | Involved in medication error with muscle relaxants |
| Staff 25 | Registered Nurse (RN) | Involved in medication error with muscle relaxants |
| Staff 21 | Dietary Manager | Acknowledged food complaints and storage issues |
| Staff 16 | Certified Nursing Assistant (CNA) | Witnessed resident abuse incident |
| Staff 1 | Administrator | Acknowledged multiple deficiencies including medication errors and call light issues |
| Staff 7 | Physical Therapist | Confirmed resident contractures and lack of services |
| Staff 11 | Certified Nursing Assistant (CNA) | Commented on call light issues and improvements |
| Staff 22 | Dietary Aide | Provided information on food storage protocol |
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