Regency Care of Central Oregon

Inspectors wroteBased on observation and interview it was determined the facility failed to handle and serve food in a sanitary manner in 1 of 1 kitchen. This placed residents at risk for potential exposure to food borne illness.

Inspectors wroteBased on interview and record review it was determined the facility failed to offer the COVID-19 vaccination 2025 booster to 4 of 5 sampled residents (#s 2, 7, 6, and 19) reviewed for immunizations. This placed residents at risk to contracting COVID 19.

Inspectors wroteBased on interview and record review, the facility failed to document a stop date for provision of PRN psychotropic medication beyond 14 days from start of the medication and failed to document clinical rationale for continuation of psychotropic medications without gradual dose reduction for 2 of 5 sampled residents (#s 6 and 7) reviewed for medications. This placed residents at risk for overmedication.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's physician acted upon pharmacy recommendations timely for 1 of 5 sampled residents (#5) reviewed for medications. This placed residents at risk for an adverse medication regimen.

Inspectors wroteBased on interview and record review it was determined the facility failed to follow CDC guidelines for pneumococcal immunizations for 1 of 5 sampled residents (#19) reviewed for immunizations. This placed residents at risk for adverse side effects to immunizations. Findings Include:Resident 19 was admitted to the facility in 5/2021 with diagnoses including heart failure. A review of Resident 19's immunizations revealed she/he received a Prevnar 20 vaccine (a vaccine for pneumonia) on 8/11/24 and 9/16/24. On 12/4/25 at 12:50 PM Staff IP (LPN Infection Preventionist) stated the CDC recommendation was for Resident 19 receive a single dose of Prevnar 20 and she was unsure why Resident 19 received two doses of Prevnar 20. Staff IP acknowledged Resident 19 should have received only one dose of Prevnar 20.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide a homelike environment for 15 of 32 sampled resident rooms observed for homelike environment. This placed residents at risk for unhomelike environment.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure respiratory equipment was maintained for 1 of 2 sampled residents (#5) reviewed for respiratory care. This placed residents at risk for increased risk for respiratory concerns.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure call lights and call light cords were in good repair and operative for 3 of 5 sampled residents (#s 11,12 and 16) reviewed for environment. This placed residents at risk for unmet needs.

Inspectors wroteBased on observation and interview it was determined the facility failed to maintain a homelike environment for 3 of 3 halls reviewed for environment. This placed residents at risk for a non-homelike environment.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure meals were palatable and attractive for for 2 of 2 residents (#s 2 and 13) reviewed for food palatability. This placed residents at risk for unmet nutritional needs.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to properly store resident food for 1 of 1 resident snack refrigerators reviewed for food quality. This placed residents at risk for unmet nutritional needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to protect the residents' rights to be free from physical abuse by Staff 13 or another resident for 2 of 2 sampled residents (#s 25 and 34) reviewed for physical abuse. This placed residents at risk for being physically abused.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to accurately assess the presence of a colostomy for 1 of 1 sampled resident (#16) reviewed for constipation. This placed the resident at risk for unmet colostomy (opening into the colon from the outside of the body providing new path for waste to leave the body) care needs.

Inspectors wroteBased on interview and record review it was determined the facility failed to maintain professional standards of practice related to abuse by Staff 23 (LPN) and ensure residents were free from unecessary medications and significant medication errors by Staff 9 (LPN), Staff 24 (RN) and Staff 25 (RN) for 3 of 8 sampled residents (#s 7, 8 and 25) reviewed for pharmaceutical services and abuse. This placed residents at risk for unsafe medication administration and additional abuse.

Inspectors wroteBased on interview and record review it was determined the facility failed to maintain the appropriate care and services to maintain, restore or improve functional ability for 1 of 1 sampled resident (#17) reviewed for ADL's. This placed residents at risk for decreased functional ability.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure nail care was provided for 1 of 1 sampled resident (#185) reviewed for provision of nail care. This placed residents at risk for lack of nail care.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide services to prevent further decrease in ROM and mobility for 1 of 3 sampled residents (#12) reviewed for position and mobility. This placed residents at risk of loss of mobility, ROM and painful contractures.

Inspectors wroteBased on interview and record review it was determine the facility failed to ensure care planned interventions were followed for 1 of 2 sampled residents (#18) reviewed for falls. This placed residents at risk for falls.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the resident was free from unecessary medications for 1 of 5 sampled residents (#7) reviewed for safe medication system. This placed residents at risk for adverse medication consequences.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the resident was free of significant medication errors for 1 of 5 sampled residents (#8) reviewed for safe medication system. This placed residents at risk for adverse medication consequences.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure accurate medical records for bowel care for 1 of 5 sampled residents (#29) reviewed for unnecessary medications. This placed residents at risk for unmet bowel interventions.

Inspectors wroteBased on observation and interview it was determined the facility failed to maintain the laundry room floor in a safe and sanitary condition for 1 of 1 laundry rooms reviewed for infection control. This created a risk for infection control concerns.