Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regency Care Of Central Oregon during CMS and state inspections, most recent first.
Unsanitary food handling during tray line service. The Dietary Manager wore gloves while touching clean plates, serving utensils, refrigerator doors, beverages, and soft tacos without changing gloves or performing hand hygiene between surfaces. The Dietary Manager also dropped a food thermometer on the floor, picked it up, placed it back on the counter near the steam table, and continued serving without first cleaning hands and changing gloves.
Failure to Offer 2025 COVID-19 Booster to Multiple Residents: The facility failed to offer the COVID-19 vaccine booster to 4 sampled residents with diagnoses including Parkinson's Disease, emphysema, asthma, and heart failure. The LPN IP stated the CDC recommended two COVID-19 boosters for 2025 and that all residents should be offered the vaccine yearly, but there was no documentation that the residents were offered or received the 2025 COVID-19 vaccination.
Psychotropic medication documentation was deficient for two residents. One resident received PRN lorazepam beyond the required 14-day period without a documented stop date, and another resident had lorazepam, escitalopram, and buspirone continued without documented clinical rationale for not reducing the dose or discontinuing the meds, despite a pharmacy consult noting the need for that rationale.
A resident with diabetes had a physician order for Mounjaro, and pharmacy consults recommended increasing the dose. The medical record showed no evidence the provider reviewed the first consult, and the DNS stated the recommendation was reissued because there was no response. The DNS acknowledged the pharmacy recommendation was not followed up on within the required timeframe.
A resident with heart failure received Prevnar 20 twice, even though the LPN Infection Preventionist stated CDC guidance called for only a single dose. The LPN was unsure why the resident received two doses and acknowledged only one dose should have been given.
The facility failed to maintain a homelike environment in 15 resident rooms due to blinds with bent or missing slats. A resident with left-sided hemiplegia reported issues with their blinds, which were confirmed by the Maintenance Director and Administrator. Budget constraints were cited as a reason for not replacing the broken blinds.
A facility failed to maintain respiratory equipment for a resident with COPD who relied on supplemental oxygen. Despite a physician's order for weekly cleaning of the oxygen concentrator filter, it was observed without a filter in place. The resident confirmed using the concentrator, and staff acknowledged the oversight.
Unsanitary Food Handling During Tray Line Service
Penalty
Summary
The facility failed to handle and serve food in a sanitary manner in 1 of 1 kitchen. On 12/3/25, the Dietary Manager prepared resident lunch trays while wearing gloves and touched multiple surfaces, including clean plates, serving utensils, refrigerator doors, beverages, and each soft taco, without changing gloves or performing hand hygiene between touching clean and contaminated surfaces during tray line service. Later that same day, the Dietary Manager dropped a food thermometer on the floor during tray line service, picked it up, placed it on top of the table near the steam table, and then reached for a clean tray to continue service. During an interview on 12/4/25, the Dietary Manager acknowledged failing to complete proper hand hygiene and glove changes after touching equipment and stated she should not have picked up a dropped item from the floor during tray line.
Failure to Offer 2025 COVID-19 Booster to Multiple Residents
Penalty
Summary
The facility failed to offer the COVID-19 vaccination 2025 booster to 4 of 5 sampled residents reviewed for immunizations: Resident 2, Resident 6, Resident 7, and Resident 19. Resident 2 was admitted in 9/2024 with diagnoses including Parkinson's Disease, and the last COVID-19 vaccination documented was on 9/4/24. Resident 6 was admitted in 11/2020 with diagnoses including emphysema, and the last COVID-19 vaccination documented was on 8/11/24. Resident 7 was admitted in 1/2019 with diagnoses including asthma, and the last COVID-19 vaccination offered was on 2/1/24. Resident 19 was admitted in 5/2021 with diagnoses including heart failure, and the last COVID-19 vaccination offered was on 8/11/24. On 12/4/25 at 12:50 PM, the LPN Infection Preventionist stated the CDC recommended two COVID-19 boosters for 2025 and that all residents should be offered the COVID-19 vaccination yearly. The LPN Infection Preventionist acknowledged there was no documentation that Resident 2, Resident 6, Resident 7, or Resident 19 received or were offered the COVID-19 vaccination in 2025.
Psychotropic Medication Documentation Deficiencies
Penalty
Summary
The facility failed to document a stop date for a PRN psychotropic medication beyond 14 days from the start of the medication and failed to document a clinical rationale for continuing psychotropic medications without a gradual dose reduction for 2 of 5 sampled residents. Resident 6 was re-admitted to the facility on 10/24/25 with diagnoses of prostate cancer, falls, and depression. The physician orders from that date included lorazepam PRN with a start date of 10/24/25 and no stop date. The 11/2025 MAR showed Resident 6 received lorazepam once per day for five days after the 14th day of 11/6/25, and the DNS confirmed on 12/5/2025 that lorazepam had been administered PRN for more than 14 days without a documented stop date. Resident 7 was admitted in 1/2019 with diagnoses including anxiety. Orders included lorazepam, escitalopram, and buspirone. A 5/22/25 pharmacy consultation report noted that Resident 7 was taking three psychotropic medications and recommended documentation of the specific rationale for why dose reduction or discontinuation was clinically contraindicated. The report was signed by the provider on 5/27/25, but no rationale was documented in the medical record, and the DNS acknowledged on 2/4/25 that there was no clinical rationale indicated for continuation without dose reduction of the resident's psychotropic medications.
Delayed Response to Pharmacy Recommendation for Diabetes Medication
Penalty
Summary
The facility failed to ensure a resident's physician acted on pharmacy recommendations in a timely manner for Resident 5, who was admitted in 4/2021 with diagnoses including diabetes. A physician order dated 9/2/25 included Mounjaro for diabetes treatment. Pharmacy consultation reports dated 10/16/25 and 11/20/25 both recommended increasing the resident's Mounjaro dose. Review of the medical record showed no evidence that the provider reviewed the 10/16/25 pharmacy consultation report. On 12/4/25 at 10:48 AM, the DNS stated the provider did not respond to the 10/16/25 report, so it was reissued and sent again on 11/20/25, and that pharmacy consultation recommendations must be addressed by the provider within 30 days. The DNS acknowledged the recommendation was not followed up on timely.
Duplicate Prevnar 20 Administration
Penalty
Summary
The facility failed to follow CDC guidelines for pneumococcal immunizations for 1 of 5 sampled residents reviewed for immunizations. Resident 19 was admitted in 5/2021 with diagnoses including heart failure. A review of the resident’s immunization record showed receipt of a Prevnar 20 vaccine on 8/11/24 and again on 9/16/24. During an interview on 12/4/25 at 12:50 PM, the LPN Infection Preventionist stated the CDC recommendation was for Resident 19 to receive a single dose of Prevnar 20 and was unsure why the resident received two doses. The LPN acknowledged the resident should have received only one dose.
Failure to Maintain Homelike Environment Due to Disrepair of Blinds
Penalty
Summary
The facility failed to provide a homelike environment for 15 of 32 sampled resident rooms, as observed on multiple occasions. Rooms 1, 3, 4, 5, 6, 15, 17, 20, 22, 24, 26, 27, 28, 33, and 35 had blinds with bent or missing slats. Resident 30, who was admitted in February 2024 with left-sided hemiplegia and had intact cognition as per the June 2024 Quarterly MDS, reported that the blinds in their room needed replacement due to a stuck cord and bent slats. The Maintenance Director confirmed the issue of broken blinds throughout the facility, citing budget constraints as a reason for not replacing them. The Administrator also confirmed the disrepair of window blinds, contributing to an unhomelike environment.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment for a resident with COPD who was dependent on supplemental oxygen. The resident was admitted in 2017 and was cognitively intact as per the 10/11/23 Annual MDS. A physician's order dated 7/9/24 required the oxygen concentrator filter to be cleaned weekly. However, the Treatment Administration Record (TAR) for September 2024 indicated that the external filter was last cleaned on 9/9/24. On 9/10/24, the oxygen concentrator was observed to be powered on without an external filter, and the resident confirmed using the concentrator while in bed. Staff 6, an RN, stated that the night nurse was responsible for cleaning the filter weekly and ensuring its placement. Staff 3, an RNCM, acknowledged the absence of the filter upon observation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bend
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pilot Butte Rehabilitation Center | 1.3 mi | ★★★★★ | 19 | 0 |
| Bend Transitional Care | 2.2 mi | ★★★★★ | 0 | 0 |
| Regency Redmond Rehabilitation And Nursing Center | 14.9 mi | ★★★★★ | 8 | 0 |
| Regency Prineville Rehabilitation And Nursing Cent | 29.2 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.