Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Rogue Valley during CMS and state inspections, most recent first.
Failure to provide required bed-hold and discharge documentation for two residents. One resident with muscle weakness and stroke left for an appt, later stayed out overnight, and staff did not call the spouse, provide discharge paperwork, or offer a bed hold before treating the absence as AMA and discharging the resident. Another resident with respiratory failure and kidney disease was transferred to the hospital after severe respiratory decline, but the resident/POA was not offered a bed hold or given the required information.
The facility failed to maintain safe water temperatures, with two residents experiencing excessively hot water in their rooms, posing a risk for burns. Despite weekly checks, the Maintenance Director had not been informed of any concerns, yet temperatures were recorded at 125 and 126 degrees Fahrenheit.
The facility failed to address residents' concerns about cold food, as observed during a Resident Council meeting and through interviews. Residents reported that staff were not allowed to reheat food, and the Dietary Manager confirmed that food handled by residents could not be reheated due to cross-contamination risks. Despite having an additional meal available, the facility did not ensure food was served at an appetizing temperature, leading to dissatisfaction among residents with chronic conditions and nutritional needs.
A resident with paralysis and cognitive impairment expressed the importance of choosing activities, preferring pet interaction and reading. Despite a care plan addressing activity involvement risks, the resident received minimal 1:1 activities and no reading materials. Observations showed the resident often in bed with closed blinds, lacking engagement. Staff acknowledged infrequent pet visits and the availability of an unused audible book player, highlighting the facility's failure to provide meaningful activities.
A resident with dementia and a history of MASD developed a Stage 3 pressure ulcer on the coccyx. Despite worsening conditions and new red spots indicating potential Stage 1 ulcers, the facility failed to revise the treatment plan. Staff focused on the original wound, neglecting the deteriorating surrounding skin, leading to a significant increase in wound size due to adhesive irritation.
A facility failed to implement a recommended RA program for a resident with paralysis, leading to a lack of documented care for maintaining ROM and mobility. Despite a PT discharge summary recommending the program, it was not included in the care plan, and staff interviews revealed a lack of communication and follow-through.
A resident with a history of stroke experienced delays in receiving prescribed respiratory care and diagnostic results. A PRN nebulizer was ordered by an NP for shortness of breath but was not started until two days later. Additionally, a chest x-ray ordered due to chest pain was completed but not received by the facility until over two weeks later. An RN acknowledged the delays but was unsure of the reasons.
A facility failed to monitor a resident's thyroid hormone levels after administering Synthroid, a medication to increase thyroid levels. The resident, admitted with obesity, had their last TSH test in November 2022, which was within the therapeutic range. However, no further TSH tests were documented, despite staff indicating that such tests were usually conducted annually. This oversight placed the resident at risk for a non-therapeutic medication regimen.
A resident with depression was not informed of changes to their medication regimen, resulting in a lack of informed consent. The resident, who was cognitively intact, had their antidepressant dosages reduced without their knowledge. Despite a provider note indicating no unaddressed concerns, there was no documentation of notification in the resident's chart, which was confirmed by the Social Services Director.
Failure to Provide Bed-Hold and Discharge Documentation
Penalty
Summary
The facility failed to provide required communication and documentation related to hospitalization, discharge, and bed-hold rights for 2 of 3 sampled residents, Resident 49 and Resident 51. The facility’s 8/2024 Bed Hold Policy and Agreement Form stated that a resident temporarily absent because of a hospitalization or leave of absence could apply for a bed hold, and that the discharging nurse would give the resident and representative a copy of the Bed Hold Policy and Agreement at the time of discharge to the hospital. Resident 51, admitted with diagnoses including muscle weakness and stroke, left the facility for a physician appointment and later went home with a family member. Staff later determined the resident did not return by midnight and treated the absence as an AMA departure, but staff acknowledged they did not call the spouse about the resident’s return, did not send discharge or bed-hold documentation, and did not offer a bed hold. Staff and the Administrator also acknowledged the resident was discharged without notification, without a safe discharge assessment, and that the discharge was unplanned and unsafe. Resident 49, admitted with diagnoses including respiratory failure and kidney disease, was sent to the hospital after a progress note documented oxygen saturation of 52% on room air, labored respirations, and secretions that could not be cleared with suctioning; the family agreed to hospital transfer. Staff and the POA stated the resident was not offered a bed hold, and staff acknowledged no bed-hold information was provided to the resident or POA.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain safe water temperatures for two residents, placing them at risk for burns. Resident 27, who was cognitively intact and admitted with a wedge compression fracture, reported using the sink to wet their hair. Upon testing, the hot water temperature in Resident 27's room was found to be 125 degrees Fahrenheit, which was acknowledged by the Maintenance Director as needing adjustment. Similarly, Resident 88, also cognitively intact and admitted following hip surgery, experienced excessively hot water in their bathroom. The surveyor noted the water was hot to the touch, and the resident confirmed the water was very hot if not adjusted carefully. The Maintenance Director measured the water temperature at 126 degrees Fahrenheit and noted that the hot water heater was located adjacent to Resident 88's bathroom. Despite performing weekly water temperature checks, the Maintenance Director had not received any reports of concerns regarding high water temperatures in resident rooms.
Failure to Address Cold Food Concerns
Penalty
Summary
The facility failed to address concerns regarding proper food temperatures for residents, as observed during a Resident Council meeting and through interviews with staff and residents. During the meeting, a majority of the residents expressed that staff were not allowed to warm or address cold food concerns. The Dietary Manager stated that the kitchen had one additional meal available if a resident requested warmer food, but food handled by a resident could not be reheated due to cross-contamination risks. The Administrator was unaware of reports related to residents' cold food and acknowledged the need for staff education on this issue. Resident 9, who has chronic pain and dementia, was observed eating lunch with frozen strawberries and expressed frustration about staff not addressing cold food issues. Resident 25, with a history of stroke and malnutrition, reported that staff did not reheat meals or beverages, affecting her/his food intake. Staff confirmed that they were not allowed to reheat food once touched by a resident, but the kitchen could provide new servings if requested. Despite complaints from residents, the facility did not have a clear process to ensure food was served at an appetizing temperature, leading to dissatisfaction and potential nutritional concerns.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide a meaningful activity program for a resident who was admitted with a diagnosis of paralysis and was cognitively impaired. The resident expressed that choosing activities was very important, with a preference for interacting with pets and reading. Despite these preferences, the care plan, which was revised, indicated a risk for little activity involvement due to physical and cognitive limitations. The plan included offering group activities, 1:1 visits, and providing reading material. However, the resident preferred self-directed activities and did not want to participate in group activities, with only one 1:1 activity provided in the previous quarter. Observations showed the resident often remained in bed with closed blinds and no engagement in activities like music or television. Staff interviews revealed that the resident did not enjoy television but liked talking and joking. The Activity Supervisor acknowledged the infrequent visits by a volunteer with a dog and the availability of an audible book player, which was not offered to the resident. The resident's activity log indicated participation in independent activities, primarily snacks, with no documented 1:1 visits or reading activities. The resident's family visits were infrequent, and staff noted the resident's blinds were often shut, although occasionally opened upon request. These findings highlight the facility's failure to provide adequate and meaningful activities tailored to the resident's preferences and needs.
Failure to Revise Pressure Ulcer Treatment
Penalty
Summary
The facility failed to properly assess and revise treatments for a pressure ulcer in a resident, leading to a deficiency. The resident, admitted in March 2017 with diagnoses including dementia and failure to thrive, was at risk for pressure ulcers and had recurrent Moisture Associated Skin Damage (MASD). Despite interventions, the resident developed a facility-acquired Stage 3 pressure ulcer on the coccyx. Initial wound care orders included the application of calcium alginate, marathon, and foam dressing. However, the wound deteriorated over time, with the surrounding skin becoming denuded and the wound size increasing significantly due to adhesive irritation. Staff interviews revealed that the wound treatment was not adjusted despite the worsening condition of the surrounding skin. An LPN noted the appearance of new red spots near the wound, indicating potential Stage 1 pressure ulcers, but the RN-Patient Care Coordinator focused solely on the original wound. The Director of Nursing Services acknowledged that the wound should have been assessed as two separate wounds, and a new treatment regimen should have been considered when the surrounding skin began to deteriorate.
Failure to Implement Restorative Assistance Program
Penalty
Summary
The facility failed to provide a restorative assistance (RA) program for a resident who was admitted with a diagnosis of paralysis. The resident, who had impaired cognition and was bed-bound, required assistance with activities of daily living (ADLs) and used a mechanical lift for transfers. A physical therapy discharge summary recommended an RA program to maintain and improve the resident's range of motion (ROM) and mobility, which was crucial to prevent contractures and muscle wasting. However, the care plan did not include this RA program, and there was no documentation in the clinical record indicating its implementation. Interviews with facility staff revealed a lack of communication and follow-through regarding the RA program. The Therapy Director confirmed that an RA program was established but not documented in the RA book. The RA staff member stated he had never worked with the resident, and the RN Patient Care Coordinator mentioned she was not provided with a referral to implement the RA program. The resident had a history of refusing therapy, but there was no evidence that the RA program was re-evaluated or implemented as recommended by the therapy discharge summary.
Delayed Respiratory Care and Diagnostic Results
Penalty
Summary
The facility failed to provide timely respiratory care and ensure diagnostic results were available promptly for a resident with a history of stroke. The resident was assessed by a nurse practitioner (NP) for shortness of breath, and a PRN nebulizer was ordered on October 8, 2024. However, the nebulizer treatment was not initiated until October 10, 2024. Additionally, the resident experienced chest pain with deep breaths on October 11, 2024, leading to an order for a chest x-ray. Despite the x-ray being completed on the same day, the results were not faxed to the facility until October 28, 2024. Staff 4, an RN Patient Care Coordinator, acknowledged the delay in receiving the x-ray results and was unsure why the nebulizer treatment was not started on the day it was prescribed.
Failure to Monitor Thyroid Hormone Levels
Penalty
Summary
The facility failed to monitor a resident's thyroid hormone level, specifically the TSH (thyroid stimulating hormone) test, for a resident who was administered Synthroid to increase thyroid levels. The resident was admitted in August 2021 with a diagnosis of obesity and began receiving Synthroid in October 2021. The last recorded TSH test was conducted in November 2022, and the results were within the therapeutic range. However, no further TSH test results were documented in the resident's clinical record after that date. During interviews, staff indicated that TSH levels were typically checked annually, but no documentation was provided to confirm that this was done for the resident in question. The lack of monitoring placed the resident at risk for a non-therapeutic medication regimen, as there was no evidence of ongoing assessment of the resident's thyroid function after November 2022.
Failure to Notify Resident of Medication Changes
Penalty
Summary
The facility failed to notify a resident prior to changing the administration of their medication, resulting in a lack of informed consent. Resident 139, who was admitted in 2024 with a diagnosis of depression, was cognitively intact according to the Admission MDS. The resident's initial medication orders included Citalopram 60mg and Imipramine 50mg at bedtime. However, a subsequent provider order reduced these dosages to Citalopram 20mg and Imipramine 25mg at bedtime. Despite a provider note indicating that the resident had no unaddressed concerns, there was no documentation in the resident's chart confirming that they were informed of these medication changes. On a later date, Resident 139 expressed that they were unaware of the medication reduction, which had been a successful treatment for their depression for years. This was confirmed by the Social Services Director/Admissions, who verified that there was no additional information in the resident's chart regarding notification of the medication changes.
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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 Grants Pass
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurel Hill Nursing Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Highland House Nursing & Rehabilitation Center | 2.1 mi | ★★★★★ | 17 | 0 |
| Royale Gardens Health & Rehabilitation Center | 2.1 mi | ★★★★★ | 13 | 0 |
| Avamere Health Services Of Rogue Valley | 23.6 mi | ★★★★★ | 0 | 0 |
| Avamere At Three Fountains | 24 mi | ★★★★★ | 5 | 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.