Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Florence during CMS and state inspections, most recent first.
Incomplete Care Plans for Wound VAC and Behavioral Needs: Two residents had care plans that did not include needed interventions tied to wound VAC care, and one resident’s plan also lacked target behaviors and interventions related to anxiety and depression meds. Staff acknowledged the missing care plan information for the wound and psychotropic-related needs.
Failure to follow ordered skin treatment: A resident with a history of MS and prior cellulitis had a right lower leg venous ulcer that later resolved, but ordered dressing care continued. During an observed treatment, an RN rubbed the resident’s fragile right lower leg skin and called it light debridement before an LPN applied the ordered Xeroform, ABD pad, and Kerlix dressing. The DNS stated this rubbing was not part of the physician-ordered plan of care.
Infection control procedures were not followed during medication administration and wound-related care. An RN entered a resident’s room without hand hygiene, handled the resident’s cup and medications, and returned to the cart and computer without sanitizing hands. A CMA used a pill cutter without sanitizing it afterward and also entered and exited a resident’s room and accessed the med cart and computer without hand hygiene.
The facility failed to provide ordered therapy for a resident with stroke and diabetes, as therapy orders were not received by the OT/Therapy Manager. Another resident with a Stage 4 pressure ulcer and quadriplegia-incomplete was left without incontinence care during the night shift, found soiled in the morning, and their call light was out of reach. An investigation determined that a CNA failed to provide appropriate care.
A facility failed to thoroughly investigate an abuse allegation involving a resident with failure to thrive. An LPN allegedly threatened to administer an extra dose of oxycodone, causing the resident anxiety. The LPN later claimed the extra dose was given to another resident. The investigation lacked witness statements and interviews with involved parties, as acknowledged by the DNS.
A resident admitted with depression received a COVID-19 vaccine without documented informed consent. A review of the medical records months later revealed the absence of a signed consent form, which was confirmed by the DNS during an interview.
A resident admitted with a stroke diagnosis did not have an advance directive documented despite expressing a desire for one during multiple care conferences. The Social Service Director claimed to offer advance directives but did not follow up, and the facility administrator expected staff to ensure follow-up before quarterly care conferences, which was not done.
A resident with heart disease was prescribed Ipratropium-Albuterol Inhalation Solution for five days to treat shortness of breath. However, the medication was administered for seven days beyond the prescribed discontinuation date. The DNS acknowledged the error, which placed the resident at risk of receiving unnecessary medications.
A resident did not receive prescribed corrective lenses after an eye exam, leading to unmet vision needs. The resident had an eye exam where glasses were prescribed, but months later, they reported not receiving them. The Social Service Director was unaware of the order, and the DNS acknowledged the lack of timely follow-up.
The facility failed to provide trauma-informed care for two residents with PTSD. One resident, with severe cognitive impairment, had a history of trauma from the Vietnam War, but her/his care plan lacked specific PTSD triggers or interventions. Staff were unaware of her/his PTSD or triggers, such as loud noises. Another resident, cognitively intact, had a history of abuse and PTSD, but her/his care plan also lacked specific triggers or interventions. Staff were not informed of her/his triggers, including yelling and male staff presence.
The facility failed to address pharmacy recommendations for two residents, leading to potential risks. A resident with depression did not have a timely dose reduction of citalopram, and another with heart disease did not have updated orders to administer carvedilol with food. Staff confirmed these oversights.
The facility failed to process lab orders timely for two residents, risking unnecessary medications. A resident with depression had a comprehensive metabolic panel ordered in May, completed in September. Another resident had a lipid panel ordered in August, completed in September. The DNS acknowledged these delays.
A resident admitted with depression expressed the need for a dental appointment for new dentures during a care conference. Despite this, the facility failed to schedule the appointment, as confirmed by an LPN, resulting in unmet dental needs.
The facility failed to assess and monitor pressure ulcers for two residents, leading to unassessed and unmet treatment needs. One resident developed a new pressure injury on the left heel, which was not documented or monitored, and care plans were not consistently followed. Another resident developed multiple pressure injuries, including an unstageable ulcer, without proper documentation, investigation, or care plan updates.
The facility failed to monitor a resident at risk for elopement, resulting in the resident leaving the facility and falling from a wheelchair. Additionally, another resident, who required assistance, was left alone in the shower, causing fear of falling. Staff interviews confirmed these lapses in supervision and adherence to care plans.
The facility failed to provide timely incontinence care for three dependent residents, leading to unmet care needs. One resident with dementia and TBI was found soaked and not repositioned for over three hours. Another resident with cerebral palsy was found with a wet bath blanket instead of changed bed sheets. A third resident on end-of-life hospice care was also found with wet spots and dried bowel movement. The facility's investigation confirmed the lack of appropriate and timely care.
Incomplete Care Plans for Wound VAC and Behavioral Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for 2 of 7 sampled residents reviewed for unnecessary medications and skin conditions. Resident 6 was admitted with diagnoses including surgical wound infection and adjustment disorder with depressed mood. The admission MDS showed a history of depression, use of medication for anxiety, and a wound VAC. Physician orders included care for the wound VAC, hydroxyzine for anxiety, and duloxetine for depression, but the comprehensive care plan did not include interventions related to the wound VAC, target behaviors, or interventions related to mood or anxiety associated with hydroxyzine and duloxetine. Resident 7 was admitted with diagnoses including a pressure wound and malnutrition. The admission MDS identified a wound VAC, and physician orders included care for the wound VAC. However, the revised comprehensive care plan did not include any interventions related to the wound VAC. During interviews, staff acknowledged that Resident 6’s care plan lacked wound VAC information and target behaviors or interventions for hydroxyzine and duloxetine, and that Resident 7’s care plan contained no information related to the wound VAC.
Failure to Follow Ordered Skin Treatment
Penalty
Summary
The facility failed to follow physician orders for a resident with a history of multiple sclerosis and prior cellulitis of the right lower leg. The resident was admitted with a right lower leg venous ulcer that was documented on admission as 4 cm by 4 cm with a small amount of serosanguineous drainage. A later weekly skin evaluation documented that the ulcer had resolved, but treatment to the right lower leg continued. A physician order dated 4/22/26 directed right lower extremity dressing changes with cleansing using wound cleanser, application of Xeroform, ABD pad, Kerlix wrap, and securing the dressing on Monday, Wednesday, and Friday evenings. During an observed treatment, the existing dressing had already been removed, no open areas were seen, and the skin on the right lower leg was flaking and yellowed. The RN performing the treatment stated she was doing light debridement by running gloved hands up and down the resident's right lower leg before the LPN applied the ordered dressing. The DNS stated this rubbing was not part of the physician ordered plan of care and that staff should never rub fragile skin around a healed or healing wound.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to ensure staff followed infection control procedures during wound care and medication administration for one sampled resident with pressure wounds and during medication administration for one resident. During a medication administration observation, an RN entered the resident’s room without performing hand hygiene, handled the resident’s water cup, provided eye drops and nasal spray, moved multiple cups on the overbed table, handled the medication cup and the medication bottles, and then returned to the medication cart and computer without sanitizing hands. The RN stated hand hygiene should be performed before entering and after exiting a resident’s room. During another medication administration observation, a CMA used a pill cutter to cut a medication and returned the pill cutter to the medication cart drawer without sanitizing it. The CMA then entered and exited the resident’s room without performing hand hygiene and accessed the computer and medication cart without hand hygiene. The Administrator, DNS, and Regional Nurse Consultant later stated staff should sanitize their hands before entering and after exiting a resident’s room, sanitize all equipment after each use including the pill cutter, and clean resident inhalers, eye/ear drops, and nebulizers after each use.
Failure to Provide Ordered Therapy and Incontinence Care
Penalty
Summary
The facility failed to follow physician orders for therapy for Resident 102, who was admitted with diagnoses including stroke and diabetes. Despite having admission orders for Physical and Occupational Therapy dated 9/12/24, the resident did not receive any therapy during their nine-day stay. Staff 15, the OT/Therapy Manager, stated they had not received therapy orders, and the facility's administrator was unable to locate any documentation explaining the lack of therapy provided. Resident 104, admitted with a Stage 4 pressure ulcer and quadriplegia-incomplete, was not provided incontinence care during the night shift and was found soiled in the morning with the call light out of reach. An investigation revealed that Staff 16, a CNA, failed to provide appropriate care, leaving the resident without care through the night. Staff 8 discovered the resident in a soiled state and was informed by the resident that Staff 16 and another CNA had started but not completed changing them, leaving wipes and a brief on the bed.
Failure to Investigate Alleged Abuse Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving a resident who was admitted with a diagnosis of failure to thrive. On September 12, 2024, a public complaint was received alleging that a former agency LPN threatened to administer an extra dose of oxycodone to the resident, causing them to feel threatened and anxious. The resident reported that the LPN later claimed to have given the extra dose to another resident, which further upset the resident. A CNA corroborated the resident's account, stating that the resident panicked and became upset after the LPN's statements. The facility's investigation into the incident was incomplete, lacking witness statements, interviews with other residents, and an interview with the alleged perpetrator. The Director of Nursing Services acknowledged the investigation's deficiencies.
Failure to Obtain Informed Consent for COVID-19 Vaccine
Penalty
Summary
The facility failed to obtain informed consent prior to administering a COVID-19 vaccine to a resident. The resident, who was admitted in April 2024 with a diagnosis of depression, received the vaccine in May 2024. However, upon review of the resident's medical records in December 2024, there was no evidence of a signed consent form for the vaccine. The Director of Nursing Services (DNS) confirmed the absence of the consent form during an interview conducted in December 2024.
Failure to Document Advance Directives for a Resident
Penalty
Summary
The facility failed to obtain and document information related to advance directives for a resident who was admitted in October 2021 with a diagnosis of stroke. Despite attending multiple Interdisciplinary Care Conferences, the resident expressed a desire to have an advance directive offered, yet none was documented in their electronic record. On December 3, 2024, the resident confirmed not being offered an advance directive during these conferences. The Social Service Director claimed to offer advance directives at care conferences and had residents sign an Admission Assessment document to verify receipt, but admitted to not conducting follow-up related to the provision of advance directives. The facility administrator expected staff to follow up on advance directives before quarterly care conferences, which was not done in this case.
Failure to Discontinue Medication as Ordered
Penalty
Summary
The facility failed to adhere to a doctor's orders regarding the administration of medication for a resident diagnosed with heart disease. The resident was prescribed Ipratropium-Albuterol Inhalation Solution to treat shortness of breath for a duration of five days, starting on November 22, 2024. However, a review of the Medication Administration Records (MARs) for November and December 2024 revealed that the medication was administered beyond the prescribed period, continuing until December 4, 2024, which is seven days past the discontinuation date of November 27, 2024. During an interview on December 4, 2024, at 4:00 PM, the Director of Nursing Services (DNS) acknowledged that the resident continued to receive doses of the medication beyond the ordered discontinuation date. This oversight placed the resident at risk of receiving unnecessary medications.
Failure to Provide Corrective Lenses
Penalty
Summary
The facility failed to address orders for corrective lenses for a resident, which placed them at risk for unmet vision needs. The resident was admitted to the facility with a diagnosis of depression and had an eye exam on June 3, 2024, where a prescription for glasses was written. However, by December 2, 2024, the resident reported not having received the glasses. The Social Service Director was unaware of the order for new glasses, and the Director of Nursing Services acknowledged that the resident did not receive timely follow-up for the new glasses.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents with PTSD and other behavioral needs. Resident 11, who was admitted in January 2017, had a history of trauma from the Vietnam War and a gunshot wound. Despite having severe cognitive impairment, as indicated by a BIMS score of five, Resident 11's care plan did not include specific triggers or interventions related to her/his PTSD. Interviews with staff revealed that they were unaware of the resident's PTSD or specific triggers, which included loud noises that made her/him upset and scared. Similarly, Resident 30, admitted in November 2021, had a history of abuse and PTSD, along with other diagnoses such as stroke and depression. Although Resident 30 was cognitively intact with a BIMS score of 15, her/his care plan lacked specific triggers or interventions related to her/his PTSD. The resident reported that triggers included people yelling and male staff entering her/his room, yet staff were not informed of these triggers. The Director of Nursing Services confirmed that neither resident had care plans addressing their specific trauma triggers or interventions.
Failure to Address Pharmacy Recommendations for Two Residents
Penalty
Summary
The facility failed to address pharmacy recommendations for two residents, leading to potential risks of adverse medication reactions and unnecessary medications. Resident 1, admitted with a diagnosis of depression, had pharmacy consultation reports recommending a gradual dose reduction of citalopram in September and October 2024. However, there was no evidence of a signed physician order to attempt this reduction in September, and the order to decrease the dosage was only made in October. Staff confirmed that the pharmacy recommendation was not completed in a timely manner. Resident 24, admitted with heart disease, had a pharmacist review in September 2024 that instructed the facility to clarify the order for carvedilol to ensure it was administered with food. A review of the resident's medication administration record and physician orders in December 2024 revealed that the orders were not updated to include this instruction. Staff acknowledged that the orders were not updated to reflect the need to administer carvedilol with food.
Delayed Processing of Laboratory Orders for Two Residents
Penalty
Summary
The facility failed to process physician laboratory orders in a timely manner for two residents, which placed them at risk for unnecessary medications. Resident 1, admitted in April 2024 with a diagnosis of depression, had a physician order for a comprehensive metabolic panel on May 7, 2024, to be completed on the next lab day and every six months. However, the test was not completed until September 7, 2024. Staff 2, the Director of Nursing Services (DNS), acknowledged the delay in completing the test. Similarly, Resident 20, admitted in August 2024 with a diagnosis of depression, had a physician order for a lipid panel on August 9, 2024, to be completed the next lab day and every 12 months. This test was not completed until September 5, 2024. Staff 2 also acknowledged this delay. These delays in processing laboratory orders were identified during interviews and record reviews.
Failure to Schedule Dental Appointment for Resident
Penalty
Summary
The facility failed to schedule a dental appointment for a resident who was admitted in April 2024 with a diagnosis of depression. During a care conference in October 2024, the resident expressed the need for a dental appointment to obtain new dentures. However, as of December 2024, the appointment had not been scheduled. This oversight was confirmed by a Licensed Practical Nurse (LPN) Resident Care Manager, who acknowledged that the resident did not receive timely follow-up for their dental needs.
Failure to Assess and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to assess and monitor pressure ulcers for two residents, leading to unassessed and unmet treatment needs. Resident 11, admitted with dementia, developed a new pressure injury on the left heel, which was not documented or monitored in the medical record. Despite care plans indicating the need to float the resident's heels with pillows, observations showed the resident lying in bed without a pillow under the feet on multiple occasions. Staff were aware of the bruising but did not ensure consistent implementation of the care plan or document the wound assessment. Resident 94, admitted with diabetes, developed multiple pressure injuries, including an unstageable pressure ulcer on the right heel and injuries to the coccyx and left thigh. These injuries were not documented in incident reports or investigated, and no Skin and Wound Evaluations were conducted. The resident reported pain and lack of assistance with repositioning, and staff acknowledged the development of pressure wounds but did not update the care plan or ensure proper documentation and investigation of the injuries.
Failure to Monitor Elopement Risk and Adhere to Care Plans
Penalty
Summary
The facility failed to adequately monitor and supervise residents at risk for elopement and ensure adherence to care plans related to safety. Resident 8, who was admitted with dementia and identified as having severe cognitive deficits, was at risk for elopement as indicated by an evaluation. Despite being an active exit seeker, Resident 8 managed to elope from the facility after multiple attempts to leave, eventually being found outside after falling from a wheelchair. Staff interviews revealed that Resident 8 had figured out the door code and attempted to exit the facility multiple times, yet was not placed under one-to-one supervision as acknowledged by the facility administrator. Additionally, the facility did not follow the care plan for Resident 93, who was admitted with diabetes and required one-person assistance while showering. A public complaint and subsequent interviews confirmed that Resident 93 was left alone in the shower, causing fear of falling. The Social Service Director was informed of the incident, and an agency LPN admitted to leaving Resident 93 unattended for approximately 10 minutes. The facility administrator acknowledged that residents should not be left alone in the shower unless deemed independent by therapy, which was not the case for Resident 93.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for three dependent residents, leading to unmet care needs. Resident 101, who has dementia and a traumatic brain injury, was found soaked and not repositioned for over three hours despite being on a Check and Change toileting program. Staff 8 initially claimed to have provided care but later admitted to not doing so, and no assistance was sought from other staff members. The facility's investigation confirmed the lack of care provided by Staff 8. Resident 102, diagnosed with cerebral palsy and left-sided hemiparesis, was also on a Check and Change toileting program. Staff 9 failed to change the resident's wet bed sheets, instead placing a bath blanket under the resident, which was found wet. The resident was later found soaked with urine and had dried bowel movement on their behind. The facility's investigation determined that Resident 102 did not receive appropriate or timely incontinence care. Resident 103, who has dementia and is on end-of-life hospice care, was similarly neglected. Staff 9 placed a bath blanket under the resident instead of changing the soiled bed sheets. The resident was found with wet spots under the blanket and was soaked with urine and had dried bowel movement on their behind. The facility's investigation confirmed the lack of appropriate and timely incontinence care for Resident 103.
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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 Florence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aidan Senior Living At Reedsport | 20.1 mi | ★★★★★ | 0 | 0 |
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