Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Redmond Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Failure to Assess Before Use of a Potential Restraint: A resident with dementia and severe fall risk had a pommel cushion in the wheelchair, but the record showed no documented assessment before the device was used. Staff said the cushion had been used for months after a fall and that PT and a restraint assessment were supposed to occur before initiation, but the RNCM was not aware the resident had the device.
Failure to assist a resident with grooming needs. A resident with severe dementia required extensive help with hygiene and preferred to shave daily, but staff did not offer shaving assistance during care. The resident was observed with long facial hair, could not reach the electric shaver due to room layout, and staff acknowledged the shaving preference was not reflected in the care plan.
Failure to Provide Assessed and Preferred Activities: Two residents did not receive activities aligned with their assessed preferences. One resident with PTSD, depressive episodes, and a shoulder injury wanted to go outside for fresh air, but staff communication broke down and the activity goal was not met. Another resident with dementia had documented preferences for being outside, viewing outdoors, and having a stuffed animal, but the care plan did not reflect all preferences and the resident’s bed placement limited access to the window view.
A resident with dementia and hospice services was not continuously supervised in a wheelchair despite a care plan requiring supervision, and was later found on the floor after self-propelling into another resident’s room and self-transferring. The facility also left a PRN antacid tablet at another resident’s bedside without an order for bedside medication storage, and failed to follow fall precautions for a third resident by not consistently ensuring non-slip socks were worn and the call light was within reach.
Failure to Provide Ordered Oxygen: A resident with hypoxemia, acute respiratory distress, and hospice status had an order for continuous O2, but the portable tank was observed empty and the tubing was later found not in place. Staff confirmed the tank was empty, the resident was without O2 after hospice-assisted care, and the resident’s O2 saturation was reported at 90%.
A resident with PTSD and depressive episodes had a nightmare and acted out the dream during sleep, but the record showed no PTSD assessment or care plan interventions. Staff were aware of the sleep-related event, yet the RN did not know the details, Social Services was unaware of the PTSD concerns, and the DNS confirmed there was no follow-up or thorough PTSD assessment.
The facility did not staff an RN for eight consecutive hours per day for nine days, risking unmet assessment needs for residents. This was confirmed through staff reports and payroll records, highlighting a failure to meet staffing requirements.
The facility did not follow therapeutic diet protocols, as a cook prepared meals without using recipes or diet spreadsheets, and lacked training on these tools. Nutritionally Enhanced Meals were not properly enhanced, relying instead on supplements. The RD's audits did not verify the use of required diet tools, and recipes were sourced from the internet due to a lack of facility-provided options.
A resident with palliative care and diabetes was found without their call light within reach on two occasions, despite a care plan requiring immediate response to pain relief needs. A CNA admitted to neglecting this responsibility, and an RNCM confirmed the oversight.
A resident with a stroke diagnosis reported a grievance during a care conference, stating that a CNA refused to assist them. The facility failed to document or follow up on this grievance, as confirmed by the Social Services Director and other staff members who did not recall the incident. This oversight placed residents at risk for unresolved grievances.
A facility failed to create a person-centered care plan for a resident with brain damage, quadriplegia, and a feeding tube. The care plan inaccurately described the resident as independent in toileting and transferring, despite needing a mechanical lift, and included irrelevant interventions. A registered nurse case manager acknowledged the care plan was not individualized, placing the resident at risk for unmet needs.
The facility failed to properly assess and manage pressure ulcers for three residents, leading to worsening conditions. One resident developed Stage 2 ulcers on both ankles without proper investigation or care. Another resident's coccyx pressure area was not monitored, progressing to a Stage 4 ulcer with tunneling, and old packing was found in the wound. A third resident had a misidentified Stage 2 ulcer and undocumented blisters on the thigh.
A facility failed to provide trauma-informed care for a resident with PTSD and anxiety. The resident's psychosocial assessment inaccurately reported no trauma issues, and the care plan lacked interventions for PTSD. Observations showed the resident was often sleeping during the day, with staff noting nighttime anxiety and withdrawn behavior. Staff interviews revealed a lack of awareness and specific interventions for the resident's PTSD, highlighting the need for tailored care.
A facility failed to monitor side effects of psychotropic medications for a resident with chronic mental health diagnoses, who was administered olanzapine, valproic acid, and clonazepam. Staff were expected to document side effects on the TAR and in Progress Notes, but the order was entered as PRN, preventing alerts for monitoring and documentation.
The facility did not administer flu and pneumonia vaccines to two residents who had consented, despite their documented consent. Both residents, admitted with diabetes, had no records of receiving the vaccines, which was confirmed by staff.
A facility failed to report an alleged abuse incident involving a resident with a stroke diagnosis. An LPN noted potential harm during suctioning, and multiple staff members were aware of a CNA holding the resident's hands down during care. Despite this, the incident was not reported to administration until much later, and a Facility Reported Incident was not submitted at the time.
The facility failed to follow diabetic care protocols for a resident with low blood glucose and performed unsafe suctioning on another resident, leading to bleeding. The diabetic protocol was not implemented when a resident's blood glucose was critically low, and documentation was lacking. Another resident, with a communication deficit, was suctioned too deeply, causing bleeding, and was reportedly restrained during the procedure.
The facility failed to follow care plans for fall safety and post-fall assessments for two residents. One resident with a stroke diagnosis experienced multiple unwitnessed falls, with incomplete neurological assessments. Another resident with Parkinson's disease was left unattended on the toilet due to poor staff communication, resulting in a fall and hematoma. These incidents highlight deficiencies in supervision and adherence to care plans.
Failure to Assess Before Use of a Potential Restraint
Penalty
Summary
The facility failed to ensure a resident was assessed before the use of a potential restraint for Resident 17, who was admitted with a diagnosis of dementia and had severe dementia and severe fall risk documented on the 8/12/25 annual MDS. The assessment also noted the resident’s behaviors and memory were becoming worse. The resident’s 11/10/25 quarterly MDS did not indicate a restraint when out of bed, and the care plan last revised on 1/13/26 contained no interventions related to the use of a pommel cushion. On 1/14/26, a pommel cushion was observed in Resident 17’s wheelchair while the resident was in bed. The clinical record contained no documented evidence that an assessment was completed before the device was used. Staff 12 stated the resident had used the pommel cushion for a few months and that it had been implemented after a fall because the resident slid out of the wheelchair. Staff 3 stated that if a resident was to use a potential restraint, PT was to evaluate the resident and a restraint assessment was to be completed prior to initiation, and stated she was not aware Resident 17 had a pommel cushion.
Failure to Assist Resident With Grooming
Penalty
Summary
The facility failed to ensure a resident was assisted with grooming for 1 of 2 sampled residents reviewed for ADLs. Resident 5 was admitted with a diagnosis of pain and, per the annual MDS, had severe dementia, it was important to the resident to make choices about bathing, and the resident required extensive assistance from one staff member for hygiene. The care plan also indicated extensive assistance from one staff member with personal hygiene, and the shower schedule showed the resident was to be showered on Mondays and Thursdays. A CNA shower review sheet documented that Staff 9 assisted the resident with a shower, but on multiple observations the resident had long facial hair and stated a preference to shave daily, while staff had not offered assistance. Staff 9 stated the resident had an electric shaver and would ask if the resident wanted to shave, and Staff 3 stated the resident preferred to shave daily and wanted to be offered shaving, but the care plan did not reflect that preference. The resident was also observed with a razor on the bedside table, but was not able to reach the electric shaver due to the room layout, and stated the resident had not been shaved for weeks.
Failure to Provide Assessed and Preferred Activities
Penalty
Summary
The facility failed to ensure assessed and preferred activities were provided for 2 residents reviewed for activities. One resident was admitted with diagnoses including orthopedic surgery aftercare, PTSD, and depressive episodes. The resident’s initial activity review documented playing games on a phone and that it was very important to get outside and get fresh air when the weather was good. The admission MDS showed a BIMS score of 14 and that the resident required extensive staff assistance to maneuver in a wheelchair due to weakness and poor coordination. The revised care plan identified the resident as at risk for little or no activity due to a right rotator cuff repair and directed staff to provide in-room visits and one-on-one activities, but it did not identify any interest in outdoor activities. The resident stated there was no follow-up on a request to go outside and felt confined to the room because of the shoulder injury. A CNA recalled the request to go outside and said she worked with an LPN to achieve the goal but was unsure whether it was granted. Activities staff stated she was not aware of the request and acknowledged the resident’s preference to go outside when the weather was good, noting communication may have fallen through the cracks because requests were verbal. The Administrator and DNS acknowledged verbal communication was expected and that the resident’s activity participation goal was not met. A second resident with dementia had documented preferences for favorite activities and being outside, and the care plan included opening curtains to view birds and people outdoors, but did not include a stuffed animal. Later assessments identified the resident as severely demented, not liking group activities, liking to be in bed and snack, and family requested the bed be moved next to the window for sunshine. Staff later stated the resident liked to observe in public sitting areas, loved to eat, liked to go outside when warmer, and had a stuffed dog, but the care plan did not include the stuffed animal and the resident’s bed placement prevented looking out the window.
Failure to Follow Fall Interventions and Medication Storage Requirements
Penalty
Summary
The facility failed to ensure fall interventions were followed for a resident with dementia, hospice services, extensive wheelchair assistance needs, and a severe fall risk. The resident’s care plan stated the resident was not to be left unattended in a wheelchair because of elopement risk and a high risk for falls related to self-transferring. After a fall, staff found the resident on the floor in another resident’s room with an empty unlocked wheelchair nearby, and the investigation indicated the resident had likely self-propelled into the room and self-transferred after staff last saw the resident about 10 minutes earlier. Staff interviews showed the resident had been placed near the nurse’s station, staff left the area, and the resident was not continuously supervised as expected. The facility also failed to ensure medications were not left at a resident’s bedside. A resident with severe dementia had an order for PRN Tums, and a large pink tablet was observed in a medication cup on the bedside table. Staff stated the resident had an order for Tums but did not have an order to keep medications at the bedside or to self-administer the medication. Another RN stated medications were not to be kept at the bedside without an order, and the DNS stated residents were not to have medications at the bedside without an assessment, physician orders, and locked storage. The facility further failed to follow fall-related interventions for another resident with cognitive decline and repeat falls. That resident had prior fall investigations showing the resident fell during self-transfer attempts and was not wearing socks or had only one sock on at the time of falls. The revised care plan directed staff to ensure the call light was within reach and that non-slip socks were worn in bed or when footwear was unavailable. However, the resident was observed wearing plain white socks instead of non-slip socks, and on another occasion the call light was not within reach. Staff confirmed the resident could use the call light, acknowledged the call light was out of reach, and stated regular white socks were provided when non-slip socks were unavailable.
Failure to Provide Ordered Oxygen
Penalty
Summary
The facility failed to administer oxygen for a resident with diagnoses including hypoxemia, acute respiratory distress, and hospice status. The resident’s care plan dated 10/28/25 indicated a need for 2 to 3 liters of continuous oxygen, and a physician order dated 11/18/25 directed staff to deliver 2 liters of oxygen per minute for comfort. During observation on 1/12/26, the resident was seated in a wheelchair with oxygen tubing positioned along the side of the face, and the portable oxygen tank gauge was in the red, indicating the tank was empty. The tank remained empty during repeated observations later that day, and Staff 4 confirmed the tank was empty and stated it should be changed every two hours. On 1/13/26, the resident was observed sitting in the wheelchair with the oxygen tubing wrapped behind the wheelchair and lying on the floor, and the resident was not wearing the tubing. Staff 9 stated hospice staff assisted the resident out of bed at approximately 9:40 AM and that the resident was not wearing oxygen; Staff 4 also confirmed that hospice staff did not apply the oxygen tubing after care. Staff 4 stated the resident was without oxygen from approximately 9:40 AM to 11:51 AM, and the resident’s oxygen saturation was reported as 90 percent. The DNS stated the resident had oxygen orders for comfort, the care plan indicated continuous oxygen at 2 to 3 L, and staff were expected to ensure the oxygen tank was full, oxygen was in place, and oxygen saturation was maintained above 91 percent.
Failure to Address PTSD-Related Sleep Triggers
Penalty
Summary
The facility failed to implement trauma informed care interventions for one sampled resident with PTSD and depressive episodes. The resident was admitted with a BIMS score of 14 and was receiving an antidepressant for mood and sleep. A clinical note documented that the resident recently had a nightmare in which he or she was choking a person and woke up acting out the dream, and the resident expressed concern about the nightmare because medication was being given for sleep. Review of the clinical record showed no assessment or care plan interventions related to the resident’s PTSD. During interviews, the resident stated there was danger for staff if he or she was awakened from sleep because of PTSD, an RN said he or she knew the resident had a stressful situation during sleep but did not know the details, Social Services stated they were not aware of PTSD concerns and contacted a psychologist, and the DNS stated the facility was aware of the nightmare but there was no follow-up and no thorough PTSD assessment had been conducted.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to staff a registered nurse (RN) for eight consecutive hours per day, seven days a week, for nine out of 60 days reviewed. This deficiency was identified through a review of Direct Care Staff Daily Reports and payroll records, which showed that on specific dates, there was no RN coverage for the required duration. The absence of RN coverage on these days placed residents at risk for unmet assessment needs. The facility's administrator confirmed the lack of RN presence on the specified dates, acknowledging the failure to meet the staffing requirement.
Failure to Follow Therapeutic Diet Protocols
Penalty
Summary
The facility failed to adhere to therapeutic diet protocols for residents, as observed in the kitchen operations. On August 15, 2024, a cook, identified as Staff 14, was seen preparing lunch without using recipes or therapeutic diet spreadsheets for portion control or meal substitutions for residents on therapeutic diets. Staff 14 admitted to not receiving training on diet spreadsheets since her hiring nearly a year ago. Additionally, when Nutritionally Enhanced Meals (NEM) were ordered, the foods were not enhanced as required; instead, nutritional supplements were provided as ordered by the Registered Dietitian (RD). The Dietary Manager, Staff 13, revealed that recipes used in the kitchen were sourced from the internet due to the absence of facility-provided recipes. Furthermore, the RD, identified as Staff 15, confirmed that her audits did not include checking the use of diet spreadsheets and system recipes. She acknowledged that system recipes with therapeutic diet spreadsheets should be used and that foods should be enhanced daily with extra calories to meet NEM diet orders.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident, which placed them at risk for unaddressed needs. The resident, who was admitted with diagnoses including palliative care and diabetes, had a care plan indicating that staff should respond immediately to their need for pain relief. On two separate occasions, the resident was observed in bed without their call light within reach. On the first occasion, a CNA admitted to neglecting to ensure the call light was accessible after providing care. On the second occasion, the RNCM confirmed that the call light should have been within reach, acknowledging the oversight.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to address a grievance reported by a resident who was admitted in June 2021 with a diagnosis of a stroke. On November 20, 2023, during an interdisciplinary conference, the resident reported that a CNA refused to assist them, and the resident care manager was supposed to follow up on this concern. However, the Social Services Director, who maintained all grievances, stated that there was no record of a grievance for this concern. Additionally, the staff responsible for reviewing the schedule and addressing grievances did not recall the resident's grievance. This lack of follow-up and documentation placed residents at risk for unresolved grievances.
Failure to Develop Person-Centered Care Plan for Resident with Quadriplegia
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident who was admitted with diagnoses including brain damage, quadriplegia, and a feeding tube. The care plan, dated the same day as the resident's admission, contained several inaccuracies and inconsistencies. For instance, it incorrectly stated that the resident was independent in toileting and transferring, despite the resident's quadriplegia and reliance on a mechanical lift for transfers. Additionally, the care plan mentioned the resident's ability to eat independently, although the resident received nourishment and medications through a feeding tube. The care plan also included interventions that were not applicable to the resident's condition, such as assisting the resident in choosing clothing to enhance self-dressing, despite the resident's quadriplegia. These inaccuracies indicate that the care plan was not individualized or person-centered, as acknowledged by a registered nurse case manager during an interview. The lack of a tailored care plan placed the resident at risk for unmet needs, as the plan did not accurately reflect the resident's capabilities and required assistance.
Failure to Properly Assess and Manage Pressure Ulcers
Penalty
Summary
The facility failed to accurately assess, investigate, and care plan pressure ulcers for three residents, leading to a risk of worsening conditions. Resident 15, admitted with no pressure ulcers, developed Stage 2 pressure ulcers on both ankles. The facility did not initially investigate the wounds, and staff were unaware of the necessary care. Observations showed that the resident was not repositioned or provided with body pillows as required, and staff misidentified the wounds as skin tears initially. Resident 27 was admitted with a pressure area on the coccyx, which was not properly monitored or documented for over three months. The resident developed a deep tissue pressure injury that progressed to a Stage 4 pressure ulcer with significant tunneling. The facility failed to conduct weekly wound assessments, and old packing was found in the wound during a wound clinic visit, causing the resident extreme pain. Staff were unclear about the wound care orders and did not document tunneling measurements. Resident 28, with bilateral above-knee amputations, had a Stage 2 pressure ulcer misidentified as Stage 3. Additionally, the resident had multiple blisters on the right thigh that were not documented or treated. The facility's documentation did not reflect the resident's actual skin condition, and staff failed to apply dressings to the open areas as reported by the resident.
Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to assess and implement trauma-informed care interventions for a resident diagnosed with PTSD and anxiety. Upon admission in December 2023, the resident's psychosocial history and discharge plan assessment inaccurately indicated no trauma, mood, or behavior issues. The care plan revised in July 2024 did not include any focus or interventions related to the resident's PTSD, despite the resident's history and diagnosis. Observations in August 2024 revealed the resident was often in bed sleeping during the day, with staff noting the resident was awake most of the night and had withdrawn behavior and anxiety, which were believed to be related to PTSD. Staff interviews highlighted a lack of awareness and specific interventions for the resident's PTSD. A registered nurse noted that the resident only interacted with select staff and expressed concerns about the absence of monitoring related to the resident's PTSD. The Social Services Director acknowledged the psychosocial assessment was inaccurate due to a lack of awareness of the PTSD diagnosis at admission and confirmed that the care plan was not tailored to the resident's behaviors, indicating a need for specific interventions for PTSD.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor side effects of psychotropic medications for one of the sampled residents, placing them at risk for adverse medication reactions. The resident, admitted in May 2017 with chronic mental health diagnoses, was administered scheduled olanzapine, valproic acid, and clonazepam in July and August 2024. However, there was no documentation indicating that the side effects of these medications were monitored. Staff 3, an LPN, stated that staff were supposed to document any side effects on the Treatment Administration Record (TAR) and in the Progress Notes if side effects were observed. Staff 4, an RNCM, explained that the psychotropic medication side effects were supposed to be entered as a scheduled nursing task, but the order was entered as PRN, which did not alert staff to monitor and document any side effects.
Failure to Administer Vaccines to Consenting Residents
Penalty
Summary
The facility failed to ensure that flu and pneumonia vaccines were administered to two residents who had consented to receive them, placing them at risk for respiratory infections. Resident 7, admitted in April 2017 with a diagnosis of diabetes, consented to a pneumonia vaccine on May 4, 2024, but there was no documentation indicating the vaccine was administered. Staff 30 confirmed that the vaccine was not given. Similarly, Resident 15, admitted in December 2023 with a diagnosis of diabetes, consented to a flu vaccine on December 19, 2023, but there was no documentation of administration. Staff 30 also verified that the flu vaccine was not administered to Resident 15.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported to administration for a resident who was admitted in January 2013 with a diagnosis of stroke. On July 31, 2023, an agency LPN noted that a nurse from the previous shift may have inserted a suction tip too far into the resident's throat, resulting in blood in the suction tubing. On September 23, 2024, a complainant reported to the state agency that facility staff were aware of an incident where a CNA held the resident's hands down while a nurse suctioned the resident's secretions. Multiple staff members, including a former CNA and anonymous staff, confirmed awareness of the incident but failed to report it to administration. The regional nurse stated that any concerns of this nature should be reported and investigated. However, the administrator was only made aware of the allegation on August 14, 2024, and confirmed that a Facility Reported Incident (FRI) was not submitted at the time of the initial incident.
Deficiencies in Diabetic Care and Suctioning Practices
Penalty
Summary
The facility failed to provide appropriate care for two residents, leading to deficiencies in their treatment. Resident 7, who was admitted with a diagnosis of diabetes, had a critical blood glucose level of 48 recorded on the Diabetic Administration Record. Despite the facility's protocol to implement hypoglycemic interventions when blood glucose levels fall below 60, there was no documentation or evidence that such interventions were provided. Staff 4 confirmed that the protocol was not followed, and the resident's clinical record lacked any indication of the necessary actions being taken. Resident 85, admitted with a diagnosis of stroke, experienced unsafe suctioning practices. The resident, who had a communication deficit and was sometimes resistive to care, was reportedly suctioned too deeply, resulting in blood being observed in the suction tubing. A progress note indicated that a nurse might have inserted the suction tip too far, and hospice staff noted dried blood in the resident's mouth. An anonymous staff member reported hearing that a CNA held the resident's hands down during the procedure, which led to bleeding. Staff 2, the Assistant DNS, did not recall any incident related to this resident's care.
Failure to Follow Fall Safety Care Plans and Conduct Post-Fall Assessments
Penalty
Summary
The facility failed to ensure staff followed the care plan related to fall safety and ascertain post-fall injuries for two residents, leading to deficiencies in supervision and accident prevention. Resident 26, admitted with a stroke diagnosis, experienced multiple unwitnessed falls. On one occasion, a neurological assessment was not completed as scheduled, and on another, there was no documentation of the assessment. Despite sustaining a hematoma during a fall, the required neurological checks were not fully conducted, indicating a lapse in following the care plan and documenting post-fall assessments. Resident 10, diagnosed with Parkinson's disease and a history of repeated falls, was identified as a fall risk requiring assistance during toileting. However, due to poor communication between staff during a shift change, Resident 10 was left unattended on the toilet, resulting in a fall and a hematoma. The care plan explicitly stated that the resident should not be left alone, yet this directive was not followed, leading to the incident. The miscommunication between staff members contributed to the failure to provide adequate supervision. These incidents highlight the facility's failure to adhere to established care plans and protocols for fall prevention and post-fall assessments. The lack of proper documentation and communication among staff members resulted in residents being placed at risk for falls and injuries. The deficiencies in supervision and adherence to care plans were evident in both cases, underscoring the need for improved staff training and communication to prevent similar occurrences in the future.
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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 Redmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bend Transitional Care | 13.4 mi | ★★★★★ | 0 | 0 |
| Pilot Butte Rehabilitation Center | 13.9 mi | ★★★★★ | 19 | 0 |
| Regency Care Of Central Oregon | 14.9 mi | ★★★★★ | 6 | 0 |
| Regency Prineville Rehabilitation And Nursing Cent | 18.3 mi | ★★★★★ | 4 | 0 |
| Willow Creek Post Acute | 27.2 mi | ★★★★★ | 2 | 0 |
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