Cycle 1
Health 2024-12-06 · Fire 2024-12-06
11 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Florence, OR
Regency Florence
3-star overall rating with 3-star inspections with $7,443 in total fines with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1951 E. 21st Street, Florence, OR
(541) 997-8436
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Regency Pacific Management
Operator or chain grouping
Approved since
1979-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing
LPN hours / resident day
1.58
Licensed practical nurse staffing
Aide hours / resident day
3.29
Nurse aide staffing
Weekend hours
4.57
Weekend nurse staffing
RN turnover
43%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
95.5%
1.2 pts better
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.2%
4.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
2.4%
1.8 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.7% |
4.7%
3 pts better
|
11.4%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.0% |
5.0%
1 pts worse
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.0% |
12.5%
7.5 pts better
|
19.6%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 3.2% |
14.7%
11.5 pts better
|
16.7%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.8% |
0.1%
0.7 pts worse
|
0.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 42.1% |
24.1%
18 pts worse
|
16.3%
25.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.6% |
15.8%
11.8 pts worse
|
14.9%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
2.0%
1.4 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
22.2%
3.8 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
6.5%
2 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
85.4%
10.1 pts better
|
81.7%
13.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.0% |
15.1%
9.9 pts worse
|
12.0%
13 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.7%
1.3 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.9% |
81.2%
5.3 pts worse
|
79.7%
3.8 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.1% |
21.6%
7.5 pts worse
|
23.9%
5.2 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-25 · Fire 2023-08-25
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-08-26 · Fire 2022-08-26
20 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-06
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-12-06
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-12-06
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-12-06
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-12-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-12-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-06
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-01-14
F · Potential for more than minimal harm
2023-08-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-08-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-29
F · Potential for more than minimal harm
2022-08-26
K163 · Construction Deficiencies
Fire Safety
Install noncombustible or limited-combustible interior walls.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-26
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-23
D · Potential for more than minimal harm
2024-12-06
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-06
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-06
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-06
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-06
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-06
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-06
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-06
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-04-24
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-05-14
D · Potential for more than minimal harm
2023-11-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-10-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-10-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-10-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-10-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-10-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-10-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-28
G · Actual harm
2023-08-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-08-25
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-08-25
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-08-25
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-08-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-21
E · Potential for more than minimal harm
2023-03-01
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-03-28
E · Potential for more than minimal harm
2023-03-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-28
E · Potential for more than minimal harm
2023-03-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-28
D · Potential for more than minimal harm
2023-03-01
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-12-20
D · Potential for more than minimal harm
2023-03-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-03-28
E · Potential for more than minimal harm
2022-08-26
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-08-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-08-26
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-08-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-08-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-08-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-10-10
Penalties and ownership
What sits behind the stars
$7,443
2023-08-25
Fine
Fine · fine $7,443
Fine
Ownership
Beddoe, Marvin
5% Or Greater Direct Ownership Interest · Individual
Lehner, Timothy
5% Or Greater Direct Ownership Interest · Individual
Beddoe, Marvin
Operational/Managerial Control · Individual
Regency Pacific Management LLC
Operational/Managerial Control · Organization
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#3
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