Cycle 1
Health 2026-01-16 · Fire 2026-01-16
6 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Redmond, OR
Regency Redmond Rehabilitation And Nursing Center
4-star overall rating with 3-star inspections with $13,204 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3025 Sw Reservoir Drive, Redmond, OR
(541) 548-5066
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
35
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Regency Pacific Management
Operator or chain grouping
Approved since
1992-06-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
27 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.81
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.82
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
5.71
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.57
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
5.24
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,981
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9910
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.11
Baseline 17.77% · Performance 19.06% · Measure score 5.11 · Achievement 5.11 · Improvement 0
Healthcare-associated infections
4.68
Baseline 5.88% · Performance 6.44% · Measure score 4.68 · Achievement 4.68 · Improvement 0
Total nurse turnover
0.73
Baseline 64.86% · Performance 60.71% · Measure score 0.73 · Achievement 0.73 · Improvement 0.54
Adjusted total nurse staffing
4.63
Baseline 4.30 hours · Performance 4.40 hours · Measure score 4.63 · Achievement 4.63 · Improvement 0.12
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.2% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 114 · Observed rate 5.26% · Lower 95% interval 6.42% |
| Discharge to community | 61.09% |
50.57%
10.5 pts better
|
Better than the National Rate · Eligible stays 124 · Observed rate 58.87% · Lower 95% interval 51.41% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.1% |
95.27%
1.8 pts better
|
Numerator 67 · Denominator 69 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 69 |
| Discharge self-care score | 82.35% |
53.69%
28.7 pts better
|
Numerator 42 · Denominator 51 |
| Discharge mobility score | 80.39% |
50.94%
29.5 pts better
|
Numerator 41 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 2.9% |
2.29%
0.6 pts worse
|
Numerator 2 · Denominator 69 · Adjusted rate 2.86% |
| Healthcare-associated infections requiring hospitalization | 6.44% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 4.23% · Lower 95% interval 3.2% |
| Staff COVID-19 vaccination coverage | 9.21% |
8.2%
1 pts better
|
Numerator 7 · Denominator 76 |
| Staff flu vaccination coverage | 38.46% |
42%
3.5 pts worse
|
Numerator 30 · Denominator 78 |
| Discharge function score | 84.31% |
56.45%
27.9 pts better
|
Numerator 43 · Denominator 51 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 46 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 60.71% |
25.2%
35.5 pts better
|
Numerator 17 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.5%
4.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.4%
2.4 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
4.7%
1.6 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 8.7% · Q4 0.0% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.0%
5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.6% |
12.5%
0.1 pts worse
|
19.6%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 8.7% · Q3 9.5% · Q4 10.0% · 4Q avg 12.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.5% |
14.7%
7.2 pts better
|
16.7%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 15.0% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.0% |
24.1%
4.1 pts better
|
16.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.0% |
15.8%
7.8 pts better
|
14.9%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 10.0% · 4Q avg 8.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
2.0%
0.9 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.7% · Q3 3.8% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.2% |
22.2%
14 pts better
|
19.8%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 13.9% · Q3 4.7% · 4Q avg 8.2% |
| Percentage of long-stay residents with pressure ulcers | 7.2% |
6.5%
0.7 pts worse
|
5.1%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 4.8% · Q3 6.2% · Q4 12.0% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
85.4%
14.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
15.1%
4.2 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 10.5% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.7%
0.9 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.4% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
81.2%
17.4 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
21.6%
3.6 pts better
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 15.8% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-16 · Fire 2024-08-16
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-04-07 · Fire 2023-04-07
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2026-01-23
D · Potential for more than minimal harm
2026-01-16
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2026-01-23
F · Potential for more than minimal harm
2024-08-16
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-09-20
F · Potential for more than minimal harm
2024-08-16
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-16
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-23
F · Potential for more than minimal harm
2023-04-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-16
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2026-02-02
D · Potential for more than minimal harm
2026-01-16
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 2026-02-02
D · Potential for more than minimal harm
2026-01-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2026-02-02
D · Potential for more than minimal harm
2026-01-16
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 2026-02-02
D · Potential for more than minimal harm
2026-01-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-02-02
D · Potential for more than minimal harm
2026-01-16
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2026-02-02
E · Potential for more than minimal harm
2024-08-16
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 2024-04-01
E · Potential for more than minimal harm
2024-08-16
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-16
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-16
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 2024-10-01
D · Potential for more than minimal harm
2024-08-16
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 2024-10-01
D · Potential for more than minimal harm
2024-08-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-16
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 2024-10-01
D · Potential for more than minimal harm
2024-08-16
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-16
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-08-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-01
G · Actual harm
2023-04-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-19
G · Actual harm
2023-04-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-19
E · Potential for more than minimal harm
2023-04-07
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 2023-05-19
E · Potential for more than minimal harm
2023-04-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-07
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-07
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 2023-05-19
D · Potential for more than minimal harm
2023-04-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-07
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 2023-05-19
D · Potential for more than minimal harm
2023-04-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-07
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-07
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 2023-05-19
Penalties and ownership
What sits behind the stars
$3,145
2023-06-05
Fine
Fine · fine $3,145
Fine
$10,059
2023-04-07
Fine
Fine · fine $10,059
Fine
Ownership
Bd Facilities LLC
5% Or Greater Direct Ownership Interest · Organization
Beddoe, Marvin
5% Or Greater Direct Ownership Interest · Individual
Beddoe, Marvin
Operational/Managerial Control · Individual
Rapp, Andrew
Operational/Managerial Control · Individual
Regency Pacific Management LLC
Operational/Managerial Control · Organization
Stauffer, Gretchen
Operational/Managerial Control · Individual
Vellody, Nita
Operational/Managerial Control · Individual
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