Regency Prineville Rehabilitation and Nursing Cent

In the surveyor’s words

From the most serious findings on record at Regency Prineville Rehabilitation and Nursing Cent, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF576Aug 16, 2024

  Based on interview it was determined the facility failed to ensure mail was delivered to residents on Saturdays for 1 of 1 facility reviewed for resident council. This placed residents at risk for lack of timely written communication. Findings include: During the resident council meeting on 8/14/24 at 2:30 PM residents stated their mail was not delivered to them on Saturdays. On 8/15/24 at 2:12 PM Staff 3 (Activities Director) stated mail was delivered to the facility Monday through Saturday, and she passed out mail to the residents Monday through Friday. […]

• No harm, potential for more than minimal, isolatedF689Jan 16, 2026

  Based on observation, interview and record review it was determined the facility failed to ensure supervision and safety interventions were in place for 1 of 1 sampled resident (#2) reviewed for smoking safety. This placed residents at risk smoking related injuries. Findings include:The facility's 4/2018 Smoking Policy indicated the following:-Residents were able to smoke tobacco only in designated areas on the premises.-If the facility had supervised smoking, times would be posted on the facility's nursing units and provided for residents who smoke. […]

• No harm, potential for more than minimal, isolatedF684May 13, 2025

  Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#1) reviewed for medication. This placed residents at risk for behaviors. Findings include: Resident 1 admitted to the facility in 2024 with diagnoses including depressive disorder. The 12/27/24 physician order indicated Resident 1 was to receive Zyprexa (antipsychotic) 2.5 mg at bedtime. The 12/2024 MAR indicated Resident 1 did not start taking Zyprexa until 12/31/24. On 5/13/25 at 12:08 PM Witness 2 (Pharmacy Technician) stated the pharmacy did not receive an order for Zyprexa until 12/31/24. On 5/13/25 at 1:19 PM Staff 2 (DNS) acknowledged Resident 1 had an order for Zyprexa on 12/27/25 and the order was not implemented until 12/31/24 (4 days later).

• No harm, potential for more than minimal, isolatedF684Aug 16, 2024

  Based on interview and record review it was determined the facility failed to follow physician's orders for blood sugar parameters for 1 of 5 sampled residents (#6) reviewed for unnecessary medications. This placed residents at increased risk for hyperglycemia. Findings include: Resident 6 admitted to the facility in 2017 with diagnoses including diabetes. A 6/23/23 physician order indicated Resident 6's insulin aspart 100 units before meals parameters to hold for blood sugar less than 120. A review of Resident 6's MAR revealed the following: -On 5/8/24 a blood sugar of 143 at 7:00 AM and the insulin aspart was withheld by Staff 4 (LPN). -On 5/11/24 a blood sugar of 148 at 7:00 AM and the insulin aspart was withheld by Staff 4. […]

• No harm, potential for more than minimal, isolatedF578May 19, 2023

  Based on interview and record review it was determined the facility failed to follow up on advance directives for 3 of 4 sampled residents (#s 12, 13 and 20) reviewed for advance directives. This placed residents at risk for receiving care in conflict with their health care wishes. Findings include: A 5/2023 review of Resident 12, 13 and 20's clinical records revealed the residents did not have advance directives, but information was provided. There was no additional information to indicate whether the residents or their representatives executed an advance directive or declined to do so. […]