Regency Prineville Rehabilitation and Nursing Center

3. Resident 3 admitted to the facility in 2023 with diagnoses including palliative care.On 6/3/25 a Facility Reported Incident indicated misappropriation of resident trust funds for three residents including Resident 3 by Staff 3 (Former Business Office Manager).An undated facility investigation indicated the following:-On 3/27/25 a Resident Trust Disbursement Authorization form for Resident 3 in the amount of $1,700 was completed. The form was signed by the resident, a disbursement signature by Staff 3 and a witness signature by Staff 4 (SSD).-On 4/22/25 a Resident Trust Disbursement Authorization form for Resident 3 in the amount of $50 was completed. The form was signed by the resident, a disbursement signature by Staff 3 and a witness signature by Staff 5 (Maintenance Director).-On 6/4/25 Staff 4 and Staff 5 signed a statement indicating the signatures on the identified forms were not theirs. Resident 3GÇÖs signature was compared to admission paperwork and was also found to be forged.-A Resident Trust spread sheet was completed by the facility and it indicated $1,700 was withdrawn on 3/27/25 and $2,200 was withdrawn on 3/26/25 from Resident 3's account.-On 6/4/25 Resident 3GÇÖs family confirmed Resident 3 had no money in her/his possession and no money was given to her/him.-Local law enforcement was notified.-On 5/30/25 Staff 3 was terminated for an unrelated matter.On 10/29/25 at 12:25 PM Staff 4 confirmed she did not sign a Resident Trust Disbursement Authorization form as a witness for Resident 3. Staff 3 stated Resident 3 was able to request money but the way it was signed on the form was not the way Resident 3 signed her/his name.On 10/29/25 at 12:31 PM Staff 5 stated he never signed as a witness for disbursement of resident funds. Staff 5 confirmed it was not his signature on the identified Resident Trust Disbursement Authorization form.Staff 3 was not contacted as part of this investigation due to the ongoing criminal investigation.-áOn 10/29/25 at 2:39 PM Staff 1 (Administrator) acknowledged the misappropriation of Resident 3GÇÖs trust funds by Staff 3.4. Resident 4 admitted to the facility in 2021 with diagnoses including anxiety and delusional disorder.On 6/6/25 a Facility Reported Incident indicated Resident 4 requested Staff 1 (Administrator) give her/his family money that was locked in the business office. Staff 1 counted the money and $920 was missing. There was no record of disbursements after the original deposit.A 6/13/25 facility investigation indicated the following:-On 5/9/25 $1946 in cash was given to the facility and was locked up in the business office.-In a 6/6/25 Care Conference Resident 4 requested the money locked up in the business office was to be given to her/his family. Staff 1 retrieved the envelope with the cash from the business office. The cash was counted out and $920 was missing. There was no documentation indicating any withdrawals occurred since 5/9/25.-Resident 4 was reimbursed the $920 on 6/11/25.-Law enforcement was notified, and an extensive investigation was completed by the facility and the misappropriation of resident funds, including Resident 4's personal funds, was found to have occurred.-On 5/30/25 Staff 3 was terminated for an unrelated offense.On 10/29/25 at 2:39 PM Staff 1 (Administrator) acknowledged the facility determined Staff 3 misappropriated Resident 4GÇÖs personal funds because she was the only staff member who had access to the safe.On 6/13/25 the facility provided information to indicate an action plan to prevent future occurrences was completed, education and an in-service was completed related to the misappropriation. The deficient practice was determined to be past non-compliance, corrected on 6/13/25.The facility's Abuse/Neglect/Misappropriation/Exploitation Policy, revised 10/2022, defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a residentGÇÖs belongings or money without the residentGÇÖs consent.-áThe facility trains employees at orientation, annually and as needed regarding what constitutes abuse, neglect and misappropriation of resident property.-á1. Resident 1 was admitted to the facility in 3/2019 with diagnoses including palliative care and dementia. The 4/13/25 Significant Change MDS indicated Resident 1GÇÖs cognition was severely impaired. A 6/4/25 FRI indicated an allegation of misappropriation of resident trust accounts for three residents, including Resident 1 by Staff 3 (Former Business Office Manager).-áAn undated facility investigation revealed the following: -It was noted on 1/15/25 Staff 3 attended the GÇ£abuse/neglect/exploitationGÇ¥ in-service.-á-Resident Trust Disbursement Authorization forms had significant disbursements to three residents, including Resident 1.-á-Resident Trust Disbursement Authorization forms for Resident 1 revealed a total of four authorization forms with varying amounts totaling $2,000 in 2025. The form included a resident signature and the date, witness signature and the date, and disbursed by signature and the date. The witness signatures included Staff 6 (CMA) and Staff 8 (Medical Records Director). -A review of signature comparisons on the disbursement authorizations to those actual signatures of the resident and witnesses revealed the signatures were forged.-Staff 3 was suspended on 5/29/25 pending an investigation on a separate allegation and was terminated on 5/30/25. -On 6/4/25 the local police department was notified.-On 6/4/25 Resident 1GÇÖs family was contacted and confirmed Resident 1 had no money in her/his possession and did not receive any money.-á-The documented evidence revealed misappropriation occurred for Resident 1.-áA 6/19/25 facility investigation further revealed the local police department requested a more extensive investigation dating back to 2018 which revealed evidence that misappropriation occurred from 2018 through 5/2025. A review of additional documentation related to an audit of the business office revealed misappropriation by Staff 3 occurred for Resident 1 from 2022 through 2025 totaling $10,640.-áOn 10/29/25 at 12:51 PM Staff 6 (CMA) and on 10/29/25 at 1:02 PM Staff 8 (Medical Records Director) stated the signatures on the Resident Trust Disbursement Authorization forms were not their signatures.-áStaff 3 was not contacted as part of this investigation due to the ongoing police investigation.-áOn 10/29/25 at 2:15 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged misappropriation of trust funds by Staff 3 did occur for Resident 1.-á2. Resident 2 was admitted to the facility in 8/2024 with diagnoses including palliative care and diabetes. The 2/18/25 Quarterly MDS indicated Resident 2GÇÖs cognition was severely impaired. A 6/4/25 FRI indicated an allegation of misappropriation of resident trust accounts for three residents, including Resident 2 by Staff 3 (Former Business Office Manager).-áAn undated facility investigation revealed the following:-It was noted on 1/15/25 Staff 3 attended the GÇ£abuse/neglect/exploitationGÇ¥ in-service.-á-Resident Trust Disbursement Authorization forms had significant disbursements to three residents, including Resident 2.-á-Resident Trust Disbursement Authorization forms for Resident 2 revealed a total of nine authorization forms with varying amounts totaling $10,900 in 2025. This form included a resident signature and the date, witness signature and the date, and disbursed by signature and the date. The witness signatures included Staff 4 (SSD), Staff 6 (CMA), Staff 7 (Activity Director), Staff 8 (Medical Records Director), Staff 10 (CNA), Staff 11 (CNA), and Staff 12 (CMA).-á-A review of signature comparisons on the disbursement authorizations to those actual signatures of the resident and witnesses revealed the signatures were forged.-Staff 3 was suspended on 5/29/25 pending an investigation on a separate allegation and was terminated on 5/30/25.-On 6/4/25 the local police department was notified.-On 6/4/25 Resident 2GÇÖs family was contacted and confirmed Resident 2 had no money in her/his possession or did not receive any money.-á-The documented evidence revealed misappropriation occurred for Resident 2.-áA 6/19/25 facility investigation further revealed the local police department requested a more extensive investigation dating back to 2018 which revealed misappropriation occurred from 2018 through 5/2025.A review of additional documentation related to an audit of the business office revealed misappropriation by Staff 3 occurred for Resident 2 from 2024 through 2025 totaling $15,725.-áOn 10/29/25 at 12:25 PM Staff 4 stated it was not her signature on the Resident Trust Disbursement Authorization forms for Resident 2. On 10/29/25 at 12:57 PM Staff 7 stated it was not her signature on the Resident Trust Disbursement Authorization forms for Resident 2. Staff 7 stated she never signed those forms. On 10/29/25 at 1:02 PM Staff 8 stated she never signed the forms as a witness and she was never a witness for Resident 2. On 10/29/25 at 1:13 PM and on 10/29/25 at 1:26 PM Staff 6 and Staff 10 stated they never signed Resident Trust Disbursement Authorization forms. On 10/29/25 at 2:15 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged misappropriation of trust funds by Staff 3 did occur for Resident 2.-á

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).

Based on interview and record review it was determined the facility failed to ensure state minimum CNA staffing ratios were maintained for 6 of 61 days reviewed for staffing. This placed residents at risk for delayed treatment and unmet care needs. Findings include:

A review of the Direct Care Staff Daily Reports from 12/1/24 through 1/31/25 revealed the facility had insufficient CNA staff for one or more shifts on the following dates:

- 12/7/24
- 12/15/24
- 12/29/24
- 1/2/25
- 1/3/25
- 1/26/25

On 5/13/25 at 12:30 PM Staff 1 (Administrator) acknowledged the facility did not meet minimum CNA staffing requirements for the identified dates.

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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684
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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. She verified mail was not delivered to residents on Saturdays.

On 8/16/24 at 10:35 AM Staff 1 (Administrator) stated mail was previously passed out to residents on Saturdays by housekeeping or activities staff, but this practice was currently on hold. He verified mail was not delivered to residents on Saturdays.

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.
-On 6/4/24 a blood sugar of 137 at 7:00 AM and the insulin aspart was withheld by Staff 4.
-On 7/11/24 a blood sugar of 148 at 5:00 PM and the insulin aspart was withheld by Staff 4.
-On 7/19/24 a blood sugar of 132 at 7:00 AM and the insulin aspart was withheld by Staff 4.
-On 7/24/24 a blood sugar of 146 at 5:00 PM and the insulin aspart was withheld by Staff 4.
-On 8/7/24 a blood sugar of 143 at 7:00 AM and the insulin aspart was withheld by Staff 4.
-On 8/7/24 a blood sugar of 137 at 5:00 PM and the insulin aspart was withheld by Staff 4.

On 8/15/24 at 10:03 AM Staff 4 stated Resident 6's blood sugars were checked three times per day before meals and if blood sugars were below 110, the insulin was withheld. The surveyor requested Staff 4 to review Resident 6's insulin aspart orders. Staff 4 stated Resident 6's previous orders indicated to hold if blood sugar was less than 150. Staff 4 stated she forgot the order changed recently.

On 8/15/24 at 1:56 PM Staff 2 (DNS) stated it was her expectation that nurses read the physician orders when administering medications every time. Staff 2 acknowledged the insulin aspart was withheld from Resident 6 when it should have been administered per physician orders.

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OAR 411-085-0310 Resident Rights: General

Refer to F576
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OAR 411-086-0110 Nursing Services: Resident Care

Refer to F684
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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.

On 5/17/23 at 8:58 AM Staff 3 (Social Services Director) stated she was not aware of the requirements regarding advance directives and was not consistent with following up to ensure advance directives were reviewed or received.

On 5/18/23 at 8:36 AM Staff 1 (Administrator) confirmed advance directives were not followed up on for Residents 12, 13 and 20.

Based on interview and record review the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 of 2 sampled residents (#34) reviewed for abuse. This placed residents at risk for psychosocial harm. Findings include:

Resident 34 admitted to the facility in 3/2022 with diagnoses including diabetes, obesity and polyosteoarthritis.

A 3/10/22 Quarterly MDS indicated Resident 34's BIMS score was 11 which indicated moderate cognitive impairment.

A Abuse Incident Report dated 5/5/22 and completed on 5/10/22 revealed the following:

- Witness 1 (Family Member) reported to Staff 1 (Administrator) that Resident 34 was verbally abused by Staff 14 (CNA) and indicated Staff 14 used foul language, was disrespectful and demeaned Resident 34.

-Resident 34 stated Staff 14 entered her/his room multiple times and did not assist with care but turned her/his call light off and did not leave the room. At one point Staff 14 entered the room and was smoking something at her/his window and then blew smoke into her/his face. Resident 34 indicated Staff 14 told her/him "you stink, you are morbid, everyone can't stand you, you fucking stink so bad." Resident 34 stated Staff 8 (CNA) overheard comments that Staff 14 made to her/him and told Staff 14 she could not talk that way to residents and Staff 14 left the room.

-Staff 8 indicated she asked for assistance with Resident 34 and Staff 14 assisted. Staff 8 indicated while performing ADL care to Resident 34 Staff 14 told her/him to "shut the fuck up, stop whining, complaining, and told Resident 34 she/he was lazy, smelled and no one wanted to care for her/him." Staff 8 finished ADL care for Resident 34 and told Staff 14 to stop talking to Resident 34 in an inappropriate way. Staff 8 indicated both of them left the room but Staff 14 continued to be loud in the hallways and curse. Staff 8 indicated Staff 14's behavior was totally out of character and something she had not witnessed before.

-Staff 6 (CNA) indicated when she started her shift at 6:00 AM Staff 14 was talking very loudly throughout the halls and was acting "out of character."

-Staff 3 (Social Service Director) stated staff reported to her, the early morning of 5/5/22 Staff 14 was acting out of character, yelling and cussing in the hallways. Witness 2 (Family Member) indicated she spoke with Resident 34 who reported Staff 14 told Resident 34 to stop using her/his call light, took up too much time and "you [Resident 34] fucking stink" and would be the last to receive any care.

-Staff 14 indicated she was not assigned to Resident 34 that night but assisted Staff 8 with Resident 34's ADL care needs and told Staff 8 it would be a good idea to have two staff in when providing ADL care. Staff 14 indicated Resident 34 refused ADL care and had behaviors on 5/3/22, became upset with her and did not want her to provide ADL care or be in Resident 34's room alone. On 5/8/22 Staff 14 submitted her resignation letter.

-It was determined based off the 5/5/22 facility reported incident verbal abuse occurred and Staff 14 made disparaging remarks and cruel comments to Resident 34. Staff 14 was to be terminated from employment however, on 5/8/22 the facility received a resignation letter from Staff 14 which was accepted.

On 5/15/23 at 4:57 PM Witness 1 (Family Member) stated he remembered the incident on 5/5/22 and Staff 14 was screaming and used vulgar language towards Resident 34. Witness 1 stated Resident 34 indicated Staff 14 was smoking something in her/his room and blew smoke into her/his face. Witness 1 stated Resident 34 initially was very upset and crying when he arrived at the facility that morning because the event had only occurred a couple hours prior. Witness 1 stated Staff 14 was no longer in the building when he arrived. Witness 1 further stated he reported his concerns to Staff 1 (Administrator) and was satisfied with the outcome regarding the incident. Witness 1 stated Resident 34 had no long-term side effects from the incident but was a little taken back by the incident.

On 5/16/23 at 11:43 AM Staff 3 stated she arrived to work and staff reported Staff 14 was acting "funny" that night and was verbally abusive towards Resident 34. Staff 3 indicated Staff 14 told Resident 34 she/he smelled bad and used vulgar language. Staff 3 stated Staff 14 was not in the building when she arrived and Staff 1 and Staff 2 (DNS) were looking into the incident.

On 5/16/23 at 12:49 PM Witness 2 stated Resident 34 spoke with Witness 2 the morning of 5/5/22 and indicated Staff 14 was blowing smoke in her/his face with a vape pen, told her/him to stop putting her/his call light on and used vulgar language towards Resident 34 which was verbally demeaning. Witness 2 stated Resident 34 was initially upset but was back to her/his baseline and felt safe at the facility.

On 5/16/23 at 2:08 PM Staff 7 (LPN) stated she worked with Staff 14 when the incident occurred on 5/5/22 with Resident 34 and noticed Staff 14 was not her normal self but thought it was just because she was "busy." Staff 7 stated Witness 1 reported his concerns to Staff 7 towards the end of her shift regarding the disparaging comments towards Resident 34 and she was going to report the incident to Staff 1 but he was already aware of the incident.

On 5/17/23 at 6:42 PM Staff 8 (CNA) stated she witnessed Staff 14 being verbally abusive to Resident 34 the morning of 5/5/22. Staff 8 stated Staff 14 assisted with ADL care and she "flipped" out on Resident 34 and stated that she/he "stunk" and used vulgar language. Staff 8 intervened and told Staff 14 that behavior was inappropriate and needed to stop and Staff 14 left the room. Staff 8 stated Resident 34 indicated Staff 14 came back into her/his room and was smoking and blew smoke into her/his face. Staff 14 stated when she checked on Resident 34 after the incident she/he was not crying but a little bit taken back over the incident and seemed to be back to her/his baseline.

On 5/18/23 at 1:30 PM Staff 1 and Staff 2 (DNS) were present for an interview. Staff 1 stated he was alerted of the 5/5/22 incident that morning by Witness 1 and initiated the investigation and determined verbal abuse occurred. Staff 1 and Staff 2 stated Resident 34 initially was upset about the incident but had no long-term psychosocial effects from the verbal abuse. Staff 1 stated they suspended Staff 14 and she turned in her resignation letter on 5/8/22, which the facility accepted.

On 5/10/22, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined there was verbal abuse. The Plan of Correction included: 1. A facility incident report which determined Resident 34 was verbally abused by Staff 14. 2. Staff 14 no longer worked for the facility after the 5/5/22 incident. 3. Staff were educated and completed abuse in-service training. 4. Continued education regarding abuse training occurred at all staff meetings.

Based on interview and record review it was determined the facility failed to ensure a resident's care plan reflected the needs of the resident for 1 of 3 sampled residents (#19) reviewed for accident. This placed residents at risk for unmet needs. Findings include:

Resident 19 was admitted to the facility in 2021 with diagnoses including adult failure to thrive and dysphagia (difficulty swallowing).

A review of Resident 19's Care Plan initiated on 2/15/21 revealed Resident 19 required 100% supervision for all meals.

On 5/16/23 at 8:05 AM resident 19 was observed alone in her/his room eating toast and drinking milk through a straw.

On 5/16/23 at 8:20 AM Staff 9 (CNA) walked by, looked at Resident 19 and kept walking while Resident 19 drank liquid through a straw.

On 5/16/23 at 8:21 AM Staff 9 stated Resident 19 ate on her/his own and staff would "help" a little. Staff 9 stated Resident 19 ate slowly and had not witnessed her/him having difficulty with consuming meals.

On 5/16/23 at 8:31 AM Staff 11 (RNCM) stated when Resident 19 was ill she/he required assistance with eating and drinking but if Resident 19 was well she/he did not require assistance with meals.

On 5/16/23 at 8:35 AM Staff 2 (DNS) confirmed Resident 19's care plan did not reflect her/his current needs.

Based on interview and record review it was determined the facility failed to administer diabetic and bowel medication according to physician orders for 1 of 5 sampled residents (#13) reviewed for medications. This placed residents at risk for low blood sugar and complications of constipation. Findings include:

Resident 13 was admitted to the facility in 2019 with diagnoses including Type 2 diabetes and constipation.

a. Resident 13's current care plan for diabetes indicated a focus for unstable blood sugar.

Resident 13's 4/2023 physician orders included the following order:

- Novolog (fast-acting) insulin three times a day with meals. The insulin was to be held for a blood sugar less than 150.

A review of the 4/2023 DAR (Diabetic Administration Record) indicated Resident 13's Novolog insulin was not held on the following dates and times for levels under 150:

- 4/8/23 7:00 AM blood sugar 135
- 4/16/23 5:00 PM blood sugar 141
- 4/30/23 7:00 AM blood sugar 114

On 5/18/23 at 11:17 AM Staff 2 (DNS) confirmed Resident 13's Novolog insulin was not held according to the physician ordered parameters on the identified dates.

b. Resident 13's 4/2023 and 5/2023 physician orders included the following medications:

- Bisacodyl (laxative) tablet prn daily for constipation
- Bisacodyl suppository prn daily if no results from the prn Bisacodyl tablet

Resident 13's bowel movement records from 4/18/23 through 5/17/23 indicated the resident did not have a bowel movement on the following dates:

- 4/24/23 through 4/28/23 (five days)
- 5/2/23 through 5/6/23 (five days)
- 5/9/23 through 5/12/23 (four days)
- 5/14/23 through 5/17/23 (four days)

A review of the 4/2023 and 5/2023 MARs indicated Resident 13 was administered a Bisacodyl tablet on 4/26/23, 4/27/23, 4/28/23, 5/4/23, 5/5/23, 5/6/23, and 5/11/23.

No evidence was found in the residents clinical record to indicate the Bisacodyl suppository was administered.

On 5/18/23 at 10:54 AM Staff 13 (LPN) stated she expected staff to offer the Bisacodyl suppository if the tablet was not effective.

On 5/18/23 at 11:17 AM Staff 2 (DNS) confirmed the Bisacodyl suppository was not administered to Resident 13 as ordered when the Bisacodyl tablet was not effective.

OAR-411-086-0040: Admission of Residents (Advance Directives)

Refer to F578
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OAR-411-085-0360: Abuse

Refer to F600
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OAR-411-086-0060: Comprehensive Assessment and Care Plan

Refer to F636
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OAR-411-086-0110: Nursing Services: Resident Care

Refer to F684
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Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.

The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 11/14/2022 and 11/20/2022, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.