Regency Florence: Wound Care Order Ignored for Resident - OR
The resident, identified in inspection records only as Resident 38, had been living at the Florence facility since December 2025. She came in with multiple sclerosis and a history of cellulitis of the right lower leg, and on admission she had a four-centimeter-by-four-centimeter venous ulcer there, draining blood-tinged fluid. By early January, evaluations showed the ulcer had resolved. Treatment of the skin continued.
On April 21, 2026, she told inspectors she was concerned about the condition of her leg.
The next afternoon, April 22, inspectors watched a registered nurse and a licensed practical nurse carry out the ordered treatment. The physician's order was specific: cleanse with wound cleanser, apply Xeroform, cover with an ABD pad, wrap with Kerlix, secure. Every Monday, Wednesday, and Friday evening.
When inspectors arrived at 3:11 PM, the old dressing had already been removed. The skin on the resident's lower leg was flaking and yellowed. No open areas were visible.
The registered nurse, identified in records as Staff 6, talked through what she was doing as she worked. After cleaning the leg, she told the resident and the inspector that she was performing "light debridement" — and demonstrated by running her gloved hands up and down the lower leg, rubbing the skin to remove it. The licensed practical nurse then applied the Xeroform, the ABD pads, and the Kerlix wrap.
Debridement was not in the physician's order. It was not in the care plan. Nobody had authorized it.
Two days later, on April 24, inspectors asked the facility's Director of Nursing Services about what they had seen. The director said rubbing the leg to remove skin was not part of the physician-ordered plan of care. She went further: staff should never rub the fragile skin around a healed or healing wound, she said, because it is unknown what lies beneath the surface. Doing so increases the risk of reopening a wound that has closed.
The violation was cited at a level of minimal harm or potential for actual harm, affecting few residents. It was the only deficiency recorded in the April 24 inspection.
That designation — minimal harm — reflects the regulatory threshold at the moment inspectors left. It does not mean nothing could have gone wrong. The nursing director's own words described exactly what the risk was: fragile skin, an unknown interior, a wound that had healed but could open again. The resident had already told someone she was worried about her leg.
What the inspection report does not say is whether the nurse understood she was improvising, or whether this was something she had done before during treatments that no inspector happened to observe. It does not say whether anyone reviewed prior treatment records to find out. It does not say whether Resident 38 was told what had been done differently that afternoon, or what, if anything, changed about her care after inspectors asked their questions.
The physician order was dated April 22 — the same day as the observation. Cleanse. Apply Xeroform. ABD pad. Kerlix. Secure. The order did not include running gloved hands across healing skin until it came away.
Resident 38 had spent four months at Regency Florence by the time inspectors watched her treatment. Her ulcer had closed. She had said she was worried. Then a nurse did something unordered to the skin above whatever was healing underneath, and called it by a clinical name, and the facility's nursing director later told inspectors it should not have happened.
The inspection was completed April 24, 2026.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Regency Florence from 2026-04-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 15, 2026 · Our methodology
REGENCY FLORENCE in FLORENCE, OR was cited for violations during a health inspection on April 24, 2026.
The resident, identified in inspection records only as Resident 38, had been living at the Florence facility since December 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.