Loading facility…
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J2 | K· | L· |
| Actual harm | G4 | H· | I· |
| Potential harm | D60 | E16 | F6 |
| Minimal | A· | B· | C· |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| May 11, 2026 | Fire safety | Fire Safety Standard | 1 | Potential harm | — | Open → |
| May 11, 2026 | Health | Health Complaint, Health Standard | 10 | Potential harm | — | Open → |
| Feb 10, 2026 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Dec 8, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Dec 5, 2025 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Apr 11, 2025 | Health | Health Complaint | 2 | Actual harm | — | Open → |
| Mar 17, 2025 | Fire safety | Fire Safety Standard | 4 | Potential harm | — | Open → |
| Mar 17, 2025 | Health | Health Complaint, Health Standard | 23 | Potential harm | — | Open → |
| Jan 9, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Nov 6, 2024 | Health | Health Complaint | 3 | Potential harm | — | Open → |
| Sep 13, 2024 | Health | Health Complaint | 1 | Potential harm | — | Open → |
| Jun 21, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Dec 28, 2023 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Dec 1, 2023 | Fire safety | Fire Safety Standard | 2 | Potential harm | — | Open → |
| Dec 1, 2023 | Health | Health Complaint, Health Standard | 28 | Actual harm | — | Open → |
| Oct 19, 2023 | Health | Health Complaint | 2 | Immediate jeopardy | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Mar 17, 2025 | Civil money penalty (fine) | $25,220 | — | 385072|Fine|46474 |
| Dec 1, 2023 | Denial of payment for new admissions | — | Mar 14, 2024 · 26 days | 385072|Payment Denial|2024-03-14 |
| Dec 1, 2023 | Civil money penalty (fine) | $164,093 | — | 385072|Fine|46386 |
| Oct 19, 2023 | Civil money penalty (fine) | $13,397 | — | 385072|Fine|46314 |
| Oct 19, 2023 | Civil money penalty (fine) | $13,397 | — | 385072|Fine|46315 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J2 | K· | L· |
| Actual harm | G4 | H· | I· |
| Potential harm | D60 | E16 | F6 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| May 11, 2026 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jun 29, 2026 | |
| May 11, 2026 | F-0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 29, 2026 | Complaint |
| May 11, 2026 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: — (case-mix index —).
CMS legal business name of the certified provider. Operates this facility only.
16 facilities in 3 states. CMS chain ID 628.
Chain average overall rating (CMS): 1.6
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Pac 12 Opco Holdco LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Mar 1, 2023 |
| Knox Healthcare Pac 12 Holdings LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided | Mar 1, 2023 |
| Pac 12 Holdings LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided | Mar 1, 2023 |
| Pac 12 Pinnacle Holdco LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided | Mar 1, 2023 |
| Alexander Hagler | Individual | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided | Mar 1, 2023 |
| Donald Knox | Individual | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided | Mar 1, 2023 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Pac 12 Opco Holdco LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Mar 1, 2023 |
| Knox Healthcare Pac 12 Holdings LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided | Mar 1, 2023 |
| Pac 12 Holdings LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided | Mar 1, 2023 |
| Pac 12 Pinnacle Holdco LLC | Organization | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Hillside Heights Rehabilitation Center 1201 Mclean Blvd., Eugene, OR 97405 CCN 385046 | 83 | Aug 27, 2026 | 521 open | — | |
| Hearthstone Nursing & Rehabilitation Center 2901 E. Barnett Road, Medford, OR 97504 CCN 385091 |
Coordinates as published by CMS.
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 385072 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 385072 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| F-0655 |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care |
| D · Potential harm Isolated |
| Corrected Jun 29, 2026 |
| May 11, 2026 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 29, 2026 |
| May 11, 2026 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 29, 2026 |
| May 11, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 29, 2026 | Complaint |
| May 11, 2026 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 29, 2026 |
| May 11, 2026 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 29, 2026 |
| May 11, 2026 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jun 29, 2026 |
| May 11, 2026 | F-0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Jun 29, 2026 |
| May 11, 2026 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Jun 29, 2026 |
| Feb 10, 2026 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 13, 2026 | Complaint |
| Dec 8, 2025 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 5, 2026 | Complaint |
| Dec 8, 2025 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Jan 5, 2026 | Complaint |
| Dec 5, 2025 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 5, 2026 | Complaint |
| Dec 5, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 5, 2026 | Complaint |
| Dec 5, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 5, 2026 | Complaint |
| Apr 11, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Apr 29, 2025 | Complaint |
| Apr 11, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 29, 2025 | Complaint |
| Mar 17, 2025 | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 25, 2025 |
| Mar 17, 2025 | E-0030 | List the names and contact information of those in the facility. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 25, 2025 |
| Mar 17, 2025 | K-0271 | Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 25, 2025 | Complaint |
| Mar 17, 2025 | F-0585 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 25, 2025 | Complaint |
| Mar 17, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 25, 2025 | Complaint |
| Mar 17, 2025 | F-0687 | Provide appropriate foot care. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0698 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0699 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0700 | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0742 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Apr 25, 2025 | Complaint |
| Mar 17, 2025 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0773 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0775 | Keep complete, dated laboratory records in the resident's record. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0803 | 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. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Apr 25, 2025 |
| Mar 17, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 25, 2025 | Complaint |
| Mar 17, 2025 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 25, 2025 |
| Jan 9, 2025 | F-0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Jan 27, 2025 | Complaint |
| Jan 9, 2025 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 27, 2025 | Complaint |
| Nov 6, 2024 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 18, 2024 | Complaint |
| Nov 6, 2024 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Dec 18, 2024 | Complaint |
| Nov 6, 2024 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Dec 18, 2024 | Complaint |
| Sep 13, 2024 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Past non-compliance Jul 16, 2024 | Complaint |
| Jun 21, 2024 | F-0727 | 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. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Jul 30, 2024 | Complaint |
| Jun 21, 2024 | F-0887 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Jul 30, 2024 | Complaint |
| Dec 28, 2023 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 25, 2024 | Complaint |
| Dec 28, 2023 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 25, 2024 | Complaint |
| Dec 1, 2023 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Apr 9, 2024 | Complaint |
| Dec 1, 2023 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Jan 19, 2024 |
| Dec 1, 2023 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Jan 19, 2024 | Complaint |
| Dec 1, 2023 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 19, 2024 |
| Dec 1, 2023 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 19, 2024 |
| Dec 1, 2023 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 19, 2024 | Complaint |
| Dec 1, 2023 | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jan 19, 2024 |
| Dec 1, 2023 | F-0578 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jan 19, 2024 |
| Dec 1, 2023 | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 19, 2024 | Complaint |
| Dec 1, 2023 | F-0585 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 19, 2024 | Complaint |
| Dec 1, 2023 | F-0625 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jan 19, 2024 | Complaint |
| Dec 1, 2023 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 9, 2024 | Complaint |
| Dec 1, 2023 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 19, 2024 | Complaint |
| Dec 1, 2023 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 19, 2024 |
| Dec 1, 2023 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jan 19, 2024 | Complaint |
| Dec 1, 2023 | F-0685 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 19, 2024 |
| Dec 1, 2023 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 19, 2024 |
| Dec 1, 2023 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 9, 2024 |
| Dec 1, 2023 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 19, 2024 | Complaint |
| Dec 1, 2023 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Jan 19, 2024 | Complaint |
| Dec 1, 2023 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Jan 19, 2024 |
| Dec 1, 2023 | F-0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jan 19, 2024 |
| Dec 1, 2023 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jan 19, 2024 |
| Dec 1, 2023 | F-0773 | Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Jan 19, 2024 | Complaint |
| Dec 1, 2023 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Jan 19, 2024 |
| Dec 1, 2023 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Feb 20, 2024 | Complaint |
| Dec 1, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Apr 9, 2024 | Complaint |
| Dec 1, 2023 | F-0940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Jan 19, 2024 | Complaint |
| Dec 1, 2023 | F-0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Jan 19, 2024 | Complaint |
| Oct 19, 2023 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Past non-compliance Oct 15, 2023 | Complaint |
| Oct 19, 2023 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | J · Immediate jeopardy Isolated | Past non-compliance Oct 15, 2023 | Complaint |
| not provided |
| Mar 1, 2023 |
| Alexander Hagler | Individual | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided | Mar 1, 2023 |
| Donald Knox | Individual | Indirect owner | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | not provided | Mar 1, 2023 |
| Volare Health LLC | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Maureen Bruns | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jan 29, 2024 |
| Tracey Henning | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Jun 11, 2025 |
| Donald Knox | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Eliezer Schwartz | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Donald Knox | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Mar 1, 2023 |
| Brian Smith | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Mar 27, 2023 |
| Conifer Propco LLC | Organization | Mortgage / security interest | 5% OR GREATER MORTGAGE INTEREST | not provided | Mar 1, 2023 |
| Conifer Propco LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Pac 12 Holdings LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Pac 12 Pinnacle Holdco LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Volare Health LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Aug 18, 2025 |
| Maureen Bruns | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jan 29, 2024 |
| Chaim Hagar | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Tracey Henning | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Jun 11, 2025 |
| Donald Knox | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Eliezer Schwartz | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Brian Smith | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 27, 2023 |
| 87 |
| Mar 4, 2026 |
794 IJ2 harm |
| $231k |
| French Prairie Nursing & Rehabilitation Center 601 Evergreen Road, Woodburn, OR 97071 CCN 385117SFF Candidate | 80 | Aug 10, 2026 | 833 IJ3 harm23 open | $103k |
| Umpqua Valley Nursing & Rehabilitation Center 525 W. Umpqua Street, Roseburg, OR 97471 CCN 385143 | 118 | Aug 22, 2025 | 46 | $8,824 |
| Royale Gardens Health & Rehabilitation Center 2075 NW Highland Avenue, Grants Pass, OR 97526 CCN 385148 | 145 | Jul 15, 2026 | 777 harm | $82k |
| Highland House Nursing & Rehabilitation Center 2201 NW Highland Avenue, Grants Pass, OR 97526 CCN 385149 | 119 | Apr 22, 2026 | 902 IJ | $37k |
| Rose Haven Nursing Center 740 NW Hill, Roseburg, OR 97471 CCN 385151 | 193 | Jun 5, 2026 | 452 harm | $85k |
| Green Valley Rehabilitation Health Center 1735 Adkins Street, Eugene, OR 97401 CCN 385156 | 110 | Jun 1, 2026 | 972 harm | $53k |