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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G2 | H· | I· |
| Potential harm | D68 | E20 | F7 |
| 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 | |
|---|---|---|---|---|---|---|
| Jun 1, 2026 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Feb 2, 2026 | Fire safety | Fire Safety Standard | 2 | Potential harm | — | Open → |
| Feb 2, 2026 | Health | Health Standard | 17 | Potential harm | — | Open → |
| Jan 15, 2026 | Health | Health Complaint | 4 | Potential harm | — | Open → |
| Dec 9, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Feb 5, 2025 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Sep 13, 2024 | Fire safety | Fire Safety Standard | 2 | Potential harm | — | Open → |
| Sep 13, 2024 | Health | Health Complaint, Health Standard | 34 | Actual harm | — | Open → |
| Feb 29, 2024 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Nov 28, 2023 | Health | Health Complaint | 6 | Potential harm | — | Open → |
| May 22, 2023 | Fire safety | Fire Safety Standard | 2 | Potential harm | — | Open → |
| May 22, 2023 | Health | Health Standard | 22 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Sep 13, 2024 | Civil money penalty (fine) | $53,024 | — | 385156|Fine|46453 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G2 | H· | I· |
| Potential harm | D68 | E20 | F7 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Jun 1, 2026 | F-0627 | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jun 26, 2026 | Complaint |
| Jun 1, 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 | E · Potential harm Pattern | Corrected Jun 26, 2026 | Complaint |
“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 | — | |
| Corvallis Manor Nursing & Rehabilitation Center 160 NE Conifer Blvd, Corvallis, OR 97330 CCN 385072 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Avamere Riverpark of Eugene 425 Alexander Loop, Eugene, OR 97401 CCN 385185 | 3.2 km | 119 | Mar 2, 2026 | 512 harm | — | |
| Marquis Springfield 1333 N. First Street, Springfield, OR 97477 CCN 385077 | 5.5 km | 136 | Jan 5, 2026 | 62 | — | |
| South Hills Rehabilitation Center 1166 E. 28th Avenue, Eugene, OR 97403 CCN 385167SFF CandidateAbuse icon | 6.3 km | 110 | Aug 18, 2026 | 852 IJ1 harm2 open | $166k | |
| Cascade Manor 65 West 30th Avenue, Eugene, OR 97405 CCN 385276 | 6.8 km | 32 | Apr 23, 2026 | 202 harm | $10k | |
| Avamere Rehabilitation of Eugene 2360 Chambers Street, Eugene, OR 97405 CCN 385053 | 6.9 km | 92 | Mar 30, 2026 | 621 IJ | $36k | |
| Hillside Heights Rehabilitation Center 1201 Mclean Blvd., Eugene, OR 97405 CCN 385046 | 7.1 km | 83 | Aug 27, 2026 | 521 open | — | |
| Creekside Health and Rehabilitation of Cascadia 3500 Hilyard Street, Eugene, OR 97405 CCN 385147 | 7.2 km | 87 | May 22, 2026 | 22 | — | |
| Valley West Health Care Center 2300 Warren Street, Eugene, OR 97405 CCN 385120 | 8.7 km | 121 | Aug 21, 2026 | 751 IJ1 harm5 open | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 385156 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 385156 | 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
| Feb 2, 2026 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 2, 2026 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 2, 2026 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 2, 2026 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 13, 2026 |
| Feb 2, 2026 | 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 | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 2, 2026 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 2, 2026 | 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 Mar 13, 2026 |
| Feb 2, 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 Mar 13, 2026 |
| Feb 2, 2026 | 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 Mar 13, 2026 |
| Feb 2, 2026 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 2, 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 Mar 13, 2026 |
| Feb 2, 2026 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 2, 2026 | 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 Mar 13, 2026 |
| Feb 2, 2026 | 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 Mar 13, 2026 |
| Feb 2, 2026 | 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 Mar 13, 2026 |
| Feb 2, 2026 | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 2, 2026 | 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 Mar 13, 2026 |
| Feb 2, 2026 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Mar 13, 2026 |
| Feb 2, 2026 | 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 Mar 13, 2026 |
| Jan 15, 2026 | 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 Feb 20, 2026 | Complaint |
| Jan 15, 2026 | 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 Feb 20, 2026 | Complaint |
| Jan 15, 2026 | 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 Feb 20, 2026 | Complaint |
| Jan 15, 2026 | 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 Feb 20, 2026 | Complaint |
| Dec 9, 2025 | F-0557 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 23, 2025 | Complaint |
| Dec 9, 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 Dec 23, 2025 | Complaint |
| Feb 5, 2025 | 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 Mar 25, 2025 | Complaint |
| Feb 5, 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 | F · Potential harm Widespread | Corrected Mar 25, 2025 | 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 | G · Actual harm Isolated | Corrected Oct 29, 2024 |
| Sep 13, 2024 | 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 Oct 29, 2024 | Complaint |
| Sep 13, 2024 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Oct 29, 2024 |
| Sep 13, 2024 | K-0920 | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Oct 29, 2024 |
| Sep 13, 2024 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Oct 29, 2024 |
| Sep 13, 2024 | F-0554 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 29, 2024 |
| Sep 13, 2024 | 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 Oct 29, 2024 |
| Sep 13, 2024 | 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 | D · Potential harm Isolated | Corrected Oct 29, 2024 |
| Sep 13, 2024 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 29, 2024 | Complaint |
| Sep 13, 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 | E · Potential harm Pattern | Corrected Oct 29, 2024 | Complaint |
| Sep 13, 2024 | 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 | E · Potential harm Pattern | Corrected Oct 29, 2024 | Complaint |
| Sep 13, 2024 | 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 Oct 29, 2024 | Complaint |
| Sep 13, 2024 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 29, 2024 |
| Sep 13, 2024 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Oct 29, 2024 |
| Sep 13, 2024 | 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 Oct 29, 2024 |
| Sep 13, 2024 | 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 Oct 29, 2024 |
| Sep 13, 2024 | 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 | Past non-compliance Jul 3, 2024 | Complaint |
| Sep 13, 2024 | 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 Oct 29, 2024 | Complaint |
| Sep 13, 2024 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 29, 2024 |
| Sep 13, 2024 | F-0680 | Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Oct 29, 2024 |
| Sep 13, 2024 | 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 Oct 29, 2024 |
| Sep 13, 2024 | 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 Oct 29, 2024 |
| Sep 13, 2024 | 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 Oct 29, 2024 | Complaint |
| Sep 13, 2024 | 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 Oct 29, 2024 |
| Sep 13, 2024 | 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 Oct 29, 2024 |
| Sep 13, 2024 | 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 Oct 29, 2024 |
| Sep 13, 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 Oct 29, 2024 | Complaint |
| Sep 13, 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 | E · Potential harm Pattern | Corrected Oct 29, 2024 | Complaint |
| Sep 13, 2024 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Oct 29, 2024 | Complaint |
| Sep 13, 2024 | F-0745 | Provide medically-related social services to help each resident achieve the highest possible quality of life. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Oct 29, 2024 | Complaint |
| Sep 13, 2024 | 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 Oct 29, 2024 |
| Sep 13, 2024 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Past non-compliance Jul 3, 2024 | Complaint |
| Sep 13, 2024 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Oct 29, 2024 | Complaint |
| Sep 13, 2024 | F-0847 | Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Corrected Oct 29, 2024 |
| Sep 13, 2024 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Oct 29, 2024 |
| Feb 29, 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 | E · Potential harm Pattern | Corrected Apr 2, 2024 | Complaint |
| Feb 29, 2024 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Apr 2, 2024 | Complaint |
| Nov 28, 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 | D · Potential harm Isolated | Corrected Jan 10, 2024 | Complaint |
| Nov 28, 2023 | 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 10, 2024 | Complaint |
| Nov 28, 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 Jan 10, 2024 | Complaint |
| Nov 28, 2023 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jan 10, 2024 | Complaint |
| Nov 28, 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 10, 2024 | Complaint |
| Nov 28, 2023 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 10, 2024 | Complaint |
| May 22, 2023 | K-0344 | Have an alternate power supply for its alarm system. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected May 22, 2023 |
| May 22, 2023 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected May 23, 2023 |
| May 22, 2023 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jul 3, 2023 |
| May 22, 2023 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 3, 2023 |
| May 22, 2023 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 3, 2023 |
| May 22, 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 | D · Potential harm Isolated | Corrected Jul 3, 2023 |
| May 22, 2023 | F-0582 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Jul 3, 2023 |
| May 22, 2023 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 3, 2023 |
| May 22, 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 Jul 3, 2023 |
| May 22, 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 Jul 3, 2023 |
| May 22, 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 | E · Potential harm Pattern | Corrected Jul 3, 2023 |
| May 22, 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 | D · Potential harm Isolated | Corrected Jul 3, 2023 |
| May 22, 2023 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 3, 2023 |
| May 22, 2023 | 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 Jul 3, 2023 |
| May 22, 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 Jul 3, 2023 |
| May 22, 2023 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jul 3, 2023 |
| May 22, 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 Jul 3, 2023 |
| May 22, 2023 | 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 Jul 3, 2023 |
| May 22, 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 Jul 3, 2023 |
| May 22, 2023 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Jul 3, 2023 |
| May 22, 2023 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Jul 3, 2023 |
| May 22, 2023 | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Jul 3, 2023 |
| May 22, 2023 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Jul 3, 2023 |
| May 22, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jul 3, 2023 |
| 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 |
| Donald Knox | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Mar 1, 2023 |
| Jason Maheia | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 7, 2025 |
| Christopher Morris | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Aug 22, 2025 |
| 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 |
| Kensington Or Propco LLC | Organization | Mortgage / security interest | 5% OR GREATER MORTGAGE INTEREST | not provided | Mar 1, 2023 |
| Kensington Or 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 19, 2025 |
| Chaim Hagar | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Donald Knox | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Mar 1, 2023 |
| Jason Maheia | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 7, 2025 |
| Christopher Morris | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Aug 22, 2025 |
| 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 |
| 135 |
| Not rated |
| May 11, 2026 |
882 IJ4 harm |
| $216k |
| Hearthstone Nursing & Rehabilitation Center 2901 E. Barnett Road, Medford, OR 97504 CCN 385091SFF CandidateAbuse icon | 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 |