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Hearthstone Nursing & Rehabilitation Center

2901 E. Barnett Road, Medford, OR 97504 · Jackson County · (541) 779-4221

87 certified beds, about 81 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1974

CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
4 of 5
Quality measures
3 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 385091 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on May 23, 2025, inspectors cited 5 health deficiencies (the Oregon average is 9.2, the national average 9.2).

Of 75 health citations since October 2023, 6 were rated as actual harm or immediate jeopardy to residents (4 immediate jeopardy).

CMS lists 3 fines totaling $230,522 in the last three years; the largest was $88,282, and the latest is dated May 31, 2024.

Nurses and nurse aides worked 4.41 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.67 of those hours.

37.1% of nursing staff left within the year CMS measured (Oregon average 47.4%).

CMS links it to Volare Health, an affiliated group of 16 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 75 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
4J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
51D
12E
6F
Potential for minimal harm
0A
0B
0C
March 4, 2026Complaint inspection · 5 citations
  1. D
    Protect each resident from the wrongful use of the resident's belongings or money.
    F602 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure residents were free from misappropriation of money for 1 of 4 sampled residents (#18) reviewed for abuse and misappropriation. This placed residents at risk for loss of property.
  2. D
    Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.
    F620 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 23, 2026
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received required admissions documents at or before admission for 1 of 3 sampled residents (#9) reviewed for resident rights. This placed residents at risk for not understanding their rights and services.
  3. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 23, 2026
    Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 3 of 5 sampled residents (#s 3, 6, and 13) reviewed for ADLs and call lights. This placed resident at risk for unmet needs.
  4. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 23, 2026
    Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 1 of 4 sampled residents (#19) reviewed for medications. This placed residents at risk for delayed treatment and unmet medication needs.
  5. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 23, 2026
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident records were complete and accurate for 3 of 14 sampled residents (#s 1, 4, and 12) reviewed for medical records. This placed residents at risk for inaccurate medical records.
November 25, 2025Complaint inspection · 1 citation
  1. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 19, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to revise care plan interventions and re-evaluate a resident's elopement to ensure a resident's safety for 1 of 3 sampled residents (#1) reviewed for elopement. This placed residents at risk for repeated elopements.
May 23, 2025Standard inspection, Complaint inspection · 5 citations
  1. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 24, 2025
    Inspectors wroteBased on interview and record review, it was determined the facility failed to protect the resident's right to be free from abuse for 2 of 2 sampled residents (#s 32 & 208) reviewed for abuse. This placed residents at risk for mental anguish and abuse.
  2. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 24, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure alleged violations involving sexual abuse were reported immediately, but no later than two hours after the allegation is made for 2 of 2 sampled residents (#s 32 and 208) reviewed for abuse. This placed residents at risk for abuse.
  3. D
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    F636 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 24, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to develop a comprehensive assessment for 1 of 3 residents (#31) reviewed for tube feeding. This placed residents at risk for unmet nutritional needs and weight loss. Resident 31 was admitted to the facility in 4/2025 with diagnoses including a feeding tube. The 5/3/25 admission Nutritional Status CAA indicated Resident 31 had nutritional problems or potential problem related to acute kidney failure, UTI, diabetes, severe septic shock, high blood pressure and Enteral feeding. (tube feeding.) The admission Nutritional CAA did not include Resident 31's eating pattern, communication problems, resident or family input, or care plan considerations. [...]
  4. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 24, 2025
    Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure dialysis (a procedure which removes waste products and excess fluid from the blood when the kidneys are no longer functioning properly) services were completed, including monitoring and communication with the dialysis provider for 1 of 1 sampled resident (#44) reviewed for dialysis. This placed residents at risk for delayed treatment and medical complications related to dialysis.
  5. D
    Provide or obtain dental services for each resident.
    F791 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 24, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to follow up on dental services for 1 of 1 sampled resident (#6) reviewed for dental services. This placed residents at risk for unmet dental health needs.
December 7, 2024Standard inspection, Complaint inspection · 10 citations
  1. E
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) January 21, 2025
    Inspectors wroteBased on observation and interview it was determined the facility failed to properly dispose of expired medications for 1 of 1 medical storage room, 2 of 3 medication carts, and 2 of 3 resident medication storage refrigerators reviewed for medication storage. This placed residents at risk for lack of medication efficacy and adverse reactions from expired medications.
  2. D
    Ensure that residents are fully informed and understand their health status, care and treatments.
    F552 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 21, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to update a resident's POLST (physician orders for life sustaining treatment; end of life choices) for 1 of 4 sampled residents (#36) reviewed for ADLs. This placed residents at risk for end-of-life choices not being honored.
  3. D
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 21, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure transfer notices with appeal rights were provided in writing to residents and their representatives, and to ensure the Office of the State Long-Term Care Ombudsman was notified of resident hospitalizations for 2 of 2 sampled resident (#s 4 and 36) reviewed for hospitalizations. This placed residents at risk of lack of access to an advocate to inform them of their options and rights, and a decreased quality of life.
  4. D
    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.
    F625 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 21, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to provide information regarding the facility's bed hold policy for 2 of 2 sampled residents (#s 4 and 36) reviewed for hospitalization. This placed residents at risk for lack of knowledge regarding the right to return to the same bed within the facility.
  5. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 21, 2025
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to assist residents with hygiene for 2 of 4 sampled residents (#s 8 and 36) reviewed for ADLs. This placed residents at risk for lack of dignity.
  6. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 21, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician's orders and provide care and services to maintain the highest practicable level of well-being for 1 of 7 sampled residents (# 36) reviewed for hospitalization.
  7. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 21, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure falls were evaluated timely and care plan interventions were updated, appropriate and followed for 2 of 2 sampled resident (#s 12 and 32) reviewed for accidents. This placed residents at risk for accidents.
  8. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 21, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received accurate provision of prescribed medications for 3 of 6 sampled residents (#s 2, 4 and 13) reviewed for medications and hospitalizations. This placed residents at risk for not receiving medications as prescribed.
  9. D
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on interview and record review it was determined the facility failed to address pharmacy recommendations for 1 of 5 sampled residents (#13) reviewed for medications. This placed residents at risk for adverse medication reactions.
  10. D
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 21, 2025
    Inspectors wroteBased on interview, and record review it was determined the facility failed to conduct a resident's psychotropic GDRs (Gradual Dose Reduction) for 1 of 5 sampled residents (#17) reviewed for medications. This placed residents at risk for receiving unnecessary psychotropic medications.
November 5, 2024Complaint inspection · 1 citation
  1. D
    Protect each resident from the wrongful use of the resident's belongings or money.
    F602 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on interview and record review it was determined the facility misappropriated narcotic medication for 1 of 3 sampled residents (#3) reviewed for abuse. This placed residents at risk for increased pain.
June 28, 2024Standard inspection, Complaint inspection · 17 citations
  1. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure adequate sanitation for 1 of 1 facility kitchen. This placed residents at risk for food-borne illnesses.
  2. E
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on observation, interview, and record review it was determine that facility failed to provide appropriate silverware for 1 of 1 dining room and 1 of 1 random resident (#4) reviewed for dining. This placed residents at risk for lack of a dignified dining experience.
  3. E
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure the environment was free of loud noises for 1 of 2 halls reviewed. This placed residents at risk for an uncomfortable environment.
  4. E
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wrote3. Resident 3 admitted to the facility in 2023 with a diagnosis of a stroke. Resident 3's clinical record revealed a MDS assessment was completed on 3/30/24. Record review revealed no evidence a care conference was conducted after the 3/30/24 MDS assessment. On 6/25/24 at 12:29 PM Staff 15 (Social Services) acknowledged Resident 3 did not have a care conference after her/his most recent MDS assessment. 4. Resident 24 admitted to the facility in 2024 with a diagnosis of Parkinson's disease. Resident 24's clinical record revealed a significant change MDS was completed on 3/26/24, and indicated Resident 24 was cognitively intact. On 6/24/24 at 9:32 AM Resident 24 stated she/he did not participate in a care conference for a long time. [...]
  5. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure narcotics were disposed timely for 3 of 4 medication carts (Wing 1, Wing 2, and Wing 3) reviewed for medication storage.
  6. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow infection control standards for 1 of 5 sampled residents (#204) reviewed for medications and 1 of 1 dining room during random observations. This placed residents at risk for exposure and contraction of infectious diseases.
  7. D
    Ensure that residents are fully informed and understand their health status, care and treatments.
    F552 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident or resident's responsible part was involved with decisions related to care for 2 of 6 sampled residents (#s 21 and 31) reviewed for medications and restraints. This placed residents at risk for lack of health care choices.
  8. D
    Allow residents to self-administer drugs if determined clinically appropriate.
    F554 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident was assessed to self-administer medications for 1 of 4 sampled residents (#6) reviewed for accidents. This placed residents at risk for unnecessary medications.
  9. D
    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.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents' advance directives were in the clinical record and residents were provided advance directive information for 2 of 8 sampled residents (#s 3 and 24 ) reviewed for advance directives. This placed residents at risk for end of life choices not being honored.
  10. D
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    F582 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a NOMNC (Notice of Medicare Non-Coverage) was provided to 1 of 3 sampled residents (#19) reviewed for beneficiary notices. This placed residents at risk for being uninformed regarding their appeal rights.
  11. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to complete a thorough investigation for falls for 1 of 5 sampled residents (#27) reviewed for medications. This placed residents at risk for accidents.
  12. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure oxygen was in place as ordered for 1 of 1 sampled resident (#12) reviewed for respiratory care. This placed residents at risk for impaired respiratory status.
  13. D
    Observe each nurse aide's job performance and give regular training.
    F730 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 3 of 5 sampled CNA staff (#s 4, 5, and 6) reviewed for staffing. This placed residents at risk for a lack of competent staff.
  14. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to monitor anticoagulants for 1 of 5 sampled resident (#20) reviewed for pain and ensure insulin was held for 1 of 5 sampled resident (# 31) reviewed for medications. This placed residents at risk for adverse side effects of medications and low blood sugar levels.
  15. D
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to consistently monitor residents on psychotropic medications for 3 of 5 sampled residents (#s 20, 27 and 38) reviewed for psychotropic medications. This placed residents at risk for receiving unnecessary psychotropic medications.
  16. D
    Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
    F847 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident understood an arbitration agreement for 1 of 3 sampled residents (#38) reviewed for arbitration. This placed residents at risk for loss of legal rights.
  17. D
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    F947 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 17, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 3 of 5 randomly selected staff members (#s 4, 6 and 8) reviewed for evidence of in-service training. This placed residents at risk for lack of competent staff.
May 31, 2024Complaint inspection · 8 citations
  1. J
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 13, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from sexual abuse for 2 of 5 sampled residents (#s 15 and 16) reviewed for abuse. This failure, determined to be an immediate jeopardy situation, placed residents at risk for sexual abuse when staff witnessed repeated intimate nonconsensual sexual activity without completing assessments to determine ability to consent and without putting appropriate interventions in place.
  2. J
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 13, 2024
    Inspectors wroteBased on interview and record review the facility administration failed to implement their abuse policy procedures in the areas of identification, investigation, protection, and reporting which resulted in repeated incidents of sexual abuse for 2 of 5 sampled residents (#s 15 and 16) reviewed for abuse. This failure to implement their abuse policy and procedures resulted in Resident 15 and Resident 16 repeatedly engaging in intimate nonconsensual sexual activity. The facility's 3/2023 Freedom from Abuse, Neglect and Exploitation policy including the Abuse Reporting and Responsibilities of Covered Individuals indicated the following: - The facility will provide a safe resident environment and protect residents from abuse . this includes freedom from . sexual or physical abuse. - Report allegation to appropriate authorities within required timeframes and conduct a thorough investigation. [...]
  3. J
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 13, 2024
    Inspectors wrote1. Based on interview and record review it was determined the facility failed to obtain treatment orders, failed to administer timely treatment, and failed to provided correct treatment for a surgical wound for 1 of 7 sampled residents (#6) reviewed for wounds. This failure, determined to be an immediate jeopardy situation, resulted in Resident 6 experiencing a delay in wound care treatment which resulted in the resident's wound to become infected and dehisced (separation of the wound due to improper healing). Resident 6 was re-hospitalized and required surgery for an above the knee amputation (AKA).
  4. J
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 13, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to comprehensively assess, monitor, treat and follow physician orders for pressure ulcer treatment for 1 of 7 sampled residents (#4) reviewed for pressure ulcers. This failure, determined to be an immediate jeopardy situation, resulted in Resident 4's Stage 2 (partial thickness skin loss) pressure ulcer observed upon admission which worsened to an infected, unstageable (full thickness tissue loss where the depth of the wound is obscured by non-viable or dead tissue) pressure ulcer. Resident 4 was admitted to the hospital where she/he required surgical debridement (the removal of damaged tissue from the wound).
  5. F
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) July 13, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure there was sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility and for 4 of 4 sampled residents (#s 11, 22, 23 and 24) reviewed for staffing. This placed residents at risk for unmet care needs.
  6. F
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) July 13, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the facility had nursing staff with the appropriate wound care competencies and skills sets for 12 of 12 licensed nurse staff reviewed for nursing services. This placed residents at risk for unmet wound care needs.
  7. F
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    F867 · Administration · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) July 13, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure effective systems were in place to identify problems, and take action to improve and monitor its performance for 1 of 1 facility reviewed for quality assessment and assurance. This failure placed residents at risk for worsening care.
  8. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 13, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were treated with respect and dignity for 1 of 3 residents (#22) reviewed for dignity. This placed residents at risk for being treated in an undignified manner.
February 27, 2024Complaint inspection · 7 citations
  1. G
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 17, 2024
    Inspectors wroteBased on interviews and record review, it was determined the facility failed to ensure residents were free from verbal and physical abuse for 2 of 6 sampled residents (#s 13 and 17) reviewed for abuse. Resident 13 experienced psychosocial harm.
  2. F
    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.
    F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) April 17, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a RN served as the DNS on a full-time basis for 1 of 1 facility reviewed for DNS staffing. This placed residents at risk for lack of nursing department oversight.
  3. E
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) April 17, 2024
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure there was sufficient nursing staff available to provide care and services to meeting the residents needs for 4 of 4 wings (Wings 1,2,3 and 4) reviewed for staffing. This placed residents at risk for unmet care needs.
  4. E
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) April 17, 2024
    Inspectors wroteBased on observation and interview it was determined the facility failed to ensure medications were properly secured and only accessible to authorized personnel for 3 of 3 random observations reviewed for medication storage. This placed residents at risk for access to potentially harmful medications.
  5. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 17, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to complete and implement baseline care plans to ensure resident safety for 1 of 1 sampled resident (#25) reviewed for behaviors. This placed residents at risk for unaddressed needs.
  6. D
    Provide care or services that was trauma informed and/or culturally competent.
    F699 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 17, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident who was a trauma survivor received trauma-informed care for 1 of 6 sampled residents (#13) reviewed for abuse. This placed residents at risk for unmet trauma needs and a decreased quality of life.
  7. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 17, 2024
    Inspectors wroteBased on observation and interview it was determined the facility failed to maintain an infection control program and provide a sanitary and comfortable environment for 1 of 1 random observation (room [ROOM NUMBER]) reviewed for infection control. This placed residents at risk for an unsanitary, non-homelike environment.
February 1, 2024Complaint inspection · 7 citations
  1. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 22, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure care plans were developed for 1 of 3 sampled residents (#7) reviewed for pressure ulcers. This placed residents at risk for worsening wounds.
  2. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 22, 2024
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure care plans were revised for 2 of 4 sampled residents (#s 5 and 6) reviewed for adaptive equipment and medical devices. This placed residents at risk for lack of resident specific care.
  3. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 22, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure provision of ADL care for 2 of 6 sampled residents (#s 1 and 8) reviewed for eating and bathing assistance. This placed residents at risk for aspiration and poor hygiene.
  4. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 8, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to provide bowel care for 1 of 3 sampled residents (#1) reviewed for bowel care, failed to monitor residents after a fall for 2 of 3 sampled residents (#s 6 and 9) reviewed for accidents, failed to provide a resident a compression boot for 1 of 3 sampled residents (#1) reviewed for medical equipment and failed to assist a resident with glasses for 1 of 3 sampled residents (#6) reviewed for glasses. This placed residents at risk for unidentified injuries and untreated medical conditions.
  5. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 8, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's visitor was monitored to ensure safety for 1 of 3 sampled residents (#7) reviewed for supervision. This placed residents at risk for adverse medical events.
  6. D
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    F773 · Administration · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 22, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a UA was obtained and results reported timely for 1 of 2 sampled residents (#1) reviewed for UTI. This placed residents at risk for untreated infections.
  7. D
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    F810 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 8, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide assistive devices for 1 of 3 sampled residents (#5) reviewed for care plans. This placed residents at risk for unmet needs.
November 8, 2023Complaint inspection · 11 citations
  1. G
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wrote2. Resident 144 was admitted to the facility in 2023 with diagnoses including cancer and chronic pain. An 10/25/23 admission Evaluation indicated Resident 144 was alert to person, place, time, and situation. An 10/27/23 Pain Evaluation indicated resident 144 could not verbalize pain. On 10/30/23 at 3:15 PM Witness 9 (Family Member) stated Resident 144 did not receive pain medication besides Tylenol since admission, which did not work for cancer pain. Witness 9 stated nursing was notified multiple times. Resident 144 was painful and in tears but the staff did not notify the physician for stronger pain medication. Witness 9 stated the resident was on hydrocodone (pain medication) in the hospital and it worked for her/his pain. On 10/31/23 at 4:43 PM Resident 144 was observed lying in bed grimacing. A physician order dated 10/31/23 included oxycodone (pain medication) as needed. [...]
  2. F
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure ADL assistance was provided for 7 of 7 sampled residents (#s 6, 7, 58, 63, 133, 144, and 222) reviewed for ADLs. This placed residents at risk for poor hygiene.
  3. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow physician orders, provide resident positioning, and identify change of condition timely for 4 of 11 sampled residents (#s 9, 46, 58, and 73) reviewed for medications, change of condition, dialysis, and pain. This placed residents at risk for unmet needs.
  4. E
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 23, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents in a timely manner for 3 of 24 sampled residents (#s 5, 72, and 73) and 4 of 4 wings (wings 1, 2, 3, and 4) reviewed for staffing and ADLs. This placed residents at risk for unmet needs.
  5. E
    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.
    F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on interview and record review it was determined the facility failed to staff a registered nurse for 8 consecutive hours per day 7 days per week for 2 out of 63 days reviewed for staffing. This placed residents at risk for unmet assessment needs.
  6. D
    Ensure that residents are fully informed and understand their health status, care and treatments.
    F552 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on interview and record review it was determined the facility failed to provide risk and benefits for the use of antipsychotic medications to a resident/responsible party prior to administration for 1 of 6 sampled resident (#73) reviewed for medications. This placed residents and responsible parties at risk for lack of informed consent.
  7. D
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    F604 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on interview and record review it was determined the facility failed to assess a resident for a seatbelt for 1 of 1 sampled resident (#58) reviewed for dialysis (the perification of blood through a machine). This placed residents at risk for being restrained.
  8. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on interview, and record review it was determined the facility failed to prevent and investigate pressure ulcers for 1 of 4 sampled residents (#73) reviewed for pressure ulcers. This placed residents at risk for pressure ulcers.
  9. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on interview, and record review it was determined the facility failed to ensure a resident was provided toileting assistance for 1 of 5 sampled residents (#72) reviewed for bowel and bladder. This placed residents at risk for UTIs and lack of dignity.
  10. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 23, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure respiratory equipment filters were clean for 1 of 3 sampled residents (#8) reviewed for environment. This placed residents at risk for impaired respiratory health.
  11. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 28, 2023
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents records were complete and accurate for 2 of 3 sampled residents (#s 7 and 73) reviewed for nutrition and change of condition. This placed residents at risk for weight loss and abnormal lab values.
October 23, 2023Complaint inspection · 3 citations
  1. E
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    F636 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 11, 2023
    Inspectors wroteBased on interview and record review it was determined the facility failed to complete a comprehensive assessment within 14 days of admission for 5 of 6 sampled residents (#s 1, 3, 4, 5 and 6) reviewed for comprehensive assessments. This placed residents at risk for unmet needs.
  2. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 11, 2023
    Inspectors wroteBased on interview and record review it was determined the facility failed to complete an investigation to rule out neglect within five working days for 1 of 2 sampled residents (#1) reviewed for elopement. This placed residents at risk for accidents.
  3. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 11, 2023
    Inspectors wroteBased on interview and record review it was determined the facility failed to update the care plan after an elopement for 1 of 2 sampled residents (#1) reviewed for elopement.

Fire safety inspections

4 fire safety citations on file: 2 on May 23, 2025, 2 on June 28, 2024.

Every fire safety citation4 citations
  1. F
    Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
    K 111 · May 23, 2025 · Corrected (the home has a date of correction)
  2. F
    Have simulated fire drills held at unexpected times.
    K 712 · May 23, 2025 · Corrected (the home has a date of correction)
  3. F
    Have simulated fire drills held at unexpected times.
    K 712 · June 28, 2024 · Corrected (the home has a date of correction)
  4. D
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · June 28, 2024 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
May 31, 2024Fine $88,282
May 31, 2024Payment Denial 48 days from June 30, 2024
February 1, 2024Fine $82,274
February 1, 2024Payment Denial 7 days from May 1, 2024
October 23, 2023Fine $59,966

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeOregonUnited States
All nursing staff (RN, LPN and aides)4.415.033.86
Registered nurses0.670.720.69
All nursing staff on weekends3.774.513.42
Nurse aides3.07
Licensed practical nurses0.66
Nursing staff turnover (share who left in a year)37.1%47.4%45.8%
Registered nurse turnover57.1%51.6%42.9%
Administrators who left2

CMS expects 3.51 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.67 on weekdays and 3.77 on weekends, 19% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.1% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.04 in April to June 2025 to 4.41 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20264.410.674.673.77 0.1%0 of 9081
Oct to Dec 20254.410.664.663.76 2.7%0 of 9275
Jul to Sep 20254.660.774.894.10 5.2%0 of 9262
Apr to Jun 20255.040.685.344.28 4.1%0 of 9156
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Oregon, Jan to Mar 20264.910.645.124.406.2%0.4% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Oregon

JobMedianMiddle halfEmployed
Oregon, all employers
CNAs (nursing assistants)$23.96$22.83 to $28.4014,800
LPNs and LVNs$38.69$35.11 to $43.604,260
Registered nurses$62.02$51.55 to $64.6339,730
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

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For Hearthstone Nursing & Rehabilitation Center. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

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Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeOregonUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
22.614.913.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.01.40.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
2.02.01.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
0.02.43.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
1.11.41.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
47.420.614.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
5.15.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
5.613.915.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
23.121.423.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
15.116.112.0

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Hearthstone Nursing & Rehabilitation Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (57.5% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

57.5% this home

Better than the national rate

US median of homes 51.5% · Oregon: 52 better, 3 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 235 eligible stays.

Potentially preventable readmissions

9.8% this home

No different from the national rate

US median of homes 10.7% · Oregon: 3 better, 0 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 198 eligible stays.

Infections that led to a hospital stay

6.0% this home

No different from the national rate

US median of homes 7.1% · Oregon: 0 better, 0 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 106 eligible stays.

Self-care and mobility at discharge

47.3% this home

Median of homes: Oregon59.2% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 74 residents counted.

Falls with major injury

0.0% this home

Median of homes: Oregon0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 105 residents counted.

New or worsened pressure ulcers

0.9% this home

Median of homes: Oregon2.6% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 105 residents counted.

Medication list given at discharge

92.7% this home

Median of homes: Oregon98.5% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 68 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: MEDFORD NURSING & REHAB CENTER LLC. CMS links this home to Volare Health, a group of 16 nursing homes averaging 1.8 stars overall.

NameRoleTypeShareSince
Pac 12 Opco Holdco LLC5% or greater direct ownership interestOrganization100%03/01/2023
Knox Healthcare Pac 12 Holdings LLC5% or greater indirect ownership interestOrganization03/01/2023
Pac 12 Holdings LLC5% or greater indirect ownership interestOrganization03/01/2023
Pac 12 Pinnacle Holdco LLC5% or greater indirect ownership interestOrganization03/01/2023
Hagler, Alexander5% or greater indirect ownership interestIndividual03/01/2023
Knox, Donald5% or greater indirect ownership interestIndividual03/01/2023
Medford Propco LLC5% or greater mortgage interestOrganization03/01/2023
Knox, DonaldCorporate officerIndividual03/01/2023
Smith, BrianCorporate officerIndividual03/27/2023
Volare Health LLCOperational/managerial controlOrganization03/01/2023
Kahn, KarenOperational/managerial controlIndividual07/03/2023
Knox, DonaldOperational/managerial controlIndividual03/01/2023
Moore, JamesOperational/managerial controlIndividual09/03/2024
Schwartz, EliezerOperational/managerial controlIndividual03/01/2023
Medford Propco LLCAdp of the SNFOrganization03/01/2023
Pac 12 Holdings LLCAdp of the SNFOrganization03/01/2023
Pac 12 Pinnacle Holdco LLCAdp of the SNFOrganization03/01/2023
Volare Health LLCAdp of the SNFOrganization08/20/2025
Hagar, ChaimAdp of the SNFIndividual03/01/2023
Kahn, KarenAdp of the SNFIndividual07/03/2023
Knox, DonaldAdp of the SNFIndividual03/01/2023
Moore, JamesAdp of the SNFIndividual09/03/2024
Schwartz, EliezerAdp of the SNFIndividual03/01/2023
Smith, BrianAdp of the SNFIndividual03/27/2023

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 22 problems in this area, most recently on March 4, 2026: "Provide care and assistance to perform activities of daily living for any resident who is unable."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 12 problems in this area, most recently on March 4, 2026: "Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide."
  3. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 9 problems in this area, most recently on March 4, 2026: "Protect each resident from the wrongful use of the resident's belongings or money."
  4. When is the care plan meeting, and can family attend it?Inspectors cited 9 problems in this area, most recently on March 4, 2026: "Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.77 hours per resident per day, below the Oregon average of 4.51.
  6. How long has the current administrator been here?CMS counts 2 administrators who left in the period it measured.

Other nursing homes nearby

Oregon contacts for a concern about a nursing home

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Common questions

What is Hearthstone Nursing & Rehabilitation Center's Medicare star rating?
CMS rates Hearthstone Nursing & Rehabilitation Center 1 out of 5 stars overall, with 1 for health inspections, 4 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Hearthstone Nursing & Rehabilitation Center get at its last inspection?
5 health deficiencies at the standard inspection on May 23, 2025. The Oregon average is 9.2.
Has Hearthstone Nursing & Rehabilitation Center been fined?
Yes. CMS lists 3 fines totaling $230,522 in the last three years.
Does Hearthstone Nursing & Rehabilitation Center accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Hearthstone Nursing & Rehabilitation Center?
CMS lists 24 owners and managers, and links the home to Volare Health. Legal business name: MEDFORD NURSING & REHAB CENTER LLC.

Sources

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