South Hills Rehabilitation Center
1166 E. 28th Avenue, Eugene, OR 97403 · Lane County · (541) 345-0534
110 certified beds, about 76 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1985
Special Focus Facility candidate 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
3 of 5
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385167 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on August 11, 2025, inspectors cited 11 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 74 health citations since April 2019, 3 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists 3 fines totaling $165,996 in the last three years; the largest was $79,238, and the latest is dated July 15, 2026.
Nurses and nurse aides worked 4.72 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.47 of those hours.
67.5% 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.
804/19
3303/24
810/24
1108/25
212/25
102/26
304/26
807/26
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 74 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
1L
Actual harm
1G
0H
0I
Potential for more than minimal harm
52D
19E
0F
Potential for minimal harm
0A
0B
0C
July 15, 2026Complaint inspection · 8 citations
- J Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assess, develop, reassess and implement a person-centered care plan for dementia care needs to ensure resident safety for 4 of 4 sampled residents (#s 1, 2, 3, and 4) reviewed for elopement. As a result, Resident 1 left the faciity on [DATE] without staff knowledge, had an incident involving her/his power wheelchair getting stuck outside on [DATE], and on [DATE] left the facility again, which placed the resident at risk for serious injury. Resident 1 lacked a comprehensive assessment and person-centered care plan for her/his dementia with Lewy bodies. There were no interventions developed and implemented to ensure the appropriate supervision and monitoring were in place to prevent an injury. [...]
- E Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review it was determined the facility failed to develop assessments that were comprehensive and failed to complete assessments in a timely manner for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) reviewed for MDS assessments. This placed residents at risk for unassessed and unmet care needs.
- E Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Inspectors wroteBased on interview and record review it was determined the facility failed to develop, implement, and maintain an effective training program related to behavior health care and services for 1 of 1 training program reviewed for staff training. This placed residents at risk for unmet behavioral health care needs.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to notify the resident's representative for 1 of 4 sampled residents (#1) reviewed for elopement. This placed resident representatives at risk for lack of notification and participating in treatment decisions.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, it was determined the facility failed to submit a potential allegation of neglect in a timely manner to the State Agency for 1 of 3 sampled residents (#1) reviewed for elopement. This placed residents at risk for allegations of neglect not being investigated in a timely manner.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure an accurate assessment was completed for 1 of 5 sampled residents (#5) reviewed for MDS assessments. This placed residents at risk of unassessed needs.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the resident's environment remained free from accident hazards for 1 of 5 sampled residents (#2) reviewed for elopement. This placed residents at risk for elopements and accidents.
- D Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on interview and record review it was determined the facility failed to designate a staff member responsible for the coordination of hospice care for 1 of 1 sampled resident (#5) reviewed for hospice. This placed residents at risk for uncoordinated hospice care.
April 13, 2026Complaint inspection · 3 citations
- 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.
Inspectors wroteBased on observation and interview the facility failed to ensure a safe, clean, and homelike environment in a shower room for 1 of 2 halls reviewed for environment. This placed residents at risk for injuries and an unhomelike environment.
- E Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure food was palatable for 1 of 1 kitchen reviewed for food services. This placed residents at risk for poor food quality.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review the facility failed to assess skin wounds and administer medications per physician orders for 3 of 10 sampled residents (#s 1, 4 and 25) reviewed for medications and skin conditions. This placed residents at risk for worsening skin wounds and adverse medication side effects.
February 9, 2026Complaint inspection · 1 citation
- G Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interviews it was determined the facility failed to follow physician's orders for 3 of 5 (#s 1, 3, and 5) sampled residents reviewed for critical lab values and medication errors. The facility failed to follow physician's orders on [DATE] to send Resident 1 to the Emergency Department after a critical lab value was received. The resident died on [DATE]. This put residents at risk for medication errors and death.
December 9, 2025Complaint inspection · 2 citations
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#208) reviewed for medications. This placed residents at risk for unmet treatment needs.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide respiratory care and services for 1 of 3 sampled residents (#201) reviewed for respiratory services. This placed residents at risk for unmet respiratory needs.
August 11, 2025Standard inspection · 11 citations
- L Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to implement infection control practices to prevent the spread of clostridioides difficile (c-diff, a bacterium that can cause severe diarrhea and inflammation of the colon) for all residents, staff, and visitors for 1 of 1 sampled resident (#78). This failure, determined to be an Immediate Jeopardy situation, placed all residents, staff, and visitors at risk for exposure to c-diff, which is highly contagious and can cause serious illness, including life-threatening colitis and death.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview the facility failed to ensure staff properly washed hands for 2 of 3 kitchen staff observed. This placed residents at risk for foodborne illness.
- D Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review the facility failed to assess a resident for safe self-administration of medication for 1 of 1 sampled resident (#15) reviewed for choices. This placed resident at risk for adverse side-affects.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteNumber of residents sampled:Number of residents cited:F580- Based on interview and record review the facility failed to notify the physician of a resident's change of condition for 1 of 2 sampled residents (#40 and 72) reviewed for hospitalizations.
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were free from abuse for 2 of 3 sampled residents (#s 43 and 49) reviewed for abuse. This placed residents at risk for further abuse.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to prevent abuse for 2 of 3 residents (#s 43 and 49) reviewed for abuse. This placed residents at risk for abuse.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for 3 of 3 sampled residents reviewed for abuse resident (#s 43, 49 and 69). This placed residents at risk for uninvestigated abuse.
- D Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review the facility failed to inform the resident of the Bed Hold Policy for 2 of 2 sampled residents (#40 and 72) reviewed for hospitalization. This placed residents at risk for being uninformed of their rights.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders related to labs for 1 of 1 sampled residents (#62) reviewed for mood and behavior. This placed residents as risk for unmet needs.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, and record reviews it was determined the facility failed to monitor a resident after a fall for 1 of 3 sampled residents (# 10) reviewed for accidents. This placed residents at risk for injury.
- D Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview the facility failed to ensure refuse containers were covered for 1 of 1 exterior refuse containers. This placed residents at risk for pest infestations.
October 16, 2024Complaint inspection · 8 citations
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 3 of 5 sampled residents (#14, 17, and 22) and 2 of 2 floors (1st floor and 2nd floor) reviewed for staffing. This placed residents at risk for unmet needs.
- E Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents at risk for incomplete and inaccurate staffing information.
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review it was determined the facility failed to protect residents' right to be free from verbal abuse by staff for 1 of 3 residents (#10) reviewed for abuse and neglect. This placed residents at risk for abuse.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review it was determined the facility failed to report investigations timely to the State Survey Agency for 3 of 6 sampled residents (#s 12, 19, and 20) reviewed for medications, abuse, and neglect. This placed residents at risk for abuse and neglect.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to conduct timely or thorough investigations for 3 of 6 sampled residents (#s 11, 19, and 20) reviewed for medications and accidents. This placed residents at risk for falls, uncontrolled pain, and overdose.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review it was determined facility staff failed to follow professional standards of practice during care and services for 1 of 3 (#12) sampled residents reviewed for abuse and neglect. This placed residents at risk for abuse and neglect.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 2 of 3 sampled residents (#s 21 and 22) reviewed for ADLs. This placed residents at risk for unmet needs.
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident records related to controlled medications were complete and accurate for 1 of 3 sampled residents (#20) reviewed for medications. This placed residents at risk for medication errors.
March 22, 2024Standard inspection, Complaint inspection · 33 citations
- E Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to address resident choice for 5 of 22 sampled residents (#s 2, 18, 30, 35, and 38) reviewed for dining. This placed residents at risk for lack of choice and meal satisfaction.
- E Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and record review it was determined the facility failed to respond timely to resident concerns related to dining for 1 of 1 Resident Council reviewed for dining. This placed residents at risk for unresolved dining issues.
- E Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on interview it was determined the facility failed to have a system in place to deliver mail on Saturdays for 1 of 1 facility reviewed for Resident Council. This placed residents at risk for lack of timely written communications.
- E Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure past survey results were readily available for 1 of 1 facility reviewed for survey results. This placed residents and visitors at risk for not being informed of the facility's survey results.
- E Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide care and treatment to prevent accidents for 4 of 10 sampled residents (#s 4, 22, 35, and 220) reviewed for accidents, hospice, ADLs and medications. This placed residents at risk for injury.
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview, and record review it was determined the facility failed to have adequate staff available to meet the needs of residents in a timely manner for 1 of 14 sampled residents (#10) and 1 of 2 floors (2nd floor) reviewed for staffing. This placed residents at risk for unmet needs.
- 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.
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 15 out of 123 days reviewed for staffing. This placed residents at risk for unmet assessment needs.
- E Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 5 of 5 sampled CNA staff (#s 18, 19, 20, 21, and 22) reviewed for staffing. This placed residents at risk for lack of competent staff.
- E 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to adequately monitor psychotropic medications for 1 of 5 sampled residents (#19) reviewed for medications. This placed residents at risk for lack of effective medication management.
- E Dispose of garbage and refuse properly.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure waste was properly contained in the garbage storage area for 1 of 1 garbage area reviewed for kitchen sanitation. This placed residents at risk for exposure to pathogens related to pests.
- E Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Inspectors wroteBased on interview and record review it was determined the facility failed to submit mandatory staffing information based on the payroll data journal and other verifiable and auditable data as required. This placed residents at risk for inaccurate staffing information.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 4 sampled residents (#4) and 1 of 2 floors (1st floor) reviewed for accidents and infection control. This placed residents at risk for cross contamination.
- D Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure residents were assessed to self-administer medications for 2 of 2 sampled residents (#s 13 and 47) reviewed for pain and dialysis (process to remove fluids and waste from the blood when kidney function fails). This placed residents at risk for an ineffective medication regimen.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to notify residents' representatives regarding changes in status or condition for 3 of 9 sampled residents (#s 19, 41, and 220) reviewed for notification failure and medications. This placed residents and responsible parties at risk for delayed notification.
- D 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.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure rooms were homelike and in good repair for 2 of 10 sampled residents (#s 2 and 7) reviewed for environment. This placed residents at risk for lack of a homelike environment and disrepair.
- D 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's missing items were addressed timely for 1 of 2 sampled residents (#22) reviewed for personal property. This placed residents at risk for loss of meaningful items.
- D Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to monitor and assess the continued use of a physical restraint for 1 of 4 sampled residents (#4) reviewed for accidents. This placed residents at risk for potential abuse or neglect.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review it was determined the facility failed to report an elopement event to the State Survey Agency within 24 hours of the incident for 1 of 4 sampled residents (#220) reviewed for accidents. This placed residents at risk for accidents.
- D Assess the resident when there is a significant change in condition
Inspectors wroteBased on interview and record review it was determined the facility failed conduct a Significant Change MDS assessment within the required timeframe for 1 of 1 sampled resident (#22) reviewed for hospice. This placed residents at risk for unassessed needs.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a care plan was revised for 3 of 3 sampled residents (#s 13, 22, and 47) reviewed for dialysis, hospice and pain. This placed residents at risk for increased injury and pain.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 3 of 9 sampled residents (#s 4, 35, and 41) reviewed for ADLs and accidents. This placed resident at risk for unmet needs.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide care and treatment as care planned, follow physician orders for blood sugar parameters, and provide bowel care for 3 of 9 residents (#s 4, 35 and 41) reviewed for accidents, and medications. This placed residents at risk for delayed treatment, constipation, and risk for adverse side effects.
- D 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.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide splints to reduce contractures (a permanent tightening of muscles, and tendons) for 1 of 1 sampled resident (#18) reviewed for position and mobility. This placed residents at risk for compromised mobility and pain.
- 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.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide catheter care for 1 of 3 sampled residents (#6) reviewed for catheter care. This placed residents at risk for increased infections.
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review the facility failed to maintain healthy parameters of nutritional status for 1 of 3 sampled residents (#4) reviewed for nutrition. This placed residents at risk for weight loss.
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure pain interventions were implemented to ensure a resident's pain was managed for 1 of 1 sampled resident (#47) reviewed for pain. This placed residents at risk for decreased activity.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review it was determined the facility failed to address pharmacy recommendations for 1 of 5 sampled residents (#43) reviewed for medications. This placed residents at risk for medication complications.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain routine labs to monitor medication effectiveness for 1 of 5 sampled residents (#43) reviewed for medications. This placed residents at risk for ineffective medication management and unnecessary medications.
- D Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident colonoscopy (scope passed through the rectum to visualize the large intestine and part of the small intestine) was rescheduled for 1 of 3 sampled residents (#35) reviewed for nutrition. This placed residents at risk for delayed treatment.
- D Provide or obtain dental services for each resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain dental services for 1 of 1 sampled resident (#18) reviewed for dental. This placed residents at risk for dental pain and difficulty eating.
- D Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure snack requests were honored and provided for 1 of 5 sampled residents (#2) and 1 of 1 Resident Council reviewed for dining. This placed residents at risk for lack of response to dietary requests and snack preferences.
- D Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Inspectors wroteBased on interview and record review it was determined the facility failed to coordinate care with hospice for 1 of 1 sampled resident (#22) reviewed for hospice. This placed residents at risk for unmet needs.
- D Implement a program that monitors antibiotic use.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure an antibiotic was indicated for use for 1 of 3 sampled residents (#60) reviewed for beneficiary. This placed residents at risk for antibiotic resistant organisms.
April 5, 2019Standard inspection · 8 citations
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to treat residents with dignity and respect during dining for 1 of 3 sampled residents (#5) reviewed for dignity. This placed residents at risk for an undignified dining experience.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to investigate an incident related to medications for 2 of 2 sampled residents (#s 70 and 275) reviewed for discharge and dignity. This placed residents at risk for drug diversion.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to develop and implement a compressive person centered care plan for 1 of 1 sampled residents (#26) reviewed for dental needs. This placed residents at risk for unmet dental needs.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review it was determined the facility failed to review and revise the in-room care plan for 1 of 1 sampled resident (#26) reviewed for dental needs. This placed resident at risk for unmet dental needs.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure adequate nail care was provided for 1 of 2 residents (#35) reviewed for ADLs. This placed residents at risk for poor grooming and bleeding related to anticoagulant use.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow or obtain physician orders for 3 of 7 sampled residents (#s 50, 73 and 126) reviewed for respiratory care, discharge and mobility. This placed residents at risk for unmet needs.
- D Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide routine dental services for 1 of 1 sampled resident (#26) reviewed for routine dental care. This placed residents at risk for unmet dental needs.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure resident equipment was kept sanitary and failed to ensure proper hand hygiene was completed during meals for 2 of 5 sampled residents (#s 50 and 60) reviewed for environment, positioning and mobility. This placed residents at risk for cross contamination.
Fire safety inspections
9 fire safety citations on file: 2 on August 11, 2025, 3 on March 22, 2024, 4 on April 5, 2019.
Every fire safety citation9 citations
- D Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- D Have exits that are accessible at all times.
- F Have simulated fire drills held at unexpected times.
- F To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D Provide properly protected cooking facilities.
- F Address subsistence needs for staff and patients.
- F Establish procedures for tracking staff and patients during an emergency.
- F Install an approved automatic sprinkler system.
- F Have power receptacles that are properly grounded.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| July 15, 2026 | Fine | $57,888 |
| February 9, 2026 | Fine | $28,870 |
| August 11, 2025 | Fine | $79,238 |
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.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.72 | 5.03 | 3.86 |
| Registered nurses | 0.47 | 0.72 | 0.69 |
| All nursing staff on weekends | 4.12 | 4.51 | 3.42 |
| Nurse aides | 3.11 | ||
| Licensed practical nurses | 1.14 | ||
| Nursing staff turnover (share who left in a year) | 67.5% | 47.4% | 45.8% |
| Registered nurse turnover | 92.3% | 51.6% | 42.9% |
| Administrators who left | 2 |
CMS expects 3.43 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 4.96 on weekdays and 4.12 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 2.1% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.10 in April to June 2025 to 4.72 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.72 | 0.47 | 4.96 | 4.12 | 2.1% | 0 of 90 | 76 |
| Oct to Dec 2025 | 5.72 | 0.40 | 5.86 | 5.34 | 17.4% | 0 of 92 | 66 |
| Jul to Sep 2025 | 5.51 | 0.34 | 5.74 | 4.93 | 20.9% | 1 of 92 | 64 |
| Apr to Jun 2025 | 5.10 | 0.32 | 5.35 | 4.50 | 28.5% | 5 of 91 | 62 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 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.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 26.1 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.1 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.7 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 3.1 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 29.5 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.6 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 14.6 | 13.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 28.5 | 21.4 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 18.0 | 16.1 | 12.0 |
Owners and operators
Legal business name: CAMAS RIDGE REHABILITATION CENTER LLC. CMS links this home to Volare Health, a group of 16 nursing homes averaging 1.8 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Pac 12 Opco Holdco LLC | 5% or greater direct ownership interest | Organization | 100% | 03/01/2023 |
| Knox Healthcare Pac 12 Holdings LLC | 5% or greater indirect ownership interest | Organization | 03/01/2023 | |
| Pac 12 Holdings LLC | 5% or greater indirect ownership interest | Organization | 03/01/2023 | |
| Pac 12 Pinnacle Holdco LLC | 5% or greater indirect ownership interest | Organization | 03/01/2023 | |
| Hagler, Alexander | 5% or greater indirect ownership interest | Individual | 03/01/2023 | |
| Knox, Donald | 5% or greater indirect ownership interest | Individual | 03/01/2023 | |
| Camas Ridge Propco LLC | 5% or greater mortgage interest | Organization | 03/01/2023 | |
| Knox, Donald | Corporate officer | Individual | 03/01/2023 | |
| Smith, Brian | Corporate officer | Individual | 03/27/2023 | |
| Volare Health LLC | Operational/managerial control | Organization | 03/01/2023 | |
| Dunham, Sarah | Operational/managerial control | Individual | 04/01/2025 | |
| Knox, Donald | Operational/managerial control | Individual | 03/01/2023 | |
| Murer, Emily | Operational/managerial control | Individual | 03/10/2025 | |
| Schwartz, Eliezer | Operational/managerial control | Individual | 03/01/2023 | |
| Camas Ridge Propco LLC | Adp of the SNF | Organization | 03/01/2023 | |
| Pac 12 Holdings LLC | Adp of the SNF | Organization | 03/01/2023 | |
| Pac 12 Pinnacle Holdco LLC | Adp of the SNF | Organization | 03/01/2023 | |
| Volare Health LLC | Adp of the SNF | Organization | 08/11/2025 | |
| Dunham, Sarah | Adp of the SNF | Individual | 04/01/2025 | |
| Hagar, Chaim | Adp of the SNF | Individual | 03/01/2023 | |
| Knox, Donald | Adp of the SNF | Individual | 03/01/2023 | |
| Murer, Emily | Adp of the SNF | Individual | 03/10/2025 | |
| Schwartz, Eliezer | Adp of the SNF | Individual | 03/01/2023 | |
| Smith, Brian | Adp of the SNF | Individual | 03/27/2023 |
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.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 20 problems in this area, most recently on July 15, 2026: "Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 14 problems in this area, most recently on July 15, 2026: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 10 problems in this area, most recently on July 15, 2026: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
- When is the care plan meeting, and can family attend it?Inspectors cited 7 problems in this area, most recently on July 15, 2026: "Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 4.12 hours per resident per day, below the Oregon average of 4.51.
- How long has the current administrator been here?CMS counts 2 administrators who left in the period it measured.
Other nursing homes nearby
- Cascade Manor Eugene, 0.5 mi · 4 of 5 stars · 16 citations
- Creekside Health and Rehabilitation of Cascadia Eugene, 0.6 mi · 5 of 5 stars · 9 citations
- Hillside Heights Rehabilitation Center Eugene, 1.5 mi · 3 of 5 stars · 43 citations
- Avamere Rehabilitation of Eugene Eugene, 2 mi · 1 of 5 stars · 52 citations
- Valley West Health Care Center Eugene, 3.5 mi · 2 of 5 stars · 56 citations
- Avamere Riverpark of Eugene Eugene, 3.9 mi · 2 of 5 stars · 47 citations
- Green Valley Rehabilitation Health Center Eugene, 3.9 mi · 1 of 5 stars · 91 citations
- Marquis Springfield Springfield, 4.1 mi · 4 of 5 stars · 33 citations
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is South Hills Rehabilitation Center's Medicare star rating?
- CMS rates South Hills Rehabilitation Center 1 out of 5 stars overall, with 1 for health inspections, 3 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did South Hills Rehabilitation Center get at its last inspection?
- 11 health deficiencies at the standard inspection on August 11, 2025. The Oregon average is 9.2.
- Has South Hills Rehabilitation Center been fined?
- Yes. CMS lists 3 fines totaling $165,996 in the last three years.
- Does South Hills 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 South Hills Rehabilitation Center?
- CMS lists 24 owners and managers, and links the home to Volare Health. Legal business name: CAMAS RIDGE REHABILITATION CENTER LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.