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Nursing HomeMedicaid Investigative

Hearthstone Nursing & Rehabilitation Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

2901 E. Barnett Road, Medford, OR 9750487 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
2.6/5

based on 64 Google reviews

5
4
3
2
1
Hearthstone Nursing & Rehabilitation Center Nursing Home in Medford, OR — Street View
Street View

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6/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Abuse citation on record
  • Low overall rating (1/5 stars)
  • High staff turnover (55%)
  • High RN turnover (67%)

Bottom 25% in OR · Meets national RN staffing standard · Above recommended total nurse staffing · Worst in VOLARE HEALTH chain · $230,522 in fines · Abuse citation

Source: Medicare data

What this means for your family

While some residents have had successful rehab outcomes, the high frequency of reports regarding neglect, hygiene failures, and unresponsiveness is deeply concerning. If you consider this facility, we strongly advise conducting an unannounced visit and asking specifically about their current nurse-to-patient ratios and how they handle medication management and call-light response times.

Google Reviews

Google Reviews

64 reviews on Google
Hearthstone Nursing & Rehabilitation Center receives highly polarized feedback, with many families reporting severe neglect, chronic understaffing, and poor communication. While some residents praise the physical and occupational therapy teams for aiding their recovery, a significant number of reviewers describe dangerous conditions, including unaddressed medical needs, hygiene failures, and unresponsive staff.

Quality Themes

Tap a score for details
Food2.0Staff3.0Clean2.0ActivitiesN/AMeds1.0Memory1.0Comms1.0ValueN/A

Strengths

  • Effective physical and occupational therapy
  • Some dedicated and kind individual staff members
  • Convenient location for local residents

Concerns

  • Chronic understaffing leading to long wait times for call lights (mentioned by 12 reviewers)
  • Poor hygiene and failure to assist with basic personal care (mentioned by 9 reviewers)
  • Unresponsive or rude administrative and nursing communication (mentioned by 8 reviewers)
  • Medication management errors and delays (mentioned by 5 reviewers)
  • Poor food quality and failure to accommodate dietary needs (mentioned by 4 reviewers)

Rating Trends

Tap a year to see what changed

234'17(3)'19(3)'21(4)'23(13)'25(13)'26(2)

Distribution · 67 analyzed

5
25
4
0
3
0
2
3
1
39

How They Respond to Reviews

60%response rate

This facility responds to some reviews.

Questions for Your Tour

  • 1Given that physical and occupational therapy are noted as strengths here, how do you integrate those therapy goals into the resident's daily routine outside of scheduled sessions?
  • 2I noticed the facility has a 4/5 staffing rating; could you explain how you manage call light response times during shift changes to ensure residents aren't waiting too long for assistance?
  • 3What specific protocols are in place to ensure consistent hygiene and personal care assistance, especially during peak morning and evening hours?
  • 4How does your nursing team coordinate with families to ensure medication management is accurate and that any changes in prescriptions are clearly communicated?
  • 5I see you actively respond to feedback online; what is your process for addressing family concerns or communication gaps once a resident has moved in?
  • 6Could you walk me through how the kitchen team handles specific dietary needs and how you ensure residents are receiving high-quality, nutritious meals that they actually enjoy?

Personalized based on this facility's data


Key Review Excerpts

I sat in urine while my call light was on for an hour and a half. Medication was given hours and hours after it was due.

Family member · 2023☆☆☆☆

The Physical and Occupational Therapy staff are incredible. The CNAs have taken good care of me. I am leaving here with skills to help me return to being able to walk.

Rehab patient · 2023☆☆☆☆

They stopped a needed medication without a Dr. Order. They took all of my Dads belongings and locked them up in Social workers office and forgot to give them back.

Long-term resident's family · 2023☆☆☆☆
Source: 64 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.66hrs
88%
Registered nurses for medical care
Total Nursing
4.41hrs
OK
All nurses + aides combined
Staff Turnover
49%
Lower is better (< 30% = good)
RN Turnover
57%
Lower is better (< 30% = good)

RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
4/ 5
Better Than Avg

12

measures

Worse Than Avg

3

measures

Mixed Results

2

measures

Long-Stay Residents
🚶

Residents whose walking got worse

↓ Lower is better
This Facility43.3%
Worse than Avg
Here
43.3%
US
15.3%
OR
22.5%
Jackson
16.8%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility6.0%
Better than Avg
Here
6.0%
US
19.5%
OR
12.5%
Jackson
24.0%
😔

Residents with depression symptoms

↓ Lower is better
This Facility1.7%
Better than Avg
Here
1.7%
US
12.1%
OR
4.9%
Jackson
17.9%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on antipsychotic medication

↓ Lower is better
This Facility5.1%
Better than Avg
Here
5.1%
US
15.5%
OR
14.0%
Jackson
19.5%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
OR
95.3%
Jackson
90.6%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility27.8%
Worse than Avg
Here
27.8%
US
19.4%
OR
22.1%
Jackson
20.4%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility94.0%
Better than Avg
Here
94.0%
US
81.8%
OR
85.5%
Jackson
78.3%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility87.6%
Better than Avg
Here
87.6%
US
79.8%
OR
81.2%
Jackson
79.0%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.2%
Better than Avg
Here
1.2%
US
1.6%
OR
1.5%
Jackson
1.5%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

11deficiencies
5penalties
Above state avg (10.4)
50 complaint-triggered
$230,522 in fines

This facility shows a concerning pattern with 45 complaint-triggered deficiencies across multiple surveys, indicating families have repeatedly filed reports about care problems. The most recurring issues involve abuse and neglect protection, nursing staffing adequacy, and medication management. While all deficiencies show correction dates, the persistent nature of complaints about fundamental safety issues like resident protection and adequate nursing coverage suggests ongoing systemic problems that families should carefully investigate before considering placement.

Mar 4, 2026Complaint
5
0602Potential for harm · IsolatedResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

0620Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Nov 25, 2025Complaint
1
0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

May 23, 2025Routine
5
0111Potential for harm · WidespreadCorrected

Construction Deficiencies

Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.

0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0636Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

0698Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0791Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide or obtain dental services for each resident.

May 23, 2025Complaint
2
0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Dec 7, 2024Routine
8
0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0623Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0625Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0756Potential for harm · IsolatedResolved (past non-compliance)

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Dec 7, 2024Complaint
2
0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

Federal Penalties

Fine

May 31, 2024

$88,282

Payment Denial

May 31, 2024

48-day denial

Fine

Feb 1, 2024

$82,274

Payment Denial

Feb 1, 2024

7-day denial

Fine

Oct 23, 2023

$59,966

Ownership & Operations

Who Operates This Facility

Owner / Operator

Hearthstone Nursing & Rehabilitation Center

Organization Type

for profit

Chain Affiliation

Chain Name

Volare Health

Chain Size

16 facilities nationwide

Chain avg rating: 1.7/5 · Rank 12 of 15 (Worst)

Ownership & Management

Owners

Pac 12 Opco Holdco LLC

Owner · Organization

100%

Knox Healthcare Pac 12 Holdings LLC

Owner (parent company) · Organization

Pac 12 Holdings LLC

Owner (parent company) · Organization

Pac 12 Pinnacle Holdco LLC

Owner (parent company) · Organization

Hagler, Alexander

Owner (parent company)

Knox, Donald

Owner (parent company)

Key personnel

Medford Propco LLC5% or Greater Mortgage InterestKnox, DonaldOfficer / DirectorSmith, BrianOfficer / DirectorVolare Health LLCManagerKahn, KarenManager
Source: Medicare provider data

Contact

Get in Touch

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References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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