Cycle 1
Health 2025-01-16 · Fire 2025-01-16
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Medford, OR
Avamere At Three Fountains
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
835 Crater Lake Avenue, Medford, OR
(541) 773-7717
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avamere
Operator or chain grouping
Approved since
1975-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.49
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.79
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.41
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
4.75
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,938
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9884
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.16
Baseline 16.33% · Performance 19.04% · Measure score 5.16 · Achievement 5.16 · Improvement 0
Healthcare-associated infections
0
Baseline 4.78% · Performance 8.23% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.86
Baseline 46.08% · Performance 43.82% · Measure score 4.86 · Achievement 4.86 · Improvement 0.56
Adjusted total nurse staffing
3.79
Baseline 4.42 hours · Performance 4.16 hours · Measure score 3.79 · Achievement 3.79 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.04% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 248 · Observed rate 8.06% · Lower 95% interval 7.28% |
| Discharge to community | 66.82% |
50.57%
16.2 pts better
|
Better than the National Rate · Eligible stays 263 · Observed rate 66.16% · Lower 95% interval 60.41% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.37% |
95.27%
4.1 pts better
|
Numerator 157 · Denominator 158 |
| Falls with major injury | 0.63% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 158 |
| Discharge self-care score | 39.25% |
53.69%
14.4 pts worse
|
Numerator 42 · Denominator 107 |
| Discharge mobility score | 43.93% |
50.94%
7 pts worse
|
Numerator 47 · Denominator 107 |
| Pressure ulcers or injuries, new or worsened | 1.9% |
2.29%
0.4 pts better
|
Numerator 3 · Denominator 158 · Adjusted rate 1.9% |
| Healthcare-associated infections requiring hospitalization | 8.23% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 166 · Observed rate 7.83% · Lower 95% interval 5.17% |
| Staff COVID-19 vaccination coverage | 4.1% |
8.2%
4.1 pts worse
|
Numerator 5 · Denominator 122 |
| Staff flu vaccination coverage | 25.32% |
42%
16.7 pts worse
|
Numerator 40 · Denominator 158 |
| Discharge function score | 34.58% |
56.45%
21.9 pts worse
|
Numerator 37 · Denominator 107 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 115 · Denominator 115 |
| Transfer of health information to patient | 91.67% |
96.28%
4.6 pts worse
|
Numerator 22 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 34.33% |
25.2%
9.1 pts better
|
Numerator 23 · Denominator 67 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.4
0.4 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.2 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
2.5
2.3 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.5%
4.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.2%
4.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
2.4%
1.8 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
4.7%
3.5 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 2.2% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
5.0%
0.1 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 7.5% · Q3 2.9% · Q4 2.9% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.9% |
12.5%
5.6 pts better
|
19.6%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.5% · Q3 8.6% · Q4 11.4% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
14.7%
6.4 pts better
|
16.7%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 6.1% · Q3 10.3% · Q4 7.1% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.2% |
24.1%
6.1 pts worse
|
16.3%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.3% |
15.8%
8.5 pts better
|
14.9%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 2.7% · Q3 0.0% · Q4 8.8% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
2.0%
0.3 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.4% · Q4 4.3% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.0% |
22.2%
10.2 pts better
|
19.8%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 8.7% · Q3 14.7% · Q4 10.7% · 4Q avg 12.0% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
6.5%
0.1 pts better
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.9% · Q3 5.2% · Q4 3.5% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
85.4%
14.2 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.1% |
15.1%
5 pts better
|
12.0%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.1% · Observed 8.9% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.7%
1.3 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
81.2%
18.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.9% |
21.6%
7.7 pts better
|
23.9%
10 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 12.1% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-25 · Fire 2023-08-25
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-07-15 · Fire 2022-07-15
1 health deficiencies
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-06
F · Potential for more than minimal harm
2025-01-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-01-16
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2025-03-06
F · Potential for more than minimal harm
2023-08-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-25
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-25
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-30
F · Potential for more than minimal harm
2022-07-15
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2022-08-17
F · Potential for more than minimal harm
2022-07-15
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-08-17
F · Potential for more than minimal harm
2022-07-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-17
E · Potential for more than minimal harm
2022-07-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-08-17
D · Potential for more than minimal harm
2022-07-15
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-08-17
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-16
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-02-14
G · Actual harm
2024-04-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-08-30
G · Actual harm
2024-04-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-30
D · Potential for more than minimal harm
2024-04-01
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-11-27
F · Potential for more than minimal harm
2023-08-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-30
E · Potential for more than minimal harm
2023-08-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-30
E · Potential for more than minimal harm
2023-08-25
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-25
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-25
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-25
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-25
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-25
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-25
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-09-30
F · Potential for more than minimal harm
2022-07-15
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-08-17
Penalties and ownership
What sits behind the stars
Ownership
Ariso LLC
5% Or Greater Direct Ownership Interest · Organization
Ari Operations, LLC
5% Or Greater Indirect Ownership Interest · Organization
Avamere Group LLC
5% Or Greater Indirect Ownership Interest · Organization
Avamere Health Services LLC
Operational/Managerial Control · Organization
Avamere Skilled Advisors LLC
Operational/Managerial Control · Organization
Becerra, Shannon
Operational/Managerial Control · Individual
Bothwell, Marlon
Operational/Managerial Control · Individual
Feakin, Cody
Operational/Managerial Control · Individual
Fowler, Katherine
Operational/Managerial Control · Individual
Kahn, Karen
Operational/Managerial Control · Individual
Karl Rickard Miler Jr Revocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Kofstad, Mary
Operational/Managerial Control · Individual
Loewen, Michelle
Operational/Managerial Control · Individual
Midcap Finco LLC
Operational/Managerial Control · Organization
Midcap Finco LLC
5% Or Greater Security Interest · Organization
Miller, Karl
5% Or Greater Indirect Ownership Interest · Individual
Munro, Jolynn
Operational/Managerial Control · Individual
Powelson, Michele
Operational/Managerial Control · Individual
Presley, Yolanda
Operational/Managerial Control · Individual
Prevatt, Naomi
Operational/Managerial Control · Individual
Reid, Misty
Operational/Managerial Control · Individual
Simpson, Andrew
Operational/Managerial Control · Individual
Sutton, Holly
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Avamere Health Services Of Rogue Valley
Medford, OR
2-star overall rating with 2-star inspections with 12 recent health deficiencies
#2
Hearthstone Nursing & Rehabilitation Center
Medford, OR
1-star overall rating with 1-star inspections with abuse icon flag with $230,522 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Rogue Valley Manor
Medford, OR
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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