6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Medford, OR
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1200 Mira Mar Avenue, Medford, OR
(541) 857-7777
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
68
Certified beds
Average residents
26
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Pacific Retirement Services
Operator or chain grouping
Approved since
1995-12-07
CMS approved date
Coverage
Medicare
Participation flags
Staffing
RN hours / resident day
1.85
Registered nurse staffing
LPN hours / resident day
0.45
Licensed practical nurse staffing
Aide hours / resident day
4.28
Nurse aide staffing
Weekend hours
5.79
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
56%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.4%
2.4 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.7%
4.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.0%
5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.3% |
12.5%
0.8 pts worse
|
19.6%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
14.7%
14.7 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.1% |
24.1%
3 pts better
|
16.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.3% |
15.8%
13.5 pts worse
|
14.9%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 4.0% |
2.0%
2 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.9% |
22.2%
2.3 pts better
|
19.8%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
6.5%
4.2 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
85.4%
14 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.1% |
15.1%
About the same
|
12.0%
3.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.7%
1.1 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.1% |
81.2%
14.9 pts better
|
79.7%
16.4 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.0% |
21.6%
7.6 pts better
|
23.9%
9.9 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-05-16
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-16
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-16
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-02-26
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-20
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-20
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-21
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-05-21
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-05-21
Health
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.
Corrected 2025-05-21
Health
Provide activities to meet all resident's needs.
Corrected 2025-05-21
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 2025-05-21
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-29
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-29
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 2024-04-29
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-29
Health
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.
Corrected 2023-02-24
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-02-24
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 2023-02-24
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-02-24
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 2023-02-24
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-24
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-02-24
Penalties and ownership
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
5% Or Greater Security Interest · Organization
Corporate Director · Individual
Nearby options
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