Cycle 1
Health 2025-04-24 · Fire 2025-04-24
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Medford, OR
Rogue Valley Manor
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
Facility snapshot
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
Chain footprint
10 facilities
Chain averages 5 overall / 4 health / 4 staffing / 5 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
1.85
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.45
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
4.28
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
6.58
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
2.30
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
5.79
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
1.57
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
2.03
CMS adjusted RN staffing hours
Adjusted total hours
7.23
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
506
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
68.61
Composite VBP score used to determine payment impact.
Payment multiplier
1.0216
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 19.34% · Performance 16.90% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
8.42
Baseline 5.68% · Performance 5.32% · Measure score 8.42 · Achievement 8.42 · Improvement 4.78
Total nurse turnover
0
Baseline 51.72% · Performance 63.38% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
9.02
Baseline 6.3 hours · Performance 5.64 hours · Measure score 9.02 · Achievement 9.02 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.29% |
10.72%
2.4 pts better
|
No Different than the National Rate · Eligible stays 212 · Observed rate 4.25% · Lower 95% interval 5.68% |
| Discharge to community | 67.43% |
50.57%
16.9 pts better
|
Better than the National Rate · Eligible stays 214 · Observed rate 67.76% · Lower 95% interval 61.39% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.92% |
95.27%
2.7 pts better
|
Numerator 141 · Denominator 144 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 144 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 61 · Denominator 122 |
| Discharge mobility score | 43.44% |
50.94%
7.5 pts worse
|
Numerator 53 · Denominator 122 |
| Pressure ulcers or injuries, new or worsened | 2.08% |
2.29%
0.2 pts better
|
Numerator 3 · Denominator 144 · Adjusted rate 2.7% |
| Healthcare-associated infections requiring hospitalization | 5.32% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 153 · Observed rate 1.96% · Lower 95% interval 3.18% |
| Staff COVID-19 vaccination coverage | 21.69% |
8.2%
13.5 pts better
|
Numerator 18 · Denominator 83 |
| Staff flu vaccination coverage | 16.67% |
42%
25.3 pts worse
|
Numerator 18 · Denominator 108 |
| Discharge function score | 49.18% |
56.45%
7.3 pts worse
|
Numerator 60 · Denominator 122 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 99.14% |
96.28%
2.9 pts better
|
Numerator 115 · Denominator 116 |
| Resident COVID-19 vaccinations up to date | 59.02% |
25.2%
33.8 pts better
|
Numerator 36 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| 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 · 4Q avg 100.0% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 13.3% |
| 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 · 4Q avg 0.0% · 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 · 4Q avg 0.0% |
| 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 · 4Q avg 21.1% · Used in QM five-star |
| 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 · 4Q avg 29.3% · 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 4.0% · Used in QM five-star |
| 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 · 4Q avg 19.9% |
| 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 · 4Q avg 2.3% · Used in QM five-star |
| 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 · Q1 98.4% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| 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 · Adjusted 15.1% · Observed 13.2% · Expected 9.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.5% · 4Q avg 0.6% · Used in QM five-star |
| 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 · 4Q avg 96.1% |
| 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 · Adjusted 14.0% · Observed 11.4% · Expected 19.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-05 · Fire 2024-04-05
4 health 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.
Cycle 3
Health 2023-01-27 · Fire 2023-01-27
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-24
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-16
F · Potential for more than minimal harm
2023-01-27
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-02-26
E · Potential for more than minimal harm
2023-01-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-24
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 2025-05-21
D · Potential for more than minimal harm
2025-04-24
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-24
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-24
F578 · Resident Rights Deficiencies
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
D · Potential for more than minimal harm
2025-04-24
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-24
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 2025-05-21
E · Potential for more than minimal harm
2024-04-05
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 2024-04-29
D · Potential for more than minimal harm
2024-04-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-04-05
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 2024-04-29
D · Potential for more than minimal harm
2024-04-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-29
E · Potential for more than minimal harm
2023-01-27
F584 · Resident Rights Deficiencies
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
E · Potential for more than minimal harm
2023-01-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-02-24
E · Potential for more than minimal harm
2023-01-27
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 2023-02-24
E · Potential for more than minimal harm
2023-01-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-02-24
D · Potential for more than minimal harm
2023-01-27
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 2023-02-24
D · Potential for more than minimal harm
2023-01-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-24
D · Potential for more than minimal harm
2023-01-27
F756 · Pharmacy Service Deficiencies
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
What sits behind the stars
Ownership
Beattie, Julie
Corporate Director · Individual
Bhasin, Anirudh
Corporate Director · Individual
Brophy, Timothy
Corporate Director · Individual
Christlieb, Carl
Corporate Director · Individual
Heysell, Russell
Corporate Director · Individual
Jacobs, William
Corporate Director · Individual
Mayers, Robert
Corporate Director · Individual
Pacific Retirement Services Inc
Operational/Managerial Control · Organization
Sevick, April
Corporate Director · Individual
Sholty, Eric
Corporate Officer · Individual
Solmonson, Stan
Corporate Director · Individual
Solmonson, Stan
W-2 Managing Employee · Individual
Us Bank National Association
5% Or Greater Security Interest · Organization
Willms, Fredric
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
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
#2
Avamere At Three Fountains
Medford, OR
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Avamere Health Services Of Rogue Valley
Medford, OR
2-star overall rating with 2-star inspections with 12 recent health deficiencies
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