Hearthstone Nursing: Accident Hazard Violation - OR
The incidents exposed confusion among nursing staff about guardianship protocols and emergency notification procedures. Federal inspectors found that key personnel failed to contact the guardian's emergency number during either episode, instead leaving voicemails on a primary line that went unanswered.
Staff 3, an LPN and Assistant Director of Nursing, permitted the resident to leave during the first incident. She told inspectors she allowed the departure because she believed the resident's guardianship papers had expired. Rather than calling the guardian's emergency contact number, Staff 3 left a message on the main phone line.
The resident left again on a second date.
Staff 7, a registered nurse, handled the second departure. He attempted to reach the guardian's primary number but never tried the emergency contact. "There was no stopping her/him," Staff 7 told inspectors, explaining he felt the resident was alert and oriented. He did not contact police because he was unaware the resident was prohibited from leaving the facility independently.
Multiple staff members expressed safety concerns about the resident being alone in the community. Staff 28, a certified nursing assistant, stated the resident "was not safe to be in the community by herself/himself." Staff 29, an LPN Unit Manager, called allowing the departures "a misunderstanding."
The facility's Administrator, Director of Nursing, and Regional RN all confirmed both incidents occurred when questioned by federal inspectors.
Staff 8 told investigators she did not know why the resident was allowed to leave the facility.
The case highlights gaps in staff training on guardianship requirements and emergency protocols. While Staff 7 knew to contact the guardian, he was unaware additional emergency contact numbers existed for urgent situations. Staff 3's belief that guardianship papers had expired suggests inadequate tracking of legal documents affecting resident care.
Neither incident prompted a police notification, despite the resident being under legal guardianship and staff concerns about community safety. Staff 7's reasoning that the resident appeared alert and oriented contradicted the underlying guardianship arrangement, which typically indicates a person cannot make independent decisions about their care and living situation.
The repeated nature of the incidents compounds the safety concerns. After the first departure, facility protocols should have been reviewed and reinforced to prevent a recurrence. Instead, a second episode occurred with similar communication failures.
Federal inspectors classified the violations as causing minimal harm or potential for actual harm, affecting few residents. However, the case demonstrates how administrative confusion can create serious safety risks for vulnerable residents under legal protection.
The inspection narrative does not detail how long the resident remained outside the facility during either incident or whether they were safely returned. It also does not specify what steps, if any, the facility took between the two departures to prevent future occurrences.
Guardianship arrangements exist specifically to protect individuals who cannot safely make independent decisions about their care, living situation, or daily activities. When nursing home staff allow such residents to leave against medical advice without proper authorization or emergency notifications, they undermine the legal protections designed to ensure resident safety.
The Administrator, Director of Nursing, and Regional RN's confirmation of both incidents suggests facility leadership was aware of the problems but the inspection report does not indicate what corrective measures were implemented to prevent future unauthorized departures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hearthstone Nursing & Rehabilitation Center from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
HEARTHSTONE NURSING & REHABILITATION CENTER in MEDFORD, OR was cited for violations during a health inspection on November 25, 2025.
The incidents exposed confusion among nursing staff about guardianship protocols and emergency notification procedures.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.