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Complaint Investigation

Hearthstone Nursing & Rehabilitation Center

November 25, 2025 · Medford, OR · 2901 E. Barnett Road
Citations 1
CMS Rating 1/5
Beds 87
Provider ID 385091
Healthcare Facility
Hearthstone Nursing & Rehabilitation Center
Medford, OR  ·  View full profile →
Inspection Summary

HEARTHSTONE NURSING & REHABILITATION CENTER in MEDFORD, OR — inspection on November 25, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

8 stated she did not know why Resident 1 was allowed to leave the facility.On [DATE] at approximately 3:30 PM, Staff 3 (LPN, Assistant DON) verified on [DATE] she allowed Resident 1 to leave AMA and did not call the guardian's emergency number to notify the guardian of the situation but instead left a voice message on her main number.

Staff 3 stated at the time of the [DATE] elopement, she believed Resident 1's previous guardianship papers had expired.On [DATE] at 3:49 PM, Staff 28 (CNA) stated Resident 1 was not safe to be in the community by herself/himself.On [DATE] at 3:53 PM, Staff 29 (LPN Unit Manager) stated Resident 1 left AMA on [DATE] and [DATE] and allowing the resident to leave AMA was a misunderstanding.On [DATE] at 4:00 PM, Staff 7 (RN) stated when Resident 1 left AMA on [DATE], there was no stopping her/him.

Staff 7 stated he attempted to notify the guardian's primary number and not the emergency number because he was unaware there were additional contact numbers to reach the guardian.

Staff 7 stated he did not call the police as he felt the resident was alert and oriented and was not aware the resident was not allowed to leave the facility. On [DATE] at 5:05 PM, Staff 1 (Administrator), Staff 2 (DON), and Staff 4 (Regional RN) verified Resident 1 left the faciity on [DATE] and [DATE].

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MEDFORD, OR, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HEARTHSTONE NURSING & REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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