Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avamere At Three Fountains during CMS and state inspections, most recent first.
An LPN was observed cleaning a community-use glucometer with an alcohol pad instead of the bleach wipe or equivalent required by the facility policy. The LPN stated he always used alcohol pads, while the DNS stated staff were to use bleach wipes. The glucometer was used for CBG checks on several residents with diabetes, and their records did not indicate a BBP.
Furniture Not Kept in Good Repair: Armchairs in multiple resident rooms and chairs in the front sitting area were observed with torn or cracked upholstery exposing cloth material. The Maintenance Director stated the furniture was not in good repair and had not been notified of the damage, while the Administrator stated staff were to remove furniture with tears.
Failure to assist a resident with oral hygiene. A cognitively intact resident admitted with a fracture required ADL assistance, including oral hygiene, per MDS and care plan. The resident stated staff did not provide a toothbrush or offer help brushing teeth, and the toothbrush was later found still in its original wrapper by the sink. The assigned CNA confirmed oral care was not provided, and the DNS stated residents should be offered oral care twice daily.
Failure to provide activity accommodations for a resident with highly impaired hearing. A cognitively intact resident with a fracture preferred watching older TV shows but stated he/she could not hear the television when wanting to watch it. Staff observed the resident in bed with the TV off on multiple occasions, and staff reported that headsets were used for hard-of-hearing residents, but one was not offered to this resident.
Missing Order for CPAP Use and Maintenance: A resident with sleep apnea and stroke had a CPAP in the room, but there was no physician order or care plan documentation for its use or maintenance. Staff knew the resident had the CPAP, yet CNAs and an RN reported they did not routinely clean the mask or tubing, and the LPN Resident Care Manager confirmed no order existed for the CPAP or its care.
The facility failed to follow proper infection control protocols, including PPE usage and linen handling. Staff did not change N-95 masks and face shields after exiting COVID-19 rooms, and linen carts were left uncovered in hallways. Additionally, hand hygiene was not consistently practiced, and Enhanced Barrier Precautions were not followed, increasing the risk of cross-contamination.
A resident was self-administering topical pain medications without an assessment or physician orders in place, contrary to facility policy. The resident, who was cognitively intact and experienced chronic pain, used Biofreeze and Icy Hot provided by their family. Staff were aware of the self-administration, but no nurse was informed, and no orders were documented. The facility's administrator and DNS acknowledged the oversight.
Two residents at the facility did not receive consistent restorative services, risking decreased range of motion. One resident, with cellulitis and peripheral vascular disease, had a care plan for exercise assistance but received limited services due to staff shortages. Another resident, with diabetes and cellulitis, required mobility assistance but also experienced service gaps, leading to increased stiffness and pain. Staff confirmed the lack of consistent care due to insufficient CNA availability.
A resident was prescribed an antibiotic for a UTI without proper indication, as the urine culture was not completed due to an incorrectly obtained sample. Despite the lack of culture results, the antibiotic treatment continued, highlighting a communication breakdown between nursing staff and medical providers.
The facility did not ensure that CNAs received the required 12 hours of annual in-service training, including dementia care. One CNA received only 6.75 hours, and another received 10.25 hours, both falling short of the requirement. The DNS and Assistant DNS confirmed the shortfall, acknowledging their responsibility for monitoring training hours.
An LPN at the facility administered ten medications prescribed for another resident to a resident with a recent cardiac pacemaker placement, respiratory failure, and end-stage kidney disease, leading to a drug overdose and hospitalization. The LPN failed to verify the correct resident and did not follow protocol for safe medication administration, resulting in severe consequences for the resident.
A resident was hospitalized after an LPN administered ten medications prescribed for another resident, followed by the resident's own medications without verifying with a physician. The LPN failed to follow proper identification protocols, leading to severe health complications.
The facility failed to protect residents from misappropriation of their narcotic medications, affecting three residents. Narcotic medication cards were signed to incorrect pages with forged signatures, and doses were missing. The incidents were reported to the physician, state agency, and law enforcement, and the facility acknowledged the misappropriation.
Improper Cleaning of Community-Use Glucometer
Penalty
Summary
The facility failed to ensure a community-use glucometer was cleaned with an EPA-approved disinfectant for 1 of 4 halls reviewed for infection control, specifically Hall 2. The facility’s 10/2025 glucometer cleaning policy stated staff were to clean glucometers with a bleach germicidal wipe or equivalent, but on 7/7/26 at 7:46 AM an LPN was observed cleaning a community-used glucometer with an alcohol pad and stated he always used alcohol pads to clean the glucometers. The LPN identified residents on Hall 2 who had CBG checks as Residents 7, 13, 63, 68, 71, and 99. Each of these residents had diabetes, and their clinical records did not indicate they had a BBP. At 8:38 AM, the DNS stated staff were to use bleach wipes to clean the community-use glucometers.
Furniture Not Kept in Good Repair
Penalty
Summary
The facility failed to ensure furniture was in good repair for 1 of 1 facility reviewed for physical environment. During an observation with the Maintenance Director, armchairs in rooms 10, 16, 18, 42, and 44 were observed with torn fabric on the armrests and exposed cloth material, with the torn areas measuring at least one inch in diameter. In the general sitting area by the front entrance, two chairs had multiple cracks in the synthetic leather on the seat covering exposing cloth material, and one armchair had missing synthetic leather exposing cloth material. The Maintenance Director stated the furniture was not in good repair, Staff 18 stated staff were to notify maintenance when furniture was ripped, and the Maintenance Director stated he had not been notified of the torn furniture. The Administrator stated that if there were tears in the furniture, staff were to remove the furniture.
Failure to Assist Resident With Oral Hygiene
Penalty
Summary
The facility failed to ensure a resident was assisted with oral hygiene for 1 of 2 sampled residents reviewed for ADLs. Resident 81 was admitted in 6/2026 with a diagnosis of a fracture, and the 6/29/26 admission MDS indicated the resident was cognitively intact and required assistance with ADLs including oral hygiene. The 6/25/26 care plan stated the resident required the assistance of one person for personal hygiene and mobility. During interview on 7/6/26, Resident 81 stated that since admission staff had not provided a toothbrush for oral care or offered assistance with oral hygiene. On 7/7/26, the resident’s toothbrush was observed still in its original plastic wrapper in a basin by the sink, and the resident stated that although a bed bath had been provided, no one had offered to help brush teeth. Staff 8, the assigned CNA for day shift, stated the toothbrush was by the sink but she did not assist the resident with oral care during the morning shift. Staff 2, the DNS, stated residents were to be offered oral care at least two times a day, in the morning and in the evening.
Failure to Provide TV Accommodations for a Hard-of-Hearing Resident
Penalty
Summary
The facility failed to ensure a resident was provided accommodations for activities for 1 of 1 sampled resident reviewed for activities. Resident 81 was admitted in 6/2026 with a diagnosis of fracture. The 6/29/26 admission MDS indicated the resident was cognitively intact and had highly impaired hearing. The resident was assessed as not using hearing aids, and the 6/29/26 Activity Profile noted a preference for watching older television shows. The resident’s 6/25/26 through 7/7/26 Self Directed Activity form showed the resident watched television on 7/2/26. However, during observations on 7/7/26 at 10:38 AM, 1:42 PM, and 3:37 PM, and on 7/8/26 at 8:13 AM and 11:32 AM, the resident was observed in bed with eyes shut and the television was not on. On 7/6/26 at 2:16 PM, the resident stated he/she could not hear the television when wanting to watch it. Staff stated that hard-of-hearing residents who wanted to listen to television were asked to have a headset brought in by family, that the resident was very hard of hearing and staff had to stand close to the right ear to communicate, and that the activity director did not offer a headset. The DNS stated the facility should have provided headsets for residents who could not hear the television.
Missing Order for CPAP Use and Maintenance
Penalty
Summary
The facility failed to obtain physician orders for the use and maintenance of a CPAP for Resident 76, who was admitted in 6/2026 with diagnoses including sleep apnea and stroke. There was no documentation in the admission MDS or care plan showing that the resident used a CPAP. Observations from 7/6/26 through 7/10/26 showed the CPAP in the resident’s room on the nightstand. The resident stated that a friend brought the CPAP to the facility a day after admission, but staff did not clean the mask or tubing daily and the mask did not fit well. Staff interviews showed the CNA staff were aware of the CPAP but did not clean the mask or hose, one CNA reported washing the mask one time, and an RN stated she filled the chamber with water a few times but did not clean the mask or tubing. The LPN Resident Care Manager confirmed the resident did not have an order for the CPAP or for cleaning and caring for the equipment.
Infection Control Deficiencies in PPE and Linen Handling
Penalty
Summary
The facility failed to adhere to transmission-based precautions, resulting in potential cross-contamination risks. Staff members were observed not changing their N-95 masks and face shields after exiting COVID-19 positive rooms, contrary to the facility's PPE instructions. Additionally, contaminated equipment, such as stethoscopes, was improperly handled, and door handles were not sanitized, further increasing the risk of infection spread. Staff members, including a newly employed RN, were not adequately informed about the correct PPE protocols, leading to improper PPE usage and handling. The facility also failed to ensure proper linen transportation and handling. Linen carts were observed uncovered in hallways, including areas with droplet precautions, contrary to the facility's procedures. Staff members were not consistently following protocols for Enhanced Barrier Precautions, such as wearing gowns when required. Furthermore, hand hygiene practices were not consistently followed, as observed when a staff member changed their N-95 mask without sanitizing their hands. These deficiencies highlight lapses in infection control practices, placing residents and staff at risk for cross-contamination.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was assessed for self-administration of medications and that physician orders were in place for a resident reviewed for medications. The facility's policy required an interdisciplinary team to assess each resident's cognitive and physical abilities to determine whether self-administration was safe and appropriate. However, there was no assessment conducted for the resident in question, who was admitted with diagnoses including cellulitis and peripheral vascular disease. The resident was cognitively intact and experienced chronic pain, which occasionally interfered with sleep and daily activities. The resident self-administered topical pain medications, Biofreeze and Icy Hot, provided by their family, without any physician orders or assessments in place. Staff members, including a CNA and a CMA, were aware of the resident's self-administration of these medications, but no nurse was informed, and no orders were documented. The facility's administrator and DNS acknowledged the lack of assessment and the need for orders for the resident's self-administered topical pain medication.
Failure to Provide Consistent Restorative Services
Penalty
Summary
The facility failed to provide restorative services to two residents, leading to a risk of decreased range of motion. Resident 13, admitted with cellulitis and peripheral vascular disease, was cognitively intact and at risk for mobility decline. Despite a care plan indicating the need for restorative assistance with exercise bands and standing tolerances, Resident 13 received limited services. Documentation showed sporadic service provision, with gaps in care due to staff shortages. Resident 13 reported that services ceased after a period, and staff confirmed the lack of consistent restorative assistance. Similarly, Resident 30, admitted with diabetes and cellulitis, required assistance with mobility and was at risk for falls. The care plan included restorative exercises to maintain function, but records indicated minimal service provision. Resident 30 expressed concerns about the lack of services, noting increased stiffness and pain. Staff acknowledged the resident's complaints and the facility's failure to meet the scheduled restorative services due to insufficient CNA availability. Both residents were affected by the facility's inability to consistently provide the necessary restorative care.
Failure to Ensure Antibiotic Indication
Penalty
Summary
The facility failed to ensure that an antibiotic was indicated for use for a resident reviewed for unnecessary medications, placing residents at risk for developing drug-resistant organisms. The resident was admitted with a diagnosis of anxiety and later reported painful urination. A nurse practitioner ordered a urine sample and culture, and subsequently prescribed Ciprofloxacin before the culture results were finalized. The urine analysis was reviewed, but the culture was not performed due to an incorrectly obtained sample. Despite this, the antibiotic treatment continued without proper verification of its necessity. There was a communication breakdown between the nursing staff and the medical providers. The staff failed to notify the resident's physician about the incomplete urine culture and continued the antibiotic treatment based on the initial order. The physician stated that if she had been informed of the urine test results, she would have stopped the antibiotics, as the only symptom was burning with urination. The facility's infection prevention protocols were not followed, as staff did not reach out to the medical provider within the required timeframe after the antibiotic was initiated.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistant (CNA) staff received the required 12 hours of annual in-service training, including dementia care, for two out of five sampled CNAs. Staff 17 received only 6.75 hours of training, which did not include dementia training, despite working at the facility for over a year. Staff 17 acknowledged the incomplete training hours. Staff 18 received 10.25 hours of training in the past year, also falling short of the required 12 hours. Both the Director of Nursing Services (DNS) and the Assistant DNS confirmed the deficiencies in training hours for Staff 17 and Staff 18, acknowledging that they and the resident care managers were responsible for monitoring the in-service training hours. A call placed to Staff 18 for further verification was not returned.
Significant Medication Error by LPN
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) adhered to professional standards of practice for medication administration, resulting in a significant medication error for a resident. The incident involved the LPN administering ten medications prescribed for another resident to the affected resident, who had a recent cardiac pacemaker placement, respiratory failure, and end-stage kidney disease with dialysis. The error led to the resident experiencing a decline in condition and requiring hospitalization for a drug overdose. The medications administered included antipsychotics, an anti-diabetic medication, and other drugs not prescribed to the resident, causing an altered mental status and acute encephalopathy due to the overdose. The LPN realized the mistake after the resident commented on the number of medications being administered but did not verify the correct resident before giving the medications. The LPN also administered the resident's prescribed medications after realizing the initial error, further complicating the situation. The resident received additional medications, including an antidepressant, a blood thinner, vitamin D, artificial tears, and nitroglycerin, without consulting a physician. This lapse in practice and failure to follow protocol for safe medication administration led to the resident's hospitalization. The facility's Administrator and Director of Nursing Services (DNS) confirmed that the LPN made a significant medication error and did not follow the protocol for safe medication administration. The LPN also failed to provide appropriate documentation in the medical record for the other resident whose medications were administered to the affected resident. The incident highlights a critical failure in adhering to professional standards and protocols for medication administration, resulting in severe consequences for the resident involved.
Significant Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the hospitalization of Resident 101 for a drug overdose. On the evening of 8/16/23, Resident 101 was mistakenly administered ten medications prescribed for another resident, Resident 106, by Staff 6 (LPN). The medications included Advair, Clozaril, Olanzapine, Metformin, D-Mannose, Flomax, Combivent, Tylenol, Vitamin C, and Systane eyedrops. Staff 6 realized the error after the administration and noted a decrease in Resident 101's level of consciousness. The resident was subsequently sent to the hospital, where they were diagnosed with an accidental overdose and severe hypotension, among other complications. The incident report indicated that Staff 6 failed to follow the facility's protocol for medication administration, including not asking the resident to state their name or using any acceptable identifiers such as a picture identifier or nameplate on the resident's door. Additionally, Staff 6 administered Resident 101's own prescribed medications after realizing the initial error, further complicating the resident's condition. The resident received mirtazapine, Eliquis, vitamin D, artificial tears eye drops, and nitroglycerin after the initial error, which was not verified with a physician. Interviews with Staff 1 (Administrator) and Staff 2 (DNS) confirmed that Staff 6 made a significant medication error and did not follow the protocol for safe medication administration. Staff 6 admitted to the lapse in practice and acknowledged not verifying the correct resident before administering the medications. The failure to follow proper procedures and the subsequent administration of additional medications without consulting a physician led to the resident's hospitalization and severe health complications.
Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to ensure residents were free from misappropriation of their narcotic medications, affecting three residents. Resident 103, who was admitted with diagnoses including palliative care and chronic pain, had a narcotic medication card of oxycodone that was signed to another page in the facility's Narcotic Book with a different medication and resident name. The signature was identified as a forgery, and the medication card could not be located. Similarly, Resident 104, admitted with a fractured leg and chronic pain, had two cards of oxycodone missing. The narcotic log book pages indicated the medications were transferred to other books and pages, but these pages had different medications and residents on them, and the signatures were also identified as forgeries. The missing medications were discontinued, and an audit showed no further concerns in the narcotic books in use at the time of the investigation. Resident 105, admitted with a traumatic brain injury and neuralgia, had a dose of oxycodone signed out of the narcotic book after a medication count was completed and after the keys were handed off. The signature appeared to be forged, and the resident did not receive the dose. The missing dose of medication was not documented on the eMAR, and staff were unable to find it. The signature on the narcotic book page resembled those identified in the previous drug diversion investigation. The facility's investigation revealed that Staff 8 was the only one with keys to the cart during the timeframe the narcotics went missing. The incidents were reported to the physician, state agency, and law enforcement. The facility acknowledged the misappropriation of medications had occurred, and the investigation confirmed the forgery and misappropriation of narcotic medications for the three residents involved.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Medford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Health Services Of Rogue Valley | 0.5 mi | ★★★★★ | 0 | 0 |
| Hearthstone Nursing & Rehabilitation Center | 2.1 mi | ★★★★★ | 6 | 0 |
| Rogue Valley Manor | 2.4 mi | ★★★★★ | 0 | 0 |
| Ashland Post Acute | 11.5 mi | ★★★★★ | 8 | 0 |
| Regency Care Of Rogue Valley | 24 mi | ★★★★★ | 2 | 0 |
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