Oregon ›Eugene

South Hills Rehabilitation Center

1166 E. 28th Avenue, Eugene, OR 97403 · Lane County · 110 certified beds · avg 76 residents/day · certified since May 17, 1985

Abuse citation flag (CMS)SFF Candidate

Part of chain: VOLARE HEALTH (16 facilities, chain avg rating 1.8★)

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

1/5
Health inspection rating (on-site)
2
Serious findings on record
$165,996
Fines, last 3 years
5.28
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, facility-wide · Aug 11, 2025 · F-0880

The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.

Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.

Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.

Corrected: Sep 29, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Feb 9, 2026 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Mar 24, 2026 (Deficient, Provider has date of correction)

All citations in the current public record (66)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Apr 13, 2026E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Apr 13, 2026E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint
Apr 13, 2026D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Feb 9, 2026▲ G · Actual harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Dec 9, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Dec 9, 2025D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint
Aug 11, 2025▲ L · Immediate jeopardy, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Aug 11, 2025E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Aug 11, 2025D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Aug 11, 2025D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Aug 11, 2025D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Aug 11, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Aug 11, 2025D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Aug 11, 2025D · Potential for harm, one-offThe facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
Aug 11, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Aug 11, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Aug 11, 2025D · Potential for harm, one-offThe facility did not dispose of garbage and refuse properly.
Oct 16, 2024E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Oct 16, 2024E · Potential for harm, repeatedThe facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint
Oct 16, 2024D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Oct 16, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Oct 16, 2024D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Oct 16, 2024D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Oct 16, 2024D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Oct 16, 2024D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Mar 22, 2024E · Potential for harm, repeatedThe facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint
Mar 22, 2024E · Potential for harm, repeatedThe facility did not honor residents' right to form and take part in resident or family groups, such as a resident council.
Mar 22, 2024E · Potential for harm, repeatedThe facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately.
Mar 22, 2024E · Potential for harm, repeatedThe facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman.
Mar 22, 2024E · Potential for harm, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Mar 22, 2024E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Mar 22, 2024E · Potential for harm, repeatedThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · from a complaint
Mar 22, 2024E · Potential for harm, repeatedThe facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint
Mar 22, 2024E · Potential for harm, repeatedThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Mar 22, 2024E · Potential for harm, repeatedThe facility did not dispose of garbage and refuse properly.
Mar 22, 2024E · Potential for harm, repeatedThe facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. · from a complaint
Mar 22, 2024E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Mar 22, 2024D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Mar 22, 2024D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Mar 22, 2024D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Mar 22, 2024D · Potential for harm, one-offThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Mar 22, 2024D · Potential for harm, one-offThe facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Mar 22, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Mar 22, 2024D · Potential for harm, one-offThe facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way.
Mar 22, 2024D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Mar 22, 2024D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Mar 22, 2024D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Mar 22, 2024D · Potential for harm, one-offThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Mar 22, 2024D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Mar 22, 2024D · Potential for harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Mar 22, 2024D · Potential for harm, one-offThe facility did not provide safe and appropriate pain management for a resident who needed it.
Mar 22, 2024D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Mar 22, 2024D · Potential for harm, one-offThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Mar 22, 2024D · Potential for harm, one-offThe facility did not provide timely, approved x-ray services or have an agreement with an approved provider to supply them.
Mar 22, 2024D · Potential for harm, one-offThe facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care.
Mar 22, 2024D · Potential for harm, one-offThe facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times.
Mar 22, 2024D · Potential for harm, one-offThe facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · from a complaint
Mar 22, 2024D · Potential for harm, one-offThe facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. · from a complaint
Apr 5, 2019D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Apr 5, 2019D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Apr 5, 2019D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Apr 5, 2019D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Apr 5, 2019D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Apr 5, 2019D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Apr 5, 2019D · Potential for harm, one-offThe facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care.
Apr 5, 2019D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (33 → 11).

YearCitationsSerious (G–L)Worst severity that year
201980D
2024410E
2025131L ▲
202641G ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

3 fines totaling $165,996.

DateTypeAmount / length
Jul 15, 2026Fine$57,888
Feb 9, 2026Fine$28,870
Aug 11, 2025Fine$79,238

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityOregon avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)5.285.423.95bottom 43% in Oregon; top 10% in the U.S.
Registered Nurse hours0.530.780.69bottom 27% in Oregon; bottom 42% in the U.S.
Weekend total nurse staffing4.614.853.50bottom 37% in Oregon; top 10% in the U.S.
Weekend RN hours (not acuity-adjusted)0.340.480.48bottom 34% in Oregon; bottom 40% in the U.S.
Total nursing staff turnover (%)67.547.445.8bottom 8% in Oregon; bottom 8% in the U.S.
RN turnover (%)92.351.642.9bottom 1% in Oregon; bottom 2% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.72, RN 0.47, weekend 4.12. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Hagler, AlexanderIndividual5% or Greater Indirect Ownership Interest—03/01/2023
Knox Healthcare Pac 12 Holdings LLCOrganization5% or Greater Indirect Ownership Interest—03/01/2023
Knox, DonaldIndividual5% or Greater Indirect Ownership Interest—03/01/2023
Pac 12 Holdings LLCOrganization5% or Greater Indirect Ownership Interest—03/01/2023
Pac 12 Opco Holdco LLCOrganization5% or Greater Direct Ownership Interest100%03/01/2023
Pac 12 Pinnacle Holdco LLCOrganization5% or Greater Indirect Ownership Interest—03/01/2023
Camas Ridge Propco LLCOrganization5% or Greater Mortgage InterestNOT APPLICABLE03/01/2023
Camas Ridge Propco LLCOrganizationADP of the SNFNOT APPLICABLE03/01/2023
Dunham, SarahIndividualOperational/Managerial ControlNOT APPLICABLE04/01/2025
Dunham, SarahIndividualADP of the SNFNOT APPLICABLE04/01/2025
Hagar, ChaimIndividualADP of the SNFNOT APPLICABLE03/01/2023
Knox, DonaldIndividualCorporate OfficerNOT APPLICABLE03/01/2023
Knox, DonaldIndividualOperational/Managerial ControlNOT APPLICABLE03/01/2023
Knox, DonaldIndividualADP of the SNFNOT APPLICABLE03/01/2023
Murer, EmilyIndividualOperational/Managerial ControlNOT APPLICABLE03/10/2025
Murer, EmilyIndividualADP of the SNFNOT APPLICABLE03/10/2025
Pac 12 Holdings LLCOrganizationADP of the SNFNOT APPLICABLE03/01/2023
Pac 12 Pinnacle Holdco LLCOrganizationADP of the SNFNOT APPLICABLE03/01/2023
Schwartz, EliezerIndividualOperational/Managerial ControlNOT APPLICABLE03/01/2023
Schwartz, EliezerIndividualADP of the SNFNOT APPLICABLE03/01/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Cascade Manor0.5 miEugene, OR★★★★☆4/5
Creekside Health and Rehabilitation of Cascadia0.6 miEugene, OR★★★★★4/5
Hillside Heights Rehabilitation Center1.5 miEugene, OR★★★☆☆3/5
Avamere Rehabilitation of Eugene2.0 miEugene, OR★☆☆☆☆1/5
Valley West Health Care Center3.5 miEugene, OR★★☆☆☆2/5
Avamere Riverpark of Eugene3.9 miEugene, OR★★☆☆☆2/5
Green Valley Rehabilitation Health Center3.9 miEugene, OR★☆☆☆☆1/5
Marquis Springfield4.1 miSpringfield, OR★★★★☆3/5
Creswell Post Acute8.4 miCreswell, OR★★☆☆☆2/5
Avamere Rehabilitation of Junction City14.5 miJunction City, OR★★★★☆3/5
Cottage Grove Post Acute16.9 miCottage Grove, OR★★★☆☆3/5

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Facility data as of CMS processing date 2026-08-01. CCN 385167.