South Hills Rehabilitation Center
1166 E. 28th Avenue · Eugene, OR · 97403 · 5413450534
110 certified beds For profit - Limited Liability company Chain: Volare Health
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $123,653 in fines in the last 24 months.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
$123,653 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
68% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 5.72 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.40 | 0.55–0.75 |
| Weekend hours / resident-day | 5.34 | ≈ weekday level |
| Nursing turnover / year | 68% | median 45% |
| Fines (3-yr window) | 2 · $123,653 |
Inspection citations (66 in the current record)
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Potential for harm · E April 13, 2026 · found via complaint
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 June 2, 2026 · Resident Rights
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Potential for harm · D April 13, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected June 2, 2026 · Quality of Life and Care
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Potential for harm · E April 13, 2026 · found via complaint
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected June 2, 2026 · Nutrition and Dietary
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Actual harm · G February 9, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 24, 2026 · Quality of Life and Care
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Potential for harm · D December 9, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected January 5, 2026 · Quality of Life and Care
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Potential for harm · D December 9, 2025 · found via complaint
Provide safe and appropriate respiratory care for a resident when needed.
Corrected January 5, 2026 · Quality of Life and Care
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Immediate jeopardy · L August 11, 2025
Provide and implement an infection prevention and control program.
Corrected September 29, 2025 · Infection Control
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Potential for harm · D August 11, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected September 29, 2025 · Resident Rights
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Potential for harm · D August 11, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected September 29, 2025 · Resident Rights
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Potential for harm · D August 11, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 29, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 11, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected September 29, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 11, 2025
Respond appropriately to all alleged violations.
Corrected September 29, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 11, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected September 29, 2025 · Resident Rights
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Potential for harm · D August 11, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected September 29, 2025 · Quality of Life and Care
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Potential for harm · D August 11, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 29, 2025 · Quality of Life and Care
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Potential for harm · E August 11, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 29, 2025 · Nutrition and Dietary
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Potential for harm · D August 11, 2025
Dispose of garbage and refuse properly.
Corrected September 29, 2025 · Nutrition and Dietary
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Potential for harm · D October 16, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 5, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D October 16, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected December 5, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D October 16, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected December 5, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D October 16, 2024 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected December 5, 2024 · Resident Assessment and Care Planning
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Potential for harm · D October 16, 2024 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected December 5, 2024 · Quality of Life and Care
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Potential for harm · E October 16, 2024 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected December 5, 2024 · Nursing and Physician Services
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Potential for harm · E October 16, 2024 · found via complaint
Post nurse staffing information every day.
Corrected December 5, 2024 · Nursing and Physician Services
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Potential for harm · D October 16, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 5, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 9, 2026 | Fine | $44,415 |
| August 11, 2025 | Fine | $79,238 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 385167 · certified since May 17, 1985. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.