Legacy Hospice Services
A hospice in Tualatin, Oregon 97062
6475 SW Borland Road, Suite J, Tualatin, Oregon 97062. (503) 220-1000.
Watch and the shortlist are kept with a free account, on every device. Your watch list. CMS’s own record is on Care Compare.
The short answer
Record last released by CMS on Oct 23, 2026.
- 3 deficiencies cited in the last three years
- 4of 5 family caregiver rating
- 10of 10 CMS’s Hospice Care Index
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
3 deficiencies cited in the last three years
The middle of the 24 hospices serving ZIP code 97062 had 5.
The last inspection on record was on Sep 26, 2025: a reaccreditation inspection by The Joint Commission.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
When those deficiencies happened
3 deficiencies in 1 month of the last 36. Last cited Sep 2025. Most serious: Standard-level. The last 3 years, to Oct 27, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Nov | Dec | ||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Sep 26, 2025: reaccreditation inspection by The Joint Commission3 deficiencies
-
Content of comprehensive assessment (42 CFR 418.54(c)(5))
The inspectors’ words, 94 words
“Observed in Record Review. In 2 of 12 patient records reviewed, The hospice did not conduct patient-specific comprehensive assessments and reassessments that identified the patient’s need for hospice care and service. The surveyor noted in two of eighteen active records wound assessments and reassessments were not performed. Examples: In NHV#5 a post surgical open foot wound (unable to be staged as residual from necrotizing fasciitis) was not assessed or reassessed despite ongoing treatment. In NHV#4 wound assessments were not performed for multiple wounds including heels, buttocks, coccyx and sacral area. Reviewed with Clinical Director.”
-
Content of plan of care (42 CFR 418.56(c)(1))
The inspectors’ words, 382 words
“Observed in Record Review. In 2 of 6 home visits conducted, The organization did not provide the patient with care, treatment, or services according to the patient’s needs identified needs. The frequency of skilled nursing assessments the assessed on admission as one visit within each two week period was not not increased in response to changes in condition and need for symptom management in two records (HVRR#1 and HVRR#2). Examples: In record (HHRR#1) on a patient with end stage asthma with symptoms of anxiety, shortness of breath and nausea persisted through the first four weeks on service. The patient stated during the home visit that my symptoms are not managed. Prior to this visit the hospice had observed the patient on admission, and during two skilled assessments in a four-week period. During the same period of time ten triage calls were received symptom support. In addition to active symptoms a Stage I sacral ulcer assessed on admission as 1cm by 1cm had deteriorated to 8 by 10 cm’s by the second visit approximately two weeks later and had not been reassessed for treatment effectiveness since. The patient presents with significant cachexia with boney prominences. In record (HHV#2) on patient with ES Multiple Sclerosis that pain and symptom management for nausea, constipation, pain and anxiety required many medication changes. During the last forty days of her life skilled nursing assessments were made in accordance to the initial frequency assessed on admission as one visit within each two week period; this was not changed despite receiving over twenty triage calls during the same period of time. It was noted on a clinical note the last week of life the caregiver stated on a Chaplain check in call can a nurse come and lay eyes on her. The patient experienced unresolved, persistent constipation issues as evidenced by not having a bowel movement for over two weeks in one period only to experience another delayed bowel movement of over a week again. Reviewed with Clinical Manager. Observed in Record Review. The organization did not obtain an order for an acupuncture treatment prior to performing the procedure. The surveyor noted this in one of eighteen active record reviews. Example: In NHV#12 a consult and treatment for an acupuncture treatment was not obtained. Reviewed with Director of Nursing.”
-
Level of activity (42 CFR 418.78(e))
“Observed in Document Review. Volunteer staff did not provide day-to-day administrative or direct patient care in an amount that equals 5% of the total patient care hours of all paid hospice employees and contract staff. The surveyor noted during review of volunteer hours and through interview with the volunteer coordinator that the requirements were not met for the past three years. Examples: FY23 was 2.38%, FY24 3.4% and FY25 3.7%. This was confirmed by the Volunteer Coordinator and Leadership.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Sep 26, 2025 | Reaccreditation inspection by The Joint Commission | 3 deficiencies cited |
Is it certified?
- Medicare-certified hospice since Apr 8, 1988.
- Ownership: non-profit.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency or CMS’s most serious finding: the place’s failure to meet a rule caused, or was likely to cause, serious injury, harm, impairment or death to someone in its care. Source: CMS; 42 CFR 489.3. on record in the last three years.
CMS, Hospice General Information. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Has anything been proven against it?
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- 0 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
Who does the caring?
- From Medicare claims (Jan 1, 2023 to Dec 31, 2024): 13 nurse care minutes per routine home care day, 13.6% of skilled nursing minutes at weekends and a visit near death for 87.5% of patients who died.
- Where its patients were cared for (Jan 1, 2024 to Dec 31, 2024): 68% at home, 8% in assisted living, 7% in a nursing facility, 17% elsewhere.
CMS, Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | This provider |
|---|---|
| Nurse care minutes per routine home care day | 13.0 min |
| Skilled nursing minutes at weekends | 13.6% |
| Visits near death | 87.5% of patients who died |
Who owns it?
- Legacy Health runs it.
- 26 owners or officers are people: Joseph H Frankhouse (corporate director); Jack Friedman (corporate director); Edgar Navas (corporate director); Richard P Reiten (corporate director); Kathryn G Correia (corporate director); Jerry Petty (corporate director); Charles Wilhoite (corporate director); Nancy Locke (corporate director); Leslie Root (corporate director); Jeffrey Barber (corporate director); Nancy Horton (corporate director); Craig Armstrong (corporate director); Teresa L Handy (corporate officer); Teresa L Handy (managing employee (on the payroll)); Lynn T Gust (corporate director); Megan Linahan (managing employee (on the payroll)); Anna Loomis (corporate director); Gayle Goschie (corporate director); Lisa Wynn (corporate director); Nathalie Johnson (corporate director); Nasreen A Ilias-Khan (corporate director); Ruth Medak (corporate director); David Ramus (corporate director); Samir B Desai (corporate director); Sarah Jensen (corporate officer); Sarah Jensen (corporate director).
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospice All Owners and Hospice Enrollments. Released Sep 29, 2026. Updated quarterly.
What do families say?
- Family caregivers rate it 4 of 5 in CMS’s survey (Oct 1, 2023 to Sep 30, 2025): 84% rated it 9 or 10 out of 10, and 87% would definitely recommend it.
- CMS’s Hospice Care Index: 10 of 10 (Jan 1, 2023 to Dec 31, 2024).
- 96.74% of patients were assessed on all seven of CMS’s measures at the start of care (Oct 1, 2024 to Sep 30, 2025); 47.8% had visits from a nurse or social worker on at least 2 of their last 3 days (Jan 1, 2023 to Dec 31, 2024).
CMS, CAHPS Hospice Survey and Hospice Provider Data. Released Aug 26, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Family caregiver survey ratingCMS star rating from its survey of patients’ family caregivers, 1 to 5 | 4 of 5 |
| Hospice Care IndexCMS’s Hospice Care Index, 0 to 10 (higher is better): a point for each of ten measures from Medicare claims on which the hospice meets CMS’s threshold | 10 of 10 |
How does it compare nearby?
- Of the 24 hospices CMS’s data show serving patients in ZIP code 97062, where this hospice’s office is, the middle number of deficiencies cited in the last three years was 5; this one had 3.
CMS, Hospice ZIP Data. Released Aug 26, 2026. Updated quarterly.
CMS, QCOR hospice inspection reports. Released Oct 23, 2026. Updated quarterly.
| Place | Deficiencies, 3 years |
|---|---|
| Legacy Hospice Services This hospice | 3 |
| Brighton Hospice | 0 |
| Providence Hospice | 6 |
| Kaiser Permanente Continuing Care Services Hospice | Not given |
| Adventist Health Hospice | 2 |
| CARE Partners | 2 |
| Traditions Health | 11 |
| Northwest Hospice, LLC | 0 |
| Serenity Hospice | 8 |
| Housecall Providers Hospice | 5 |
| Bristol Hospice Oregon LLC | 2 |
| Accentcare Hospice & Palliative Care of Oregon | 19 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospices, so none are shown.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- CMS ended its Special Focus Program for hospices with serious problems on Feb 14, 2025, so no hospice is marked as one.
- Hospice quality measures have a gap from October 2025: CMS replaced its patient assessment then, and public results from the new one (HOPE) are expected around November 2027.
Sources
-
Centers for Medicare & Medicaid Services, Hospice General Information (yc9t-dgbk).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Hospice Provider Data (252m-zfp9).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, CAHPS Hospice Survey (gxki-hrr8).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, QCOR hospice inspection reports (Hospice Survey Reports - Oct 2021 through Sep 2026.xlsx).
Released Oct 23, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Hospice All Owners (e983965e-1603-4cb8-82b5-c40090e380d1).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Hospice Enrollments (25704213-e833-4b8b-9dbc-58dd17149209).
Released Sep 29, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
-
Centers for Medicare & Medicaid Services, Hospice ZIP Data (95rg-2usp).
Released Aug 26, 2026 and checked Oct 27, 2026. Updated quarterly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Oct 27, 2026.
From the hospice
The public record above comes first. Anything the hospice adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospice will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospice”, and paying will never change a finding, a rating or the order of results.