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Health Inspection Summary
Ashland Post Acute
135 Maple Street
Ashland, OR 97520
(541) 482-2341
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Deficiency Category
Inspection Date:
1/22/24
Complaint Reporting Period:
4/1/24 - 3/31/25
Inspection Date:
10/7/22
Complaint Reporting Period:
4/1/23 - 3/31/24
Inspection Date:
2/27/20
Complaint Reporting Period:
4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies201
Quality of Life and Care Deficiencies736
Infection Control Deficiencies000
Resident Assessment and Care Planning Deficiencies603
Nursing and Physician Services Deficiencies200
Resident Rights Deficiencies233
Nutrition and Dietary Deficiencies213
Pharmacy Service Deficiencies221
Environmental Deficiencies000
Administration Deficiencies001

Detailed result for inspection on 1/22/24
Date of last standard health inspection:1/22/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25
No infection control inspections
Total number of Health Deficiencies for this nursing home:23
Average number of Health Deficiencies in Oregon:12.7
Average number of Health Deficiencies in the United States:9.6
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Protect each resident from the wrongful use of the resident's belongings or money.

4/19/242/2/22
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate pain management for a resident who requires such services.

1/22/242/15/24
3 - Actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

8/30/249/26/24
2 - Minimal harm or potential for actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Few

Provide care or services that was trauma informed and/or culturally competent.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Few

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

8/30/249/26/24
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure each resident receives an accurate assessment.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Few

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

8/30/249/26/24
2 - Minimal harm or potential for actual harm
Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

8/30/249/26/24
2 - Minimal harm or potential for actual harm
Few

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Few

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

8/30/249/26/24
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Observe each nurse aide's job performance and give regular training.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Some

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Some
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Reasonably accommodate the needs and preferences of each resident.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

8/30/249/26/24
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Some

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Few

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Few
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 10/7/22
Date of last standard health inspection:10/7/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24
No infection control inspections
Total number of Health Deficiencies for this nursing home:9
Average number of Health Deficiencies in Oregon:12
Average number of Health Deficiencies in the United States:9.4
Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide safe and appropriate respiratory care for a resident when needed.

10/7/2211/8/22
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate dialysis care/services for a resident who requires such services.

10/7/2211/8/22
2 - Minimal harm or potential for actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

10/7/2211/8/22
3 - Actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

10/7/2211/8/22
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

10/7/2211/8/22
2 - Minimal harm or potential for actual harm
Few

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.

10/7/2211/8/22
2 - Minimal harm or potential for actual harm
Some
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

10/7/2211/8/22
2 - Minimal harm or potential for actual harm
Many
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

10/7/2211/8/22
2 - Minimal harm or potential for actual harm
Few

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

10/7/2211/8/22
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 2/27/20
Date of last standard health inspection:2/27/20Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23
No complaint inspections
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23
No infection control inspections
Total number of Health Deficiencies for this nursing home:18
Average number of Health Deficiencies in Oregon:10.5
Average number of Health Deficiencies in the United States:8.7
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Few
Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Few

Provide safe and appropriate respiratory care for a resident when needed.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Some

Provide activities to meet all resident's needs.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Some

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Few

Provide safe, appropriate pain management for a resident who requires such services.

2/27/204/7/21
3 - Actual harm
Few

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Few
Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.
Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Few

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Few

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Few
Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.
Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure residents have reasonable access to and privacy in their use of communication methods.

2/27/204/7/21
1 - Potential for minimal harm
Some

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Few

Allow residents to self-administer drugs if determined clinically appropriate.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Few
Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Some

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Many

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Some
Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Some
Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.
Administration Deficiencies
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

2/27/204/7/21
2 - Minimal harm or potential for actual harm
Few
Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:Inspection DateDate of Correction
Level of Harm
(Least to most)
Residents Affected
(Few, Some, Many)

Protect each resident from the wrongful use of the resident's belongings or money.

4/19/242/2/22
2 - Minimal harm or potential for actual harm
Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Few

Provide care and assistance to perform activities of daily living for any resident who is unable.

8/30/249/26/24
2 - Minimal harm or potential for actual harm
Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

8/30/249/26/24
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Few

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

8/30/249/26/24
2 - Minimal harm or potential for actual harm
Few

Ensure each resident receives an accurate assessment.

8/30/249/26/24
2 - Minimal harm or potential for actual harm
Few

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

8/30/249/26/24
2 - Minimal harm or potential for actual harm
Few

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

8/30/249/26/24
2 - Minimal harm or potential for actual harm
Few

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Some

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

1/22/242/15/24
2 - Minimal harm or potential for actual harm
Some
Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.
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