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Home / Oregon / Ashland

Ashland Post Acute

135 Maple Street, Ashland, OR 97520 · Jackson County · (541) 482-2341

87 certified beds, about 81 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1989

Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
4 of 5
Quality measures
4 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 385197 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on May 9, 2025, inspectors cited 16 health deficiencies (the Oregon average is 9.2, the national average 9.2).

Of 56 health citations since October 2022, 2 were rated as actual harm or immediate jeopardy to residents.

CMS lists 1 fine totaling $31,369 in the last three years; the largest was $31,369, and the latest is dated January 22, 2024.

Nurses and nurse aides worked 4.48 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.58 of those hours.

40.8% of nursing staff left within the year CMS measured (Oregon average 47.4%).

CMS links it to PACS Group, an affiliated group of 275 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 56 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
43D
10E
1F
Potential for minimal harm
0A
0B
0C
June 8, 2026Complaint inspection · 2 citations
  1. E
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) June 29, 2026
    Inspectors wroteBased on observation and interview it was determined the facility failed to ensure a clean and homelike environment was provided for 1 of 2 shower rooms (West shower room) and 1 of 1 dining room reviewed for environment. This placed residents at risk for lack of homelike environment.
  2. E
    Observe each nurse aide's job performance and give regular training.
    F730 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) June 29, 2026
    Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure annual performance reviews for CNA staff were completed for 3 of 3 sampled CNA staff (#s 30, 31, and 32) reviewed for competent staff. This placed residents at risk for receiving care from staff who may have unidentified performance concerns.
December 8, 2025Complaint inspection · 2 citations
  1. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 17, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to notify a resident's responsible party for 1 of 3 sampled residents (#1) reviewed for UTIs. This placed residents at risk for lack of representative involvement.
  2. D
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    F627 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 17, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a safe discharge for 2 of 3 sampled residents (#s2 and 6) reviewed for discharge. This placed residents at risk for unmet post-discharge care needs.
November 14, 2025Complaint inspection · 4 citations
  1. D
    Ensure that residents are fully informed and understand their health status, care and treatments.
    F552 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 22, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to inform residents of the risks and benefits of psychotropic medication use for 1 of 3 sampled residents (#7) reviewed for medications. This placed residents at risk for being uninformed.
  2. D
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    F557 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 22, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to treat a resident with respect for 1 of 3 sampled residents (#7) reviewed for dignity. This placed residents at risk for lack of dignified treatment.
  3. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 22, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to provide wound care and assess a resident for use of a motorized wheelchair for 2 of 5 sampled residents (#s 2 and 4) reviewed for wounds and resident rights. This placed residents at risk for wound complications and lack of resident rights.
  4. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 22, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to provide necessary care and services for pressure ulcers for 1 of 3 sampled residents (#3) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers.
May 9, 2025Standard inspection, Complaint inspection · 16 citations
  1. E
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure resident needs were met for 4 of 4 sampled residents (#13, 17, 41 and 54) observed during dining and staffing observations. This placed residents at risk for late meals and pain.
  2. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to properly follow dish sanitation practices for 1 of 1 kitchen. This placed residents at risk for food borne illnesses.
  3. D
    Ensure that residents are fully informed and understand their health status, care and treatments.
    F552 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to obtain a consent for use of a mood stabilizer prior to administration for 1 of 5 sampled residents (#54) reviewed for unnecessary medications. This placed residents at risk for lack of consent.
  4. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident had a bed to accommodate her/his needs, a room had adequate room for transfers, and a resident's call light was within reach for 3 of 4 sampled residents (#s 17, 26, and 54) reviewed for environment. This placed residents at risk for lack of a homelike environment and inability to call for assistance.
  5. D
    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.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident was offered information to formulate an advance directive (AD) for 1 of 3 sampled residents (#54) reviewed for AD. This placed Residents at risk for end-of-life choices not being honored.
  6. D
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    F585 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to have a grievance policy which included a reasonable time frame to complete review of grievances and timely resolution for a resident's grievance for 1 of 2 sampled residents (#26) reviewed for oxygen. This placed residents at risk for unaddressed concerns and grievances.
  7. D
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    F605 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from unnecessary medications for 1 of 5 sampled residents (#31) reviewed for medications. This placed residents at risk for adverse side effects of medication.
  8. D
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    F644 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident's PASRR II (Pre-admission Screening and Resident Review) recommendations were incorporated into her/his care plan for 1 of 5 sampled residents (#54) reviewed for unnecessary medications. This placed residents at risk for unmet behavioral health needs.
  9. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to develop a resident centered care plan for 3 of 4 sampled residents (#s 17, 47, and 62) reviewed for hospice, smoking and incontinence. This placed residents at risk for unmet care needs.
  10. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a dependent resident received assistance with ADLs for 1 of 2 sampled residents (#26) reviewed for oxygen. This placed residents at risk for unmet needs and injuries.
  11. D
    Provide activities to meet all resident's needs.
    F679 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide meaningful activities for dependent residents for 2 of 2 sampled residents (#s 2 and 62) reviewed for activities. This placed residents at risk for lack of social interaction and isolation.
  12. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to assess a resident and failed to follow physician orders for a follow-up doctor's appointment for 2 of 3 sampled residents (#s 17 and 24) reviewed for catheter care and hospitalization. This placed residents at risk for tooth decay and delayed care.
  13. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a fall investigation was completed timely for 1 of 1 sampled resident (#54) reviewed for falls. This placed residents at risk for a delay in implementing new interventions.
  14. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's medication was available to administer for 1 of 1 sampled resident (#17) reviewed for pharmacy services. This placed residents at risk for pain. Resident 17 was admitted to the facility in 6/2021 with a diagnosis of arthritis. Resident 17's Encounter Note revealed a Nurse Practitioner visit for her/his medication review and to refill her/his Norco (narcotic medication) prescription. Resident 17's 1/2025 MAR revealed Resident 17 was to be administered Norco every four hours for pain. The MAR revealed it was not administered on 1/30/25 at 4:00 AM, 1/30/25 at 8:00 AM, 1/30/25 at 12:00 PM or 1/30/25 at 4:00 PM. Progress notes revealed the following: -1/30/25 at 5:40 AM waiting for Norco delivery. Physician notified of missed dose. [...]
  15. D
    Provide or obtain dental services for each resident.
    F791 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on interview and record review it was determined the facility failed to provide dental services for 1 of 1 sampled resident (#24) reviewed for dental services. This placed residents at risk for unmet dental needs.
  16. D
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 18, 2025
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure food was served at palatable temperatures for 1 of 5 sampled residents (#56) and 1 of 1 kitchen. This placed residents at risk for food that was not palatable, safe, or appetizing.
August 30, 2024Complaint inspection · 6 citations
  1. D
    Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
    F557 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 26, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to treat residents with dignity and respect for 1 of 3 (#19) sampled residents reviewed for dignity and respect. This placed residents at risk for loss of dignity.
  2. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 26, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to accurately assess MDS assessments for 1 of 3 sampled residents (#16) reviewed for pressure ulcers. This placed residents at risk for unassessed pressure ulcer care needs.
  3. D
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    F661 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 26, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to provide necessary information to continuing care providers pertaining to the coccyx pressure ulcer treatment for 1 of 3 sampled resident (#16) reviewed for skin conditions. This placed residents at risk for unmet treatment care needs after discharge.
  4. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 26, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to bathe residents for 1 of 5 sampled residents (#2) reviewed for ADL assistance. This placed residents at risk for lack of hygiene.
  5. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 26, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to properly assess and treat a pressure ulcer for 1 of 4 sampled residents (#16) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers.
  6. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 26, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to accurately document in the medical record for 1 of 3 sampled residents (#16) reviewed for pressure ulcers. This placed residents at risk for inaccurate medical records.
April 19, 2024Complaint inspection · 1 citation
  1. D
    Protect each resident from the wrongful use of the resident's belongings or money.
    F602 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from misappropriation of controlled (medications that are counted and stored in a locked area) narcotic and sedative medications for 2 of 2 sampled residents (#s 4 and 6) reviewed for drug diversion. This placed residents at risk for unmet medication care needs.
January 22, 2024Standard inspection, Complaint inspection · 16 citations
  1. G
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide pain medications and clarify physician orders for 2 of 6 sampled resident (#s 2 and 212) reviewed for pain management and medications. Resident 212 experienced severe pain.
  2. E
    Observe each nurse aide's job performance and give regular training.
    F730 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 4 of 5 sampled CNA staff (#s 10, 11, 12, and 13) reviewed for staffing. This placed residents at risk for a lack of competent staff.
  3. E
    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.
    F803 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure food for menus were available for 1 of 1 un-sampled resident (#12) observed during kitchen observations. This place residents at risk for lack of honored preferences and nutrition.
  4. E
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure meals were served at appriopriate temperatures for 2 of 4 sampled residents (#s 38 and 53) reviewed for food. This place residents at risk for lack of meal palatability and satisfaction.
  5. E
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    F947 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on interview and record review, it was determined the facility failed to have a system in place to ensure CNA staff received the required 12 hours of in-service training annually for 3 of 5 sampled CNAs (#s 10, 11, and 13) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of competent staff.
  6. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to accommodate resident needs for 1 of 7 sampled residents (#13) reviewed for environment. This placed residents at risk for not being able to call for assistance.
  7. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to protect the resident's right to be free from physical abuse for 1 of 1 sampled resident (#21) reviewed for abuse. This placed residents at risk for abuse.
  8. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to accurately assess 3 of 9 sampled residents (#s 2, 15 and 43) reviewed for medications and ROM. This placed residents at risk for unmet and unidentified needs.
  9. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to develop a comprehensive care plan for 1 of 5 sampled residents (#2) reviewed for medications. This placed residents at risk for lack of medical interventions.
  10. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to revise care plan interventions for 1 of 5 sampled residents (# 29) reviewed for hearing and ROM. This placed residents at risk for unmet needs.
  11. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 1 of 3 sampled residents (#18) reviewed for ADLs. This placed resident at risk for unmet needs.
  12. D
    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.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide a restorative program to prevent decline in range of motion for 1 of 4 sampled residents (#15) reviewed for ROM. This placed residents at risk for decline in their range of motion abilities.
  13. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure interventions for smoking safety were followed for 1 of 1 sampled resident (#30) reviewed for smoking. This placed residents at risk for smoking accidents.
  14. D
    Provide care or services that was trauma informed and/or culturally competent.
    F699 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a resident who was a trauma survivor received trauma-informed care for 1 of 1 sampled resident (#6) reviewed for PASRR. This placed residents at risk for unmet trauma needs and a decrease in their quality of life.
  15. D
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to address pharmacy recommendations for 1 of 5 sampled residents (#29) reviewed for medications. This placed residents at risk for inappropriate medication dosing.
  16. D
    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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) February 15, 2024
    Inspectors wroteBased on interview and record review it was determined the facility failed to monitor psychotropic medications for adverse side effects, monitor for medication effecacy, and receive a consent prior to administration for 2 of 9 sampled residents (#s 6 and 15) reviewed for psychotropic medications and ROM. This placed residents at risk for receiving unnecessary psychotropic medications.
October 7, 2022Standard inspection · 9 citations
  1. G
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) November 8, 2022
    Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician's orders for 2 of 8 sampled residents (#s 8 and 23) reviewed for hospitalization and medications. This failure resulted in Resident 8 requiring admission to the Intensive Care Unit (ICU) for recurrent seizures.
  2. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) November 8, 2022
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide a clean and sanitary kitchen and food service related to floors, surfaces, refrigeration, beverage service and food storage and failed to provide a system for nutritionally appropriate food substitutions for 1 of 1 kitchen and 1 of 1 dining room. This placed residents at risk for food borne illnesses and compromised nutrition.
  3. E
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 8, 2022
    Inspectors wroteBased on observation and interview it was determined the facility failed to provided finished and cleanable window sills in 4 of 34 rooms. This place residents at risk for lack of a sanitary and homelike environment.
  4. E
    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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 8, 2022
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were evaluated prior to receiving an antipsychotic medication, had appropriate indications for use, consented to the medication, had behaviors monitored, medications monitored for effectiveness and all psychotropic (drugs that effect brain chemistry) medications were evaluated for 4 of 6 sampled residents (#s 23, 30, 34 and 38) reviewed for medications. This placed residents at risk for lack of consent, indications for use, monitoring of behaviors, evaluation for effectiveness as well as risk for medication side effects.
  5. D
    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.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 8, 2022
    Inspectors wroteBased on interview and record review it was determined the facility failed to follow up regarding Advance Directives for 1 of 2 sampled residents (#30) reviewed for Advance Directives. This placed residents at risk for not having their healthcare wishes honored.
  6. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 8, 2022
    Inspectors wroteBased on interview and record review it was determined the facility failed to notify the physician of blood sugar levels outside of parameters and insulin refusals for 2 of 6 sampled residents (#s 30 and 34) reviewed for medications. This placed residents at risk for physicians being uninformed.
  7. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 8, 2022
    Inspectors wroteBased on interview and record review it was determined the facility failed to address respiratory care recommendations and to document oxygen use and care for 1 of 2 sampled residents (#38) reviewed for respiratory care. This placed residents at risk for complications from improper respiratory management.
  8. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 8, 2022
    Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide dialysis services for 1 of 1 sampled resident (#13) reviewed for dialysis. This placed residents at risk for lack of dialysis services.
  9. D
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 8, 2022
    Inspectors wroteBased on interview and record review it was determined the facility failed to address pharmacy recommendations timely for 1 of 6 sampled residents (#23) reviewed for medications. This placed residents at risk for unnecessary medications.

Fire safety inspections

9 fire safety citations on file: 5 on May 9, 2025, 1 on January 22, 2024, 3 on October 7, 2022.

Every fire safety citation9 citations
  1. F
    Conduct risk assessment and an All-Hazards approach.
    E 6 · May 9, 2025 · Corrected (the home has a date of correction)
  2. F
    Address patient/client population and determine types of services needed.
    E 7 · May 9, 2025 · Corrected (the home has a date of correction)
  3. F
    Establish policies and procedures including evacuation.
    E 20 · May 9, 2025 · Corrected (the home has a date of correction)
  4. F
    Have simulated fire drills held at unexpected times.
    K 712 · May 9, 2025 · Corrected (the home has a date of correction)
  5. D
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · May 9, 2025 · Corrected (the home has a date of correction)
  6. F
    Install a fire alarm system that can be heard throughout the facility.
    K 341 · January 22, 2024 · Corrected (the home has a date of correction)
  7. F
    Install noncombustible or limited-combustible interior walls.
    K 163 · October 7, 2022 · Corrected (the home has a date of correction)
  8. F
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · October 7, 2022 · Corrected (the home has a date of correction)
  9. E
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · October 7, 2022 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
January 22, 2024Fine $31,369

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeOregonUnited States
All nursing staff (RN, LPN and aides)4.485.033.86
Registered nurses0.580.720.69
All nursing staff on weekends4.254.513.42
Nurse aides3.03
Licensed practical nurses0.88
Nursing staff turnover (share who left in a year)40.8%47.4%45.8%
Registered nurse turnover56.3%51.6%42.9%
Administrators who left0

CMS expects 3.30 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.58 on weekdays and 4.25 on weekends, 7% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 8.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.75 in April to June 2025 to 4.48 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20264.480.584.584.25 8.2%0 of 9081
Oct to Dec 20254.450.594.534.23 5.7%0 of 9283
Jul to Sep 20254.480.634.574.22 7.0%0 of 9283
Apr to Jun 20254.750.744.904.39 5.0%0 of 9176
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Oregon, Jan to Mar 20264.910.645.124.406.2%0.4% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeOregonUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
18.914.913.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.41.40.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
3.42.01.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
4.32.43.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
2.61.41.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
22.820.614.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
2.45.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
18.213.915.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
23.521.423.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
12.816.112.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.01.51.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
0.62.41.8

Owners and operators

Legal business name: ASHLAND SNF HEALTHCARE LLC. CMS links this home to PACS Group, a group of 275 nursing homes averaging 2.9 stars overall.

NameRoleTypeShareSince
Truist Bank5% or greater security interestOrganization09/01/2024
Apt, FrederickOperational/managerial controlIndividual05/10/2024
Hamilton, MatthewOperational/managerial controlIndividual09/01/2024
Hinderman, VictoriaOperational/managerial controlIndividual01/20/2025
Jergensen, JoshuaOperational/managerial controlIndividual05/10/2024
Kahn, KarenOperational/managerial controlIndividual09/01/2024
Mitchell, JohnOperational/managerial controlIndividual05/10/2024
Ashland 135 Realty LLCAdp of the SNFOrganization09/01/2024
Providence Administrative Consulting Services IncAdp of the SNFOrganization09/01/2024
Hamilton, MatthewAdp of the SNFIndividual05/27/2025
Kahn, KarenAdp of the SNFIndividual05/27/2025

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 17 problems in this area, most recently on November 14, 2025: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 14 problems in this area, most recently on June 8, 2026: "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."
  3. When is the care plan meeting, and can family attend it?Inspectors cited 8 problems in this area, most recently on May 9, 2025: "Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed."
  4. Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 5 problems in this area, most recently on May 9, 2025: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 4.25 hours per resident per day, below the Oregon average of 4.51.

Other nursing homes nearby

Oregon contacts for a concern about a nursing home

These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.

Common questions

What is Ashland Post Acute's Medicare star rating?
CMS rates Ashland Post Acute 1 out of 5 stars overall, with 1 for health inspections, 4 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Ashland Post Acute get at its last inspection?
16 health deficiencies at the standard inspection on May 9, 2025. The Oregon average is 9.2.
Has Ashland Post Acute been fined?
Yes. CMS lists 1 fine totaling $31,369 in the last three years.
Does Ashland Post Acute accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Ashland Post Acute?
CMS lists 11 owners and managers, and links the home to PACS Group. Legal business name: ASHLAND SNF HEALTHCARE LLC.

Sources

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