Inspection Reports for Ashland Post Acute
135 Maple Street, Ashland, OR 97520, OR, 97520
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Inspection Report
Complaint Investigation
Capacity: 87
Deficiencies: 35
Dec 8, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022 to 2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2022 through 2025, the facility exhibited numerous deficiencies including failure to notify families of hospital transfers, inadequate care planning, insufficient staffing, medication management issues, failure to provide timely medical and dental appointments, and lapses in environmental safety and food service standards. Many deficiencies were not corrected at the time of inspections, indicating ongoing compliance challenges.
Complaint Details
Multiple complaint investigations are included, with findings of failure to notify families, inadequate care planning, abuse substantiation, medication misappropriation, and staffing shortages impacting resident care.
Severity Breakdown
warning: 38
Deficiencies (35)
| Description | Severity |
|---|---|
| F0000 - INITIAL COMMENTS | — |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.): Failed to notify resident representatives of hospital transfers and changes in condition. | warning |
| F0627 - Inappropriate Discharge: Discharged residents without proper notification or resources, including failure to notify family or friends. | warning |
| M0000 - Initial Comments | — |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES | — |
| F0552 - Right to be Informed/Make Treatment Decisions: Failed to obtain informed consent for mood stabilizer medication. | warning |
| F0557 - Respect, Dignity/Right to have Prsnl Property: Failed to treat residents with dignity and respect. | warning |
| F0585 - Grievances: Failed to have a grievance policy with timely resolution and documentation. | warning |
| F0605 - Right to be Free from Chemical Restraints: Failed to ensure residents were free from unnecessary medications. | warning |
| F0644 - Coordination of PASARR and Assessments: Failed to incorporate PASRR II recommendations into care plans. | warning |
| F0656 - Develop/Implement Comprehensive Care Plan: Failed to develop resident-centered care plans addressing individual needs. | warning |
| F0677 - ADL Care Provided for Dependent Residents: Failed to provide assistance with activities of daily living. | warning |
| F0679 - Activities Meet Interest/Needs Each Resident: Failed to provide meaningful activities for dependent residents. | warning |
| F0684 - Quality of Care: Failed to assess residents and follow physician orders for appointments and treatments. | warning |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failed to complete timely fall investigations and implement interventions. | warning |
| F0725 - Sufficient Nursing Staff: Failed to provide sufficient nursing staff to meet resident needs, causing late meals and delayed medications. | warning |
| F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records: Failed to ensure medication availability and timely prescription refills. | warning |
| F0791 - Routine/Emergency Dental Srvcs in NFs: Failed to provide dental services and schedule appointments as requested. | warning |
| F0804 - Nutritive Value/Appear, Palatable/Prefer Temp: Failed to serve food at palatable temperatures and ensure timely meal assistance. | warning |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to maintain proper dish sanitation and chemical sanitizer levels. | warning |
| M0183 - Nursing Services: Minimum CNA Staffing: Failed to meet mandated CNA staffing ratios for 36 of 66 days reviewed. | warning |
| M0273 - Care Plan Prep, Implementation & Documentatio: Failed to include dietary personnel in interdisciplinary care planning conferences. | warning |
| F0602 - Free from Misappropriation/Exploitation: Failed to prevent misappropriation of controlled narcotic medications by staff. | warning |
| F0558 - Reasonable Accommodations Needs/Preferences: Failed to ensure call lights were within reach and beds accommodated resident needs. | warning |
| F0600 - Free from Abuse and Neglect: Failed to protect resident from physical abuse by staff. | warning |
| F0641 - Accuracy of Assessments: Failed to accurately assess and code pressure ulcers and other resident conditions. | warning |
| F0657 - Care Plan Timing and Revision: Failed to revise care plan interventions timely for hearing loss and vertigo. | warning |
| F0688 - Increase/Prevent Decrease in ROM/Mobility: Failed to provide restorative range of motion program and accurate documentation. | warning |
| F0697 - Pain Management: Failed to provide pain medications and clarify physician orders for pain management. | warning |
| F0698 - Dialysis: Failed to provide dialysis services and monitor dialysis access sites appropriately. | warning |
| F0730 - Nurse Aide Peform Review-12 hr/yr In-Service: Failed to complete annual performance reviews for CNA staff. | warning |
| F0756 - Drug Regimen Review, Report Irregular, Act On: Failed to address pharmacy recommendations timely. | warning |
| F0758 - Free from Unnec Psychotropic Meds/PRN Use: Failed to evaluate, consent, and monitor psychotropic medications properly. | warning |
| F0803 - Menus Meet Resident Nds/Prep in Adv/Followed: Failed to ensure menus met resident needs and food availability. | warning |
| F0884 - Reporting - National Health Safety Network: Failed to report complete COVID-19 information to NHSN as required. | warning |
Report Facts
Inspections on page: 10
Total deficiencies: 58
Total surveys: 10
Total licensing violations: 20
Licensed beds: 87
Days with insufficient CNA staffing: 36
Days reviewed for CNA staffing: 66
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matthew Hamilton | Administrator | Named as facility administrator in facility information |
| Staff 1 | Administrator | Named in multiple findings related to staffing and abuse investigations |
| Staff 2 | Director of Nursing Services (DNS) | Named in multiple findings related to nursing care, medication management, and investigations |
| Staff 3 | Resident Care Manager (RCM) / Regional Nurse | Named in findings related to care planning, medication administration, and abuse investigations |
| Staff 4 | Resident Care Manager (LPN) | Named in medication and discharge planning findings |
| Staff 5 | Social Services | Named in grievance and advance directive findings |
| Staff 6 | LPN / Dietary Manager | Named in findings related to dialysis and dietary services |
| Staff 7 | Resident Care Manager | Named in activity and meal service findings |
| Staff 9 | RN / Dietary Manager | Named in food service and dietary findings |
| Staff 10 | CNA / Registered Dietitian | Named in staffing and dietary findings |
| Staff 11 | RN / Charge Nurse | Named in bathing and medication administration findings |
| Staff 12 | CNA | Named in meal assistance findings |
| Staff 15 | Resident Care Manager | Named in care planning and smoking policy findings |
| Staff 16 | CNA | Named in call light accessibility findings |
| Staff 19 | RN / Infection Control Nurse | Named in medication administration and training findings |
| Staff 21 | Activities Director / LPN | Named in activity and dietary findings |
| Staff 22 | Cook / Nurse Practitioner | Named in dietary and medication findings |
| Staff 23 | Cook / LPN | Named in food service and dialysis findings |
| Staff 27 | CNA | Named in bathing and transfer findings |
| Staff 30 | RN | Named in smoking safety findings |
| Staff 31 | CNA / LPN | Named in activity and smoking safety findings |
| Staff 34 | OT Manager / RN | Named in therapy and assessment findings |
| Staff 35 | CNA | Named in activity and behavioral findings |
| Staff 36 | CMA | Named in medication pass and staffing findings |
| Staff 37 | Staffing Coordinator / RN | Named in staffing and medication pass findings |
| Staff 38 | Regional Nurse Consultant | Named in psychotropic medication monitoring findings |
| Staff 39 | CNA | Named in transfer and bathing findings |
| Witness 1 | Family | Named in discharge planning findings |
| Witness 2 | Friend | Named in discharge planning findings |
| Witness 3 | Family | Named in grievance findings |
| Witness 4 | Complainant | Named in grievance findings |
| Witness 5 | Radiology Support Staff / Dishwasher Technician | Named in radiology and dish sanitation findings |
| Witness 7 | Pharmacy | Named in medication availability findings |
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