Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ashland Post Acute during CMS and state inspections, most recent first.
Surveyors found the west shower room had broken wall tiles, a black substance at the wall-floor joint, and a plant growing from the outside of the wall, with staff confirming the cracked tiles and possible mildew. In the dining room, a large orange cone was bolted to the floor between resident seating and a counter, and residents and staff reported it had been there for about two years and was being bumped into during use.
The facility failed to complete annual performance reviews for 3 sampled CNAs. Personnel records showed no performance review for each CNA, and one CNA stated she did not think she had ever completed a performance review since hire. The Administrator confirmed annual performance reviews should be completed.
A resident with a UTI experienced changes in condition and was transferred to the hospital on two occasions without documentation that their representative was notified. The DNS confirmed that family notification was required but did not occur in these instances.
Two residents were discharged without adequate coordination or verification of post-discharge support. One was sent home without confirming the availability of a friend to assist or assessing home safety, resulting in exposure to unsafe living conditions. Another was discharged with incomplete instructions, missing a follow-up appointment due to outdated paperwork. Staff did not ensure all necessary information and resources were provided prior to discharge.
A resident with depression was administered Lexapro without being informed of the medication's risks and benefits, and no signed consent was documented. The DNS confirmed that the required information was not reviewed and consent was not obtained.
A resident who was cognitively intact and unable to eat due to a feeding tube was repeatedly brought to the dining room during meal times, despite expressing distress and a desire not to attend. Family complaints were made, and staff acknowledged that this practice was undignified and inappropriate.
The facility did not provide proper wound care or ongoing assessment for a resident with a surgical incision, resulting in wound dehiscence and emergency transfer. Additionally, another resident's use of a power wheelchair was restricted without a formal assessment or documentation, despite care plan changes and staff concerns about safety.
A resident with a history of a left femur fracture and a stage 2 sacral pressure injury experienced a deterioration of the wound to an unstageable, infected state. Despite this change, staff did not notify the provider or update the care plan with new interventions, and the resident was subsequently hospitalized for the infected wound.
Due to a sudden reduction in CNA staffing after several were sent home for COVID-19, only one CNA was left to care for an entire wing, resulting in delayed meal delivery for residents on transmission-based precautions, late administration of scheduled pain medication, and missed personal care such as showers. Staff interviews confirmed that supervisory personnel were not promptly notified of the staffing shortage, leading to significant delays in meeting residents' needs.
Staff did not routinely check or maintain the chemical sanitizer levels in the kitchen's low temperature dish machine, resulting in the machine operating without the required sanitizer. The sanitizer solution container was found empty, and testing confirmed the sanitizer level was below the required standard.
A resident with a stroke history and mental health diagnosis was started on Depakote as a mood stabilizer without obtaining consent or reviewing the medication's risks and benefits, despite being cognitively intact. Staff did not secure consent because the drug was classified as an anti-seizure medication, even though it was used for mental health treatment.
Three residents experienced unmet needs related to their environment, including a resident not provided with a suitable bed despite complaints, another resident unable to be safely transferred due to lack of space in a shared room, and a third resident repeatedly left without access to a call light after care. Staff interviews and observations confirmed these issues, which were not addressed according to care plans or resident requests.
A resident who was cognitively intact and admitted with a stroke was not offered information about advance directives (AD), and there was no documentation in the medical record to indicate that AD information was provided or discussed. Staff confirmed that the new care conference form lacked a section to document the offer of AD information, resulting in a failure to follow facility policy.
A resident with PTSD and insomnia continued to receive Ambien nightly despite a psychologist's recommendation to transition to an alternative sleep aid. The resident was open to the change, but staff did not follow up on the recommendation, and the regional nurse later confirmed the medication had not been discontinued as directed.
A resident with a history of mental health disorders and behavioral concerns did not have PASRR II recommendations incorporated into their care plan. The care plan was not updated to include interventions such as providing books, art supplies, memory cues, or Crisis Team contact information, and staff interviews revealed a lack of follow-through in implementing these recommendations.
Three residents did not have individualized care plans addressing their specific needs: one resident's care plan lacked details about preferred times for incontinence care despite known preferences and refusals, another resident on hospice had no documentation of meaningful activities despite an assessment identifying them, and a third resident approved for independent smoking had no care plan for the management or storage of smoking materials, leaving staff unclear about safety procedures.
Two dependent residents did not receive meaningful activities tailored to their interests, as care plans lacked specific information and staff were unaware of individual preferences. One resident, cognitively intact and interested in group activities, was not informed about or encouraged to participate in events, while another resident on hospice with dementia spent extended periods in their room without engagement, as staff did not know what activities to offer.
Two residents did not receive appropriate follow-up care as ordered or requested. One resident with respiratory symptoms did not have timely nursing assessments or prompt communication of x-ray results showing pneumonia, leading to delayed intervention and hospitalization. Another resident and their family requested a urology appointment, but staff failed to schedule it despite being responsible for medical appointments.
A resident with a history of stroke and high fall risk, who required two staff and a mechanical lift for transfers, was left alone in a wheelchair after therapy while staff sought assistance. The resident attempted to self-transfer and fell. The facility did not complete the fall investigation or update the care plan to address this risk for over two weeks, delaying new interventions.
A resident with heart failure and kidney disease requested a dental appointment during a care conference, and the care plan noted oral health problems requiring staff coordination for dental care. Despite these needs and repeated requests, the responsible staff member did not schedule the appointment, and the regional nurse confirmed that immediate follow-up was expected.
A resident with a history of stroke and heart disease, who required meal assistance, was left waiting with a meal tray while food became cold due to delayed staff response and lack of communication about assistance needs. Observations also found that meal carts were left unattended and a test tray was served cold, indicating that food was not consistently served at safe and appetizing temperatures. Staff interviews confirmed inconsistent documentation and communication regarding meal assistance, leading to delays in meal service.
A resident with respiratory failure and chronic pain had a grievance submitted by family regarding concerns with oxygen administration, meal assistance, pressure ulcer care, and missing items. The facility did not document timely investigation or communicate findings to the complainant before a scheduled meeting, and the grievance policy lacked a clear timeline for resolution.
A resident with a history of spinal surgeries and chronic pain did not consistently receive scheduled showers or safe transfer assistance as outlined in their care plan. Staff failed to document or communicate missed showers, and a CNA used an improper bear hug transfer technique, leading to reported pain. There was no effective system in place to track missed ADL care or ensure staff followed updated care plans.
A resident with arthritis did not receive scheduled doses of Norco for pain due to a delay in obtaining a new prescription, resulting in missed medication administrations. Staff and pharmacy records confirmed the prescription was not sent promptly, and the DON was unaware of the issue.
A resident in palliative care with moderate cognitive impairment requested assistance with toileting but was told by a CNA to use their incontinence brief instead. The facility's Administrator intervened, ensuring the resident received the necessary help. The incident was reported, and the CNA was placed on administrative leave.
A facility failed to accurately assess MDS for a resident with a coccyx pressure ulcer. Despite treatment orders for the wound, both the Admission and Discharge MDS inaccurately indicated no pressure ulcer. This error was confirmed by the DNS, showing a lapse in proper documentation of the resident's condition.
A facility failed to provide necessary treatment information for a resident's coccyx pressure ulcer at discharge. The resident, admitted with diabetes, had a documented pressure ulcer, but the discharge summary lacked treatment details. This was confirmed by the DNS, highlighting a communication lapse with the receiving health care provider.
A resident with heart failure was not offered bathing assistance for over two weeks, as documented in their ADL records. This deficiency was confirmed by the DNS during an interview.
A resident's pressure ulcer was inconsistently assessed and improperly treated, with varying stages identified and inappropriate treatment ordered. The DNS acknowledged the discrepancies and confirmed the incorrect treatment for the wound.
A resident admitted with pressure ulcers had inconsistent and inaccurate documentation in their medical records. The records varied between indicating a Stage III ulcer, a Stage II ulcer, and a Deep Tissue Injury (DTI), with some assessments failing to acknowledge the ulcer entirely. These discrepancies were acknowledged by the DNS, indicating a deficiency in maintaining accurate medical records.
An agency nurse was found impaired and in possession of missing controlled medications intended for two residents, leading to her arrest. The facility staff discovered the misappropriation after observing the nurse's behavior and checking medication supplies. Despite the incident, no residents missed their medication doses.
Unsafe and Unhomelike Shower Room and Dining Room Conditions
Penalty
Summary
The facility failed to ensure a clean and homelike environment in the west shower room. Surveyors observed four broken wall tiles measuring approximately five by six inches, a black substance in the joint where the wall and floor met, and a lighter surrounding area. On the opposite side of the wall, a metal shelving unit had a plant growing from the joint beneath its bottom shelf. Staff confirmed the cracked tiles, what appeared to be black mildew, and that the plant was growing from the outside. The Administrator stated the facility had been working on remodeling the room due to the concerns. The facility also failed to maintain a safe and homelike dining room environment. Surveyors observed a large orange cone, approximately three feet high, bolted to the floor in the main dining room between resident seating and a counter. A resident stated the cone had been bumped into multiple times and that the floor should be fixed and the cone removed. Another resident was later observed bumping the cone while walking with a walker. Staff reported the cone had been present for approximately two years, following a damaged floor area that had previously been covered by a chair and then a wet floor sign. The Administrator confirmed the dining room should not have a large cone in the room.
Missing Annual Performance Reviews for CNA Staff
Penalty
Summary
The facility failed to ensure annual performance reviews were completed for 3 of 3 sampled CNA staff reviewed for competent staff. Personnel records showed no performance review for Staff 30, a CNA hired on 7/23/18; Staff 31, a CNA hired on 9/15/23; and Staff 32, a CNA hired on 12/7/20. During interview on 6/5/26 at 11:34 AM, Staff 32 stated she had worked at the facility for approximately five years and did not think she had ever completed a performance review since she was hired. On 6/8/26 at 10:23 AM, the Administrator confirmed that annual performance reviews should be completed.
Failure to Notify Responsible Party of Hospital Transfers
Penalty
Summary
The facility failed to notify the responsible party of a resident regarding two separate hospital transfers related to urinary tract infection (UTI) symptoms and changes in condition. The resident, admitted with a UTI diagnosis, experienced a change in mental status, abdominal pain, and inability to urinate, leading to an emergency department transfer on one occasion. On another occasion, the same resident reported ongoing abdominal pain and was again transported to the hospital for evaluation and treatment. In both instances, there was no documentation in the clinical record that the resident's representative was notified of the hospital transfers. The Director of Nursing Services confirmed that families were supposed to be notified but acknowledged that notification did not occur in these cases.
Failure to Ensure Safe and Coordinated Discharge Planning
Penalty
Summary
The facility failed to ensure safe discharge planning for two residents. One resident, admitted with cellulitis, was discharged home with recommendations for 24-hour care and home health services. However, the facility did not confirm with the resident's identified friend whether assistance would be available, nor did they notify the friend prior to discharge. The resident was discharged without verification of home conditions or provision of resources for in-home caregivers. Upon arrival home, the resident encountered unsafe living conditions, including the presence of rats and lack of running water, and had to seek shelter with a neighbor before being transported to the hospital for further discharge planning. Staff interviews revealed that the facility did not provide the resident with information about the risks of discharging without 24-hour caregivers, did not supply a list of local resources, and did not confirm the availability of the friend to assist post-discharge. Another resident, admitted with a fracture and cognitively intact, was discharged with instructions that included post-discharge appointments. However, the discharge paperwork did not include an updated appointment that was scheduled during a post-operative visit on the same day the discharge instructions were printed. As a result, the resident and family missed an important follow-up appointment. Staff acknowledged that the most current appointment information was not transcribed onto the discharge instruction sheet, leading to incomplete discharge instructions.
Failure to Inform Resident of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform a resident, admitted with a diagnosis of depression, about the risks and benefits associated with the use of Lexapro, an antidepressant medication. A review of the resident's medical record and physician order dated 5/3/25 showed that the resident was receiving Lexapro daily. However, there was no documentation indicating that the risks and benefits of the medication had been discussed with the resident, nor was there a signed consent form for the medication in the record. This was confirmed by the Director of Nursing Services, who acknowledged that the required information had not been reviewed with the resident and that no signed consent was present.
Resident with Feeding Tube Taken to Dining Room During Meals
Penalty
Summary
A resident with a history of stroke and a newly placed feeding tube, who was cognitively intact, was admitted to the facility and was unable to ingest food. Despite being prohibited from eating, the resident was repeatedly taken to the dining room during meal times, where other residents were eating. The resident expressed hunger and a desire not to be present in the dining room during meals, as it caused distress. Family members reported complaints to staff regarding this practice, but the situation continued. A CNA acknowledged that escorting the resident to the dining room under these circumstances was undignified and inappropriate. Facility administration also recognized that this action failed to respect the resident's dignity.
Failure to Provide Wound Care and Assess Power Wheelchair Use
Penalty
Summary
The facility failed to provide appropriate wound care and assessment for two residents. One resident was re-admitted with a surgical neck incision that was almost healed and open to air. Documentation showed conflicting information about whether the incision was covered with a dressing, and there were no orders for dressing changes or ongoing wound assessments after readmission. Staff confirmed that wounds, including incisions, should be monitored weekly and that the resident always had a dressing in place due to a neck brace. However, staff did not recall the wound's appearance prior to a significant event where the incision fully dehisced, resulting in bleeding and emergency hospital transport. The Director of Nursing Services (DNS) acknowledged that staff did not obtain wound care orders or assess the incision after readmission. Another resident, admitted with a diagnosis of seizures and dependent on staff for mobility, had their power wheelchair use restricted due to safety concerns. The care plan was revised to prohibit use of the electric wheelchair, but the clinical record lacked a required Power Mobility Device Screen assessment. Staff interviews revealed that the resident sometimes used the power wheelchair for short periods, but no formal assessment was conducted to determine safety or appropriateness. The DNS confirmed that an assessment should have been completed and findings reviewed with the resident.
Failure to Notify Provider and Update Care Plan for Worsening Pressure Ulcer
Penalty
Summary
A resident was admitted to the facility with a left femur fracture and a stage 2 pressure injury to the sacrum. Upon admission, the care plan addressed the existing pressure ulcer. Over the course of the resident's stay, wound assessments documented a deterioration of the sacral pressure injury, progressing from stage 2 to an unstageable wound with suspected infection. Despite this change, there was no documentation that the resident's provider was notified of the wound's deterioration or suspected infection as of the assessment date when the change was noted. Additionally, the care plan was not updated to reflect the worsening condition of the pressure injury or to include new interventions after the wound became unstageable and appeared infected. Staff interviews confirmed that no provider notification occurred and no new interventions were added to the care plan following the wound's decline. The resident was later admitted to the hospital with an infected unstageable pressure injury to the sacrum.
Failure to Provide Adequate Nursing Staff Resulting in Delayed Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, as evidenced by multiple observations and staff interviews. On the morning in question, several CNAs were sent home after testing positive for COVID-19, leaving only one CNA to cover an entire wing that typically required four. As a result, food trays for residents requiring transmission-based precautions remained unattended on carts for extended periods, with some residents not receiving their meals until significantly later than scheduled. Staff confirmed that the shortage prevented timely meal delivery and that residents would eventually be fed, but not according to the usual schedule. Additionally, the staffing shortage impacted medication administration. One resident, who was cognitively intact and had a diagnosis of arthritis, did not receive scheduled pain medication (Norco) until more than two hours after the scheduled time. The nurse responsible for medication administration reported being delayed due to the need to reorganize CNA assignments after the staffing shortage, and did not notify supervisory staff for assistance. This delay was confirmed by both the resident and staff involved in the medication pass. The lack of sufficient staff also affected personal care. Another resident, admitted with a history of stroke, did not receive a scheduled shower due to the staffing shortage, as confirmed by the CNA assigned to the wing. The staffing coordinator and DNS both stated they were not notified of the shortage until later in the morning, and the administrator, who was responsible for coordinating additional staffing, was not made aware of the issue until after the shortage had already impacted resident care.
Failure to Monitor and Maintain Dishwasher Sanitizer Levels
Penalty
Summary
The facility failed to properly follow dish sanitation practices in the kitchen, as required by professional standards and manufacturer instructions. The low temperature dish machine was supposed to maintain a sanitizer (chlorine) concentration of 50 parts per million. Although staff received training on the operation and chemical requirements of the new dishwasher, observations revealed that staff only monitored the temperature and soap levels, not the chemical sanitizer levels. Staff relied on an outside company to verify chemical levels, and did not perform routine checks themselves. During observation, a cook was seen using the dishwasher without verifying the sanitizer concentration, and the sanitizer solution container was found empty. When the chemical sanitizer level was tested by the administrator, it measured below the required 50 parts per million, and it was confirmed that no sanitizer was connected to the dish machine at that time. This failure to monitor and maintain proper sanitizer levels resulted in noncompliance with food sanitation standards.
Failure to Obtain Consent for Mood Stabilizer
Penalty
Summary
A resident admitted with a history of stroke and a mental health diagnosis was prescribed Depakote, an anti-seizure medication also used as a mood stabilizer. The resident was found to be cognitively intact according to the most recent assessment. Despite this, the facility did not obtain consent for the use of Depakote as a mood stabilizer, nor did staff review the risks and benefits of the medication with the resident. Staff interviews confirmed that consent was not obtained because the medication was classified as an anti-seizure drug, even though it was being used for mental health purposes.
Failure to Accommodate Resident Needs and Preferences in Environment
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of three residents in relation to their environment. One resident, admitted after shoulder surgery and at risk for pressure ulcers, repeatedly expressed that their bed was too narrow and uncomfortable, but staff were either unaware of the concern or informed the resident that a larger bed was not available. Another resident, who required a mechanical lift and assistance from two staff for transfers due to a stroke, reported that their shared room lacked sufficient space for safe transfers and wheelchair maneuvering. Staff confirmed that the room setup often required moving the bed at an angle or leaving the door open during transfers, which sometimes compromised privacy. A third resident, with cognitive intactness but impaired extremities from a stroke and heart disease, was observed without their call light within reach after care was provided. The resident stated this was a recurring issue, and staff acknowledged that the call light was not checked or placed within reach before leaving the room, despite care plan instructions. These deficiencies were identified through observations, resident and staff interviews, and record reviews.
Failure to Offer and Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that a resident was offered information to formulate an advance directive (AD) as required by its policy. According to the facility's policy, if a resident does not have an AD, the resident or their representative should be given the option to accept or decline assistance in establishing one, and nursing staff are required to document the offer and the resident's decision in the medical record. In the case of a resident admitted with a diagnosis of stroke, the care plan indicated that AD or POLST documentation should be present in the medical record at all times. However, the quarterly social history review noted that the resident did not have an AD, and there was no indication that AD information was offered. Further review revealed that the resident was cognitively intact and, during an interview, stated that no one had discussed ADs with them. Staff interviews confirmed that while residents are typically asked about ADs upon admission and quarterly, and blank forms are offered if needed, the new care conference form no longer included a section to document that AD information was provided. Staff acknowledged that there was no documentation in the resident's record to show that AD information had been offered.
Failure to Discontinue Unnecessary Psychotropic Medication
Penalty
Summary
A resident with diagnoses of PTSD and insomnia was admitted to the facility in September 2023. The clinical psychologist's management plan dated April 16, 2025, recommended transitioning the resident from Ambien, a sedative, to an alternative sleep aid, and noted the resident was open to trying a different medication. Despite this recommendation, medication administration records for April and early May 2025 showed the resident continued to receive Ambien nightly from April 1 through May 7, 2025. On May 8, 2025, the regional nurse confirmed that the resident had not been transitioned off Ambien as recommended and acknowledged that staff had not followed up on the psychologist's recommendation.
Failure to Incorporate PASRR II Recommendations into Care Plan
Penalty
Summary
The facility failed to ensure that a resident's PASRR II (Pre-admission Screening and Resident Review) recommendations were incorporated into the care plan. The resident, who was admitted with a history of stroke, mental health disorders, suicidal ideations, and aggressive behavior, had a PASRR II evaluation completed that included specific recommendations such as providing environmental and social structuring, memory cues, art supplies, increased access to books, and the contact information for a Crisis Team. However, the care plan was not updated to reflect these recommendations, and staff did not implement the suggested interventions. Observations revealed that the resident's room lacked books, art supplies, and photos of loved ones, and the resident confirmed not having access to these items. Interviews with staff indicated a lack of clarity and follow-through regarding the handling and implementation of the PASRR II recommendations. The social services staff could not recall what was done with the recommendations, and the resident care manager did not see the PASRR II after its completion. The regional nurse confirmed that staff were expected to review and implement PASRR II recommendations, but this was not done for the resident in question.
Failure to Develop Resident-Centered Care Plans for Incontinence, Hospice Activities, and Smoking
Penalty
Summary
The facility failed to develop and implement individualized, resident-centered care plans for three residents with specific needs related to incontinence, hospice activities, and independent smoking. For one resident with arthritis and a history of depression and anxiety, the care plan did not include detailed instructions regarding the resident's preferred times for incontinence care, despite staff and resident reports that the resident was particular about care routines and often refused care from unfamiliar staff. The care plan also did not reflect the resident's current status, as the most recent assessments indicated the resident was cognitively intact and did not refuse care, yet staff interactions revealed ongoing issues with care refusals and unmet incontinence needs. Another resident admitted on hospice with cancer had an activity assessment identifying several meaningful activities, such as reading, listening to music, and being outdoors. However, the care plan failed to specify which activities were important to the resident, and staff were unaware that the care plan did not automatically include these preferences. As a result, CNAs did not have access to information about the resident's preferred activities, limiting their ability to provide individualized, meaningful engagement as identified in the assessment. A third resident, approved for independent smoking, did not have a care plan addressing the management and storage of smoking materials. Staff were unclear about whether the resident was allowed to possess smoking materials or where these items were kept, and the facility had not provided a lock box to secure them. The facility's smoking policy did not address individualized care planning for independent smokers, and staff acknowledged that the lack of a care plan prevented them from ensuring the safety of the resident and others regarding access to lighters and smoking materials.
Failure to Provide Meaningful Activities for Dependent Residents
Penalty
Summary
The facility failed to provide meaningful activities for two dependent residents, both of whom were at risk for social isolation. One resident, admitted with anxiety and sepsis and assessed as cognitively intact, expressed interest in group activities such as painting and crosswords, and valued social interaction. Despite this, there was no activity care plan addressing these interests, and the resident did not participate in any activities for 30 days. Staff interviews revealed that CNAs were unaware of the resident's preferences due to the absence of an activity care plan, and the Activities Director did not ensure residents were personally invited or that staff had access to necessary information. The resident was not informed about scheduled group activities and expressed disappointment at missing them. Another resident, admitted on hospice with cancer and dementia, also had an activity assessment indicating a strong preference for reading, music, being outdoors, and group activities. However, the care plan only generically stated staff should escort the resident to activities as desired, without specifying the resident's interests. Over a month, this resident did not attend any activities and was observed spending time in bed or in the room with a CNA present. Staff interviews indicated that resident-specific activities were often not included in care plans, and CNAs did not know what to offer if the resident could not communicate preferences. The Activities Director and DNS acknowledged the lack of meaningful activities and individualized care planning for this resident.
Failure to Assess and Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to properly assess a resident and follow physician orders regarding timely notification and documentation of a significant change in condition. One resident, admitted with arthritis and cognitively intact, underwent a chest x-ray following a physician's assessment due to respiratory concerns. However, there was no nursing assessment documented regarding the resident's respiratory status or the physical condition that warranted the x-ray. The x-ray results, which indicated pneumonia, were available but not promptly communicated to the physician or acted upon. The resident's condition worsened, with increased cough, abnormal lung sounds, and low oxygen saturation, eventually requiring hospitalization. There were no additional nursing assessments documented prior to the escalation of symptoms and hospital transfer. Another resident, admitted with heart failure and kidney disease, and their family requested a urology appointment during a care conference. Despite this request, staff responsible for scheduling medical appointments did not arrange the appointment, and the request was not followed up on. The staff acknowledged the oversight when interviewed, confirming that the appointment had not been scheduled as requested by the resident and family.
Delayed Fall Investigation and Care Plan Update After Resident Fall
Penalty
Summary
A resident with a history of stroke and resulting weakness, who was identified as high risk for falls, was admitted to the facility and required assistance from two staff members and a mechanical lift for transfers. The resident's care plan included interventions such as calling for assistance, keeping the call light within reach, and wearing appropriate footwear. After completing therapy, the resident was left alone in their wheelchair while staff left the room to find additional help for a mechanical lift transfer. During this time, the resident attempted to self-transfer from the wheelchair to the bed and experienced a fall. The facility did not complete the fall investigation in a timely manner, taking over two weeks to finalize the investigation and update the resident's care plan to include assistance back to bed after therapy. Progress notes during this period did not document that the fall was related to being left alone after therapy. Staff interviews confirmed that the investigation and care plan update were not completed within the expected timeframe, resulting in a delay in implementing new interventions to prevent further falls.
Failure to Provide Timely Dental Services After Resident Request
Penalty
Summary
The facility failed to provide dental services for a resident who was admitted with diagnoses including heart failure and kidney disease. During a care conference, the resident requested a dental appointment, and the care plan documented oral/dental health problems with instructions for staff to coordinate dental care and transportation as needed. Despite these documented needs and requests, the resident reported that staff had not scheduled the dental appointment after repeated requests. The staff member responsible for making dental appointments acknowledged that the resident's request was made during the care conference but confirmed that the appointment was not scheduled. The regional nurse stated that the expectation was for staff to follow up with a dental appointment immediately when requested by residents.
Failure to Serve Meals at Palatable Temperatures Due to Delayed Assistance and Poor Communication
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures for a resident who required assistance with eating and in the kitchen overall. One resident, admitted with a history of stroke and heart disease and assessed as cognitively intact but needing supervision for eating, was observed waiting in bed with a meal tray while her food became cold. Staff interviews revealed that the resident often received meals at her bedside without timely assistance, leading to cold food. The resident's care plan indicated a need for one-person assistance with meals, but this requirement was not reflected on the diet slip or meal ticket, resulting in communication lapses among staff. Staff acknowledged that meal assistance needs were not consistently communicated or documented, and that this contributed to delays in providing timely and warm meals. Additionally, observations showed that meal carts were left unattended and that staff did not always promptly distribute meals. A test tray left in a food cart for 22 minutes was found to have cold broccoli and lukewarm potatoes and meat, confirming that food was not maintained at appetizing temperatures. Staff interviews indicated that there was an expectation for all staff, including nurses, to assist with meal distribution, but this was not consistently practiced. The lack of clear communication, documentation, and timely staff response led to residents receiving food that was not palatable or at a safe and appetizing temperature.
Failure to Establish Timely Grievance Resolution Process
Penalty
Summary
The facility failed to maintain a grievance policy that included a reasonable timeframe for reviewing and resolving grievances, as evidenced by the handling of a grievance submitted on behalf of a resident with respiratory failure and chronic pain. The resident, who was cognitively intact and required assistance with eating, had a physician order for continuous oxygen. A family member submitted a grievance regarding concerns about the resident's oxygen, meal assistance, pressure ulcer interventions, and missing items. The care plan was reviewed and updated, and a meeting was scheduled, but there was no documented communication of findings or updates to the complainant until the scheduled meeting. Staff interviews revealed that the Director of Nursing spoke with a registered nurse about the oxygen issue, but this was not documented in the medical record, nor was the complainant informed of any findings prior to the meeting. The grievance officer only spoke with the complainant at the scheduled meeting, and the facility's policy did not specify a formalized timeline for grievance resolution. The regional nurse expected a response to the complainant within five days, but the facility's process did not ensure timely communication or resolution, and the policy required revision to address these deficiencies.
Failure to Provide Consistent ADL Assistance and Safe Transfers
Penalty
Summary
A deficiency occurred when a dependent resident with a history of respiratory failure, chronic pain, lumbar spinal fusion, and cervical spine surgery did not consistently receive assistance with activities of daily living (ADLs), specifically bathing and safe transfers. Documentation showed that the resident refused a shower on one occasion and received only one shower during a multi-week period, with other scheduled showers not attempted or documented. The resident's care plan required showers on specific days and one-person assistance with transfers, but staff failed to follow this schedule and did not consistently document refusals or communicate missed showers to nursing staff. Multiple staff interviews revealed a lack of a system to track missed showers, inconsistent documentation, and poor communication between CNAs and nursing regarding ADL care. Additionally, the resident reported pain after being transferred by a CNA using a bear hug technique, which was contrary to facility policy and the resident's care plan, especially given the resident's spinal history. Staff interviews confirmed that bear hug transfers were not permitted and that the resident's transfer needs were subject to frequent updates by therapy, requiring staff to review care plans regularly. Some staff were unaware of the resident's medical history and the risks associated with improper transfer methods. The Director of Nursing Services acknowledged that staff were expected to follow care plans for both transfers and scheduled showers, and that nurses should be tracking the completion of these tasks.
Failure to Ensure Timely Availability of Pain Medication
Penalty
Summary
A resident with a diagnosis of arthritis was admitted in June 2021 and was prescribed Norco to be administered every four hours for pain management. On January 30, 2025, the Medication Administration Record (MAR) showed that the resident did not receive Norco at four scheduled times throughout the day. Progress notes indicated that the medication was not available due to a delay in obtaining a new prescription, with staff waiting for delivery and notifying the physician of the missed dose. The physician was faxed for a new prescription later that morning, and the pharmacy confirmed that they did not receive the prescription until that day, after which it was filled. Staff interviews revealed that the process for obtaining new prescriptions involved notifying the nurse when a new order was needed, and the nurse would then request it from the physician. The Director of Nursing Services was unaware of the missed doses and unclear about why the prescription was not sent to the pharmacy following the physician's visit the previous day. The resident was noted to be cognitively intact at the time of the incident.
Failure to Assist Resident with Toileting
Penalty
Summary
The facility failed to treat a resident with dignity and respect, which was identified during an incident involving a resident who required assistance with toileting. The resident, who was admitted for palliative care and had a moderate cognitive impairment, requested help to use the bathroom. However, a CNA instructed the resident to use their incontinence brief instead of providing the requested assistance with a bedpan. This interaction was overheard by the facility's Administrator, who intervened and arranged for the resident to receive the necessary assistance from other staff members. The incident was reported to the State Survey Agency, and the CNA involved was placed on administrative leave pending an investigation.
Inaccurate MDS Assessment for Pressure Ulcer
Penalty
Summary
The facility failed to accurately assess Minimum Data Set (MDS) assessments for a resident reviewed for pressure ulcers. The resident was admitted to the facility with diagnoses including diabetes and heart failure and had a coccyx pressure ulcer upon admission. Despite physician orders to treat the coccyx wound throughout the resident's stay, the Admission MDS and Discharge MDS inaccurately indicated that the resident did not have a pressure ulcer. This discrepancy was verified by the Director of Nursing Services (DNS), highlighting a failure in accurately documenting the resident's condition in the MDS assessments.
Failure to Communicate Pressure Ulcer Treatment at Discharge
Penalty
Summary
The facility failed to provide necessary information to continuing care providers regarding the treatment of a coccyx pressure ulcer for a resident at the time of discharge. The resident, who was admitted to the facility in July 2024 with a diagnosis of diabetes, had a documented coccyx pressure ulcer as per the Treatment Administration Records (TARS) from July 2024. However, the Discharge Summary dated July 30, 2024, only noted macerated skin on the coccyx and did not include any treatment information for the pressure ulcer. This omission was confirmed by the Director of Nursing Services (DNS) on August 29, 2024, during an interview, indicating a failure to communicate essential treatment details to the receiving health care provider.
Failure to Provide Bathing Assistance
Penalty
Summary
The facility failed to provide bathing assistance to a resident who was unable to perform activities of daily living independently. The resident, admitted with a diagnosis of heart failure, was not offered the opportunity to bathe from mid-April to the end of April 2023, as documented in the resident's ADL Bathing records. This deficiency was confirmed by the Director of Nursing Services during an interview conducted in late August 2024.
Inconsistent Pressure Ulcer Assessment and Treatment
Penalty
Summary
The facility failed to properly assess and treat a pressure ulcer for a resident, leading to inconsistencies in the staging and treatment of the wound. The resident was admitted with a Stage III pressure ulcer, but subsequent assessments varied, identifying the wound as Stage II, a deep tissue injury (DTI), and unstageable due to slough. These inconsistencies were acknowledged by the Director of Nursing Services (DNS), who noted the discrepancies in the wound assessments. Additionally, the treatment ordered for the resident's wound was inappropriate for the identified stage. The physician's orders included the use of Santyl and a calcium alginate pad, which are not suitable for a Stage II pressure ulcer or DTI. The DNS confirmed that the treatment was incorrect and that the wound was closed upon her visual inspection. These actions and inactions placed the resident at risk for worsening pressure ulcers.
Inaccurate Documentation of Pressure Ulcer in Resident's Medical Record
Penalty
Summary
The facility failed to accurately document the medical records of a resident admitted with pressure ulcers. The resident, who had diagnoses including diabetes and heart failure, was admitted with a Stage III pressure ulcer according to the Admission Assessment. However, subsequent documentation was inconsistent, with a Skin Assessment indicating a Stage II ulcer and treatment orders for a Deep Tissue Injury (DTI). The Care Plan did not acknowledge the presence of a pressure ulcer, and the Admission MDS incorrectly stated that the resident had no pressure ulcers. Further inconsistencies were noted in the resident's medical records, with a Progress Note revealing the wound was unstageable due to slough, while other assessments continued to describe it as a Stage II or DTI. The Nutrition Admission Assessment inaccurately reported the resident's skin as intact, and the Discharge MDS again failed to document the pressure ulcer. These inaccuracies were acknowledged by the Director of Nursing Services, highlighting a significant deficiency in maintaining accurate medical records for the resident's pressure ulcer condition.
Misappropriation of Controlled Medications by Impaired Nurse
Penalty
Summary
The facility failed to protect residents from the misappropriation of controlled medications, specifically narcotic and sedative drugs, which were intended for two residents. An agency nurse, identified as Witness 1, was observed by other staff members to be impaired while on duty. Upon investigation by the Director of Nursing Services (DNS) and a Resident Care Manager, it was discovered that two bottles of methadone prescribed to one resident were missing, and another resident's Ativan supply was less than documented. Witness 1 was found with the missing methadone bottles in her possession and was subsequently arrested for theft. The residents involved in the incident included one with end-stage kidney disease prescribed Ativan on a PRN basis, and another with burn wounds and liver disease who was receiving scheduled methadone doses. The facility staff, including a Resident Care Manager and an LPN, reported concerns about Witness 1's behavior, noting her impaired state and inability to perform her duties. Despite the misappropriation, it was confirmed that no residents missed their medication doses on the day of the incident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ashland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rogue Valley Manor | 9.3 mi | ★★★★★ | 0 | 0 |
| Hearthstone Nursing & Rehabilitation Center | 9.5 mi | ★★★★★ | 6 | 0 |
| Avamere At Three Fountains | 11.5 mi | ★★★★★ | 5 | 0 |
| Avamere Health Services Of Rogue Valley | 11.7 mi | ★★★★★ | 0 | 0 |
| Regency Care Of Rogue Valley | 34.1 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.