22 health deficiencies
Top issue: Resident Rights (8 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Ashland, OR
2-star overall rating with 2-star inspections with $31,369 in total fines with 22 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
135 Maple Street, Ashland, OR
(541) 482-2341
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
87
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1989-05-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.63
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.04
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.48
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.22
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
4.84
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
4,309
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9934
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.87
Baseline 16.59% · Performance 20.56% · Measure score 1.87 · Achievement 1.87 · Improvement 0
Healthcare-associated infections
4.98
Baseline 4.62% · Performance 6.35% · Measure score 4.98 · Achievement 4.98 · Improvement 0
Total nurse turnover
1.63
Baseline 36.91% · Performance 57.00% · Measure score 1.63 · Achievement 1.63 · Improvement 0
Adjusted total nurse staffing
7.70
Baseline 4.79 hours · Performance 5.27 hours · Measure score 7.70 · Achievement 7.70 · Improvement 4.31
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.14% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 157 · Observed rate 12.1% · Lower 95% interval 7.93% |
| Discharge to community | 50.46% |
50.57%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 199 · Observed rate 41.71% · Lower 95% interval 43.7% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.43% |
95.27%
4.2 pts better
|
Numerator 173 · Denominator 174 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 173 |
| Discharge self-care score | 50.56% |
53.69%
3.1 pts worse
|
Numerator 45 · Denominator 89 |
| Discharge mobility score | 39.33% |
50.94%
11.6 pts worse
|
Numerator 35 · Denominator 89 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 174 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.35% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 140 · Observed rate 5.71% · Lower 95% interval 4.25% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 132 |
| Staff flu vaccination coverage | 3.95% |
42%
38 pts worse
|
Numerator 6 · Denominator 152 |
| Discharge function score | 59.55% |
56.45%
3.1 pts better
|
Numerator 53 · Denominator 89 |
| Transfer of health information to provider | 85.23% |
95.95%
10.7 pts worse
|
Numerator 75 · Denominator 88 |
| Transfer of health information to patient | 90.77% |
96.28%
5.5 pts worse
|
Numerator 59 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 18% |
25.2%
7.2 pts worse
|
Numerator 18 · Denominator 100 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.4
0.3 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 2.6 · Expected 4.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
2.5
2.3 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.4 · Expected 2.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.5%
4.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.0% |
95.2%
1.2 pts worse
|
95.5%
1.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
2.4%
1.3 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
4.7%
0.2 pts worse
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.7% · Q3 5.1% · Q4 6.0% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.0%
5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.9% |
12.5%
7.4 pts worse
|
19.6%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 10.3% · Q3 20.5% · Q4 18.2% · 4Q avg 19.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
14.7%
1.8 pts worse
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 14.3% · Q3 10.0% · Q4 21.2% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 32.6% |
24.1%
8.5 pts worse
|
16.3%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 29.0% · 4Q avg 32.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
15.8%
2.6 pts better
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 10.5% · Q3 26.3% · Q4 9.1% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.7%
1.3 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
2.0%
0.3 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 2.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.5% |
22.2%
7.3 pts worse
|
19.8%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 36.5% · Q3 34.0% · Q4 26.9% · 4Q avg 29.5% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
6.5%
About the same
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 12.0% · Q3 3.6% · Q4 4.2% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
85.4%
11.2 pts better
|
81.7%
14.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 100.0% · Q3 96.3% · Q4 92.2% · 4Q avg 96.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
15.1%
5.3 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 9.1% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.7%
1.4 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.7% · Q3 2.8% · Q4 2.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.1% |
81.2%
16.9 pts better
|
79.7%
18.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
21.6%
About the same
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 19.6% · Expected 21.6% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (8 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-06-18
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-06-18
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-06-18
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-18
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-18
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-02-09
Fire Safety
Install noncombustible or limited-combustible interior walls.
Corrected 2022-11-08
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-08
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-11-08
Inspection history
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-17
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-12-17
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-12-22
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-12-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-22
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-22
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-06-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-18
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-18
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-18
Health
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.
Corrected 2025-06-18
Health
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.
Corrected 2025-06-18
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-18
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-06-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-18
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-18
Health
Provide activities to meet all resident's needs.
Corrected 2025-06-18
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-18
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-18
Health
Provide or obtain dental services for each resident.
Corrected 2025-06-18
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-18
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-09-26
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-26
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-09-26
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-26
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-26
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-09-26
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2022-02-02
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-02-15
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-02-15
Health
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.
Corrected 2024-02-15
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-15
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-02-15
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-02-15
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-15
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-15
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-15
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-02-15
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-15
Health
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.
Corrected 2024-02-15
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-15
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-02-15
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-02-15
Health
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.
Corrected 2024-02-15
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-08
Health
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.
Corrected 2022-11-08
Health
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.
Corrected 2022-11-08
Health
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.
Corrected 2022-11-08
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-11-08
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-08
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-11-08
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-11-08
Penalties and ownership
Fine · fine $31,369
Fine
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Security Interest · Organization
Nearby options
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Medford, OR
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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