Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Columbia Basin Care Facility during CMS and state inspections, most recent first.
An LPN used a shared glucometer for multiple residents and disinfected it between uses with alcohol prep pads instead of the manufacturer-approved disinfectant wipes. A resident with Hepatitis C received routine CBG checks with the shared device, and staff confirmed that glucometers were shared and that alcohol pads were being used for disinfection.
A resident with a new ileostomy had repeated pouch leakage, frequent bag changes, and worsening red, raw, excoriated skin with burning pain. Staff did not consistently use the ordered skin treatments, did not maintain adequate ostomy supplies, and at times covered the site with an incontinence brief or pad when the pouch would not stay on. The resident reported stool leaking onto the skin for days, sleep disruption, embarrassment, and inability to participate in PT, and the surgeon was not contacted until the abdomen was photographed and the resident was sent back to the hospital.
Arbitration Agreement Not Fully Explained: A Social Services Director was responsible for reviewing and explaining the facility’s arbitration agreement, but did not fully explain that signing was voluntary, not a condition of admission or continued care, and that the resident could withdraw within 30 days. Three cognitively intact residents with diagnoses including DM, COPD, and a femur fracture signed the agreement, and each later stated they were not informed of the 30-day rescission option or did not understand they were agreeing to arbitration.
Failure to assist a resident with shaving/facial hair grooming. A resident with dementia and partial-to-moderate personal hygiene needs was observed with gray and white facial hair on the chin on multiple occasions. Staff said facial hair trimming was expected on shower days and as needed, the resident had a personal shaver, and was cooperative when offered, but the resident stated no one had offered assistance in about a week and that the facial hair was irritating and unwanted.
A resident with chronic atrial fibrillation, diabetes, and hyperlipidemia had multiple ordered meds missed, including insulin, cardiac meds, bowel meds, and pain meds. An LPN said the meds were not given because the resident was sleeping and the MD was not notified until much later. The RNCM and DNS stated the MD should have been notified after each missed dose and the reason for non-administration documented in the record.
A resident with oral and oropharyngeal dysphagia had physician orders, an SLP plan, and a care plan stating no straws, along with supervision and pacing interventions at meals. However, staff were observed allowing straw use, a straw was seen on the resident’s tray and in the room, and staff gave conflicting statements about whether straws were permitted, while the resident was observed coughing after drinking with a straw.
Failure to follow tube feeding orders for a cognitively intact resident with a J-tube. Staff were observed using unlabeled, undated feeding supplies and an unlabeled nutrition bag, and an LPN flushed the feeding port with equipment from an unlabeled cylinder. Staff gave inconsistent accounts about syringe changes and labeling, while the resident reported the facility was out of the syringes needed for flushes and med administration.
Delayed Reporting of Alleged Abuse: The facility failed to timely report an allegation of physical abuse involving a resident. An LPN reported that police were at the facility for the allegation, and the DNS and Administrator later confirmed awareness of the incident, but the FRI was not submitted to the SA within the required two-hour timeframe.
The facility failed to store and handle food properly, risking cross-contamination. Raw meat was stored above eggs, and scoops were improperly placed in food bins. A dietary cook used the same gloves for different tasks without changing them, and unlabeled drinks were found in a refrigerator, violating food safety protocols.
A Gerontology Nurse Practitioner failed to adequately document the evaluation of care for three residents with chronic conditions during scheduled visits. The documentation lacked evidence of comprehensive assessments, and the practitioner was unsure of where the records were stored in the electronic health system. The facility's administration acknowledged the notes were not comprehensive.
The facility did not ensure accurate Direct Care Staff Daily Report (DCSDR) postings for 16 out of 27 days, leading to potential misinformation for residents and visitors. The Staffing Coordinator admitted to not understanding how to complete the DCSDR and failed to update it with schedule changes, while the Administrator expected accuracy in these reports.
The facility failed to implement Enhanced Barrier Precautions and ensure proper PPE use for residents, leading to potential infection risks. A resident with pneumonia had inconsistent PPE use by staff, while another with a leg wound did not have staff wearing gowns during care. Additionally, improper PPE disposal and lack of precautions for a resident with a catheter were observed, indicating systemic issues in infection control protocols.
A resident with severe cognitive impairment was physically abused by another resident with moderate cognitive impairment and a history of behavioral issues. The incident occurred when the aggressive resident, confused and agitated, believed their wheelchair was being interfered with and responded by hitting the other resident. Staff noted the aggressive resident's pattern of anger and witnessed the altercation, which resulted in a small injury to the victim.
A facility failed to maintain a resident's wheelchair in good repair, resulting in torn and cracked armrests with sharp edges. The resident, who used the wheelchair daily, found the armrests uncomfortable. Despite protocols for reporting and inspecting equipment, staff did not notice or report the disrepair.
A facility failed to conduct a significant change MDS assessment for a resident who experienced a seizure, cognitive decline, and behavioral issues. Despite these changes, no assessment was documented, and staff confirmed the oversight.
A facility failed to complete a PASARR I screening before admitting a resident with multiple sclerosis and major depressive disorder. The resident, who required substantial assistance with ADLs, was admitted without the necessary screening, which was not added to their health record even after a month. This oversight risked inappropriate placement and lack of needed services.
A resident without a documented history of epilepsy was prescribed an anticonvulsant after experiencing seizures following the administration of an antipsychotic. The facility's records did not reflect a seizure disorder diagnosis, and staff interviews revealed uncertainty about the cause of the seizures, suggesting potential links to recent infections. The facility acknowledged a lapse in consulting with a physician regarding the epilepsy diagnosis.
A resident with a self-care deficit due to a stroke and chronic pain did not receive necessary assistance with ADLs, as documented in their care plan. Observations showed a persistent brown stain on the resident's face, which staff confirmed. The facility's leadership acknowledged the expectation for staff to clean the resident's face, highlighting a failure to meet the resident's care needs.
A resident with a history of falls and multiple diagnoses, including dementia, was not provided with a fall mat as required by their care plan. Despite the care plan's directive, observations showed the mat was missing, and staff were unaware of this requirement. This oversight placed the resident at risk for injury.
A facility failed to obtain a physician order and provide timely PICC dressing care for a resident admitted with a lung abscess and pneumonia. The resident's PICC dressing was not changed for 12 days, contrary to the facility's protocol requiring changes every seven days. A nurse confirmed the oversight and lack of documentation.
A facility failed to ensure a resident, admitted with a stroke and chronic pain, was seen by a physician. A review of the resident's clinical record showed no documented physician visits since admission, confirmed by the Administrator and Social Services Supervisor.
A resident admitted with a pelvis fracture did not receive prescribed medications for five days due to unavailability. The CMA did not contact the pharmacy or notify the physician, and the RNCM was unaware of the issue, expecting staff to address medication unavailability within one day.
A facility did not follow pharmacy recommendations for a resident's trazodone prescription, which was intended to treat insomnia. The pharmacist advised separating the scheduled and PRN portions of the order for proper charting, but the June and July MARs showed the order continued unchanged. The recommendations were not fully implemented until mid-July.
A facility failed to monitor psychotropic medications for a resident, risking ineffective medication management. The resident, with insomnia, depression, and pain, was prescribed fluoxetine, trazodone, and olanzapine. The care plan required monitoring side effects and effectiveness every shift, but no documentation was found. Staff noted that a system switch led to the omission of monitoring, which was not corrected despite management being informed. This was confirmed by the administrator and social services supervisor.
Improper Disinfection of Shared Glucometers
Penalty
Summary
The facility failed to properly disinfect shared glucometers between resident uses during CBG monitoring. Surveyors observed Staff 7, an LPN, using a single shared Arkray glucometer to check residents on one hall and North hall, and between each resident she wiped the device with a 70% isopropyl alcohol prep pad rather than an approved disinfectant wipe. The facility’s policy required reusable equipment to be cleaned and disinfected between uses according to the manufacturer’s instructions, and the manufacturer’s technical brief stated that common use glucometers were to be disinfected with approved wipes left wet for two minutes. Resident 1 had an active diagnosis of Hepatitis C and received blood glucose monitoring before meals and at bedtime. Record review showed that 18 residents received daily CBG checks, including Resident 1. Staff interviews confirmed that blood glucose monitors were shared between residents, that Staff 7 used alcohol wipes to disinfect the glucometer after each use, and that no residents had their own glucometer for CBG checks. The DNS stated she was unaware staff used alcohol pads to disinfect the blood glucose monitors and acknowledged that alcohol pads were not sufficient.
Failure to Provide Adequate Ileostomy Care and Skin Protection
Penalty
Summary
The facility failed to provide appropriate ileostomy care and services for a resident who was admitted with a new ileostomy after bariatric surgery. The resident’s hospital discharge instructions and physician orders directed staff to remove the pouch with adhesive remover, cleanse and dry the skin, apply stoma powder and skin prep to red skin irritation, use a barrier ring and paste, apply a medium fistula pouch offset from the midline incision, change the pouch as needed for leakage, and complete weekly head-to-toe skin observations. The resident was cognitively intact, had an ostomy and surgical wound, and required assistance managing the ostomy bag. After admission, the resident’s ostomy repeatedly leaked and required frequent changes, with the treatment administration record showing at least one change per shift on multiple shifts and several ineffective changes. Staff documented redness, rash, excoriation, and burning around the ostomy site, and the resident reported increasing pain and discomfort. The resident was transferred to the emergency department at one point due to increased abdominal pain near the ileostomy site, and later telemedicine documentation noted burning skin around the bag related to leaking stool and a red rash around the abdomen and skin folds. The record and interviews showed that staff did not consistently follow the ordered skin treatment, did not consistently notify the provider about the worsening skin condition and leakage, and did not maintain adequate ostomy supplies. Staff stated the resident sometimes went without an ostomy bag and was covered with an incontinence brief or pad to contain leakage when supplies were unavailable or the bags would not stick. The resident described stool leaking onto the skin for days, severe burning, embarrassment, sleep disruption, and inability to participate in physical therapy because of the leaking ostomy. Multiple staff members acknowledged the resident’s skin became red, raw, and excoriated, that the ostomy was difficult to pouch because of its location, and that the resident’s surgeon was not contacted until the resident’s abdomen was photographed and the resident was directed back to the hospital.
Arbitration Agreement Not Fully Explained
Penalty
Summary
The facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 3 of 3 sampled residents reviewed for arbitration agreements. The facility’s policy required staff to explicitly inform the resident or representative that signing was not a condition of admission or continued care, explain the agreement in a form and manner the resident understood, and ensure the resident or representative acknowledged understanding. The facility’s arbitration agreement stated the resident had the option not to sign, could seek legal counsel, and had 30 days to withdraw the agreement by written notice, but Staff 25, the Social Services Director, stated she was responsible for reviewing and explaining the agreement and that she did not pay close attention to the form or discuss the 30-day withdrawal option with residents or representatives. Resident 1 was admitted with diabetes and was cognitively intact on the admission MDS; the resident signed the arbitration agreement and later stated it was explained as indicating arbitration was available, and the resident was not sure the form would have been signed if it had been understood as agreeing to arbitration. Resident 2 was admitted with COPD and was cognitively intact on the admission MDS; the resident signed the agreement but stated the 30-day rescission option was not explained. Resident 45 was admitted with a femur fracture and was cognitively intact on the admission MDS; the resident electronically signed the agreement and also stated the 30-day rescission option was not explained. The Administrator was notified that Staff 25 did not fully understand or comprehensively explain the agreement, and stated he expected residents and especially families to receive a verbal explanation of the right to rescind within 30 days, while also stating a resident’s signature meant the resident had seen and read it.
Failure to Assist with Facial Hair Grooming
Penalty
Summary
The facility failed to ensure a dependent resident received assistance with shaving. Resident 24 was admitted in 6/2024 with diagnoses including dementia, and the care plan directed staff to set the resident up for daily hand and face washing and combing of hair and to assist as needed, with one staff person assisting with bathing. The 1/2/26 quarterly MDS indicated the resident was cognitively intact and required partial-to-moderate assistance with personal hygiene. On 1/26/26, a CNA was observed preparing to assist Resident 24 with a shower, and later that day the resident was observed with gray and white facial hair on both sides of the chin. The same facial hair was still observed on 1/28/26 in the dining room, and the resident stated the facial hair really bothered him/her, wanted it gone, had not been offered assistance to trim it in about a week, and would not refuse if offered. Staff stated facial hair trimming was expected on shower days and as needed, that the resident had a personal shaver and preferred staff to remove the facial hair, and that the resident was cooperative when offered. The RNCM stated facial hair grooming should be offered daily and confirmed the resident needed facial hair trimming.
Failure to Administer Ordered Medications and Notify Physician
Penalty
Summary
The facility failed to follow physician orders for Resident 3, who was admitted with diagnoses including chronic atrial fibrillation, diabetes, and hyperlipidemia. Physician orders dated 11/2/25 included multiple scheduled medications, such as insulin aspart before meals, insulin glargine every 12 hours, potassium citrate, Senna Plus, venlafaxine, gemfibrozil, metoprolol succinate, MiraLAX, atorvastatin, digoxin, vitamin D, oxycodone, and losartan potassium. Review of the resident’s 12/2025 through 1/2026 MARs and DARs showed numerous missed doses of ordered medications, including insulin aspart, insulin glargine, potassium citrate, Senna Plus, venlafaxine, gemfibrozil, metoprolol succinate, MiraLAX, atorvastatin, digoxin, vitamin D, oxycodone, and losartan potassium. An LPN stated he did not administer the medications because the resident was sleeping and did not notify the physician until the week of 1/26/26 regarding the missed medications. The RNCM and DNS stated the physician should have been notified after each missed medication and that each missed medication should have been documented in the health record with the reason it was not given.
Failure to Follow No-Straw Orders for Resident With Dysphagia
Penalty
Summary
The facility failed to ensure physician orders and care plan interventions were followed for a resident with oral dysphagia and oropharyngeal dysphagia, resulting in the resident being allowed to use straws despite orders and care plan directions stating no straws. The resident was admitted with swallowing difficulties, and the SLP evaluation and plan of treatment from 7/3/24 indicated the resident was not to use straws. The resident’s 10/20/25 care plan also directed staff to supervise meals, encourage upright positioning, cue small bites and sips, reduce distractions, and use no straws. The current physician orders likewise stated the resident was not to use straws. During observation, the resident was seen drinking with a straw in the assisted dining room and coughed after taking a drink. Later, a straw was observed on the resident’s meal tray in the independent dining room, and a water bottle with a large bore straw was observed on the resident’s overbed table in the room. Staff interviews showed conflicting practice: one CNA stated the resident used straws all of the time because they helped the resident swallow, while another CNA stated the resident was allowed to use straws but needed reminders to slow down. Other staff reviewed the care plan and physician orders and stated the resident was not to use straws, and the dietary program also indicated no straws. The Director of Rehabilitation stated the no-straw intervention had been in place since admission.
Failure to Follow Tube Feeding Orders
Penalty
Summary
The facility failed to follow physician orders related to enteral feeding for a cognitively intact resident who was admitted with a feeding tube and a diagnosis indicating the presence of an artificial opening in the gastrointestinal tract. The resident’s orders specified Jevity via J-tube for 18 hours per day, daily labeling and changing of the nutrition container, syringe, and administration set, daily syringe changes, and scheduled water flushes before and after medication administration and every eight hours. During observations, staff were seen using an undated and unlabeled plastic cylinder and syringe kept in the resident’s room, and the resident stated staff had told them the facility was out of the syringes needed for tube feed flushes and medication administration. The resident also stated they could not tell how long the syringe had been in use. Staff later observed the tube feeding bag was unlabeled and undated, and one LPN used water from the unlabeled cylinder with the unlabeled syringe to flush the feeding port. Staff gave inconsistent statements about how often syringes were changed and whether feeding bags were labeled and dated, while an NP and RNCM stated they expected staff to follow the tube feeding orders.
Delayed Reporting of Alleged Abuse
Penalty
Summary
The facility failed to timely report an allegation of physical abuse for Resident 24. The facility policy dated 1/1/26 directed the Executive Director or designee to immediately report all allegations of suspected abuse through a FRI. During the entrance conference on 1/26/26, the Administrator stated the facility had an incident over the weekend and was going to submit a FRI to the SA. The DNS later stated Resident 24 was involved in an allegation of abuse on 1/24/26 and that the facility would complete a FRI when the investigation was complete. The SA received the FRI and investigation on 1/29/26 at 7:16 PM. An LPN stated she/he called the DNS the morning of 1/24/26 to report that police were at the facility for an allegation of abuse involving Resident 24. The Administrator later stated he was aware of the allegation by 1/26/26 and expected reporting to the SA within 24 hours, then acknowledged the facility was aware of the two-hour reporting requirement and that the FRI was not reported within the required two hours.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to store and handle food properly, leading to potential cross-contamination risks. During an inspection, raw meat was found stored on a wire rack shelf directly above eggs and cartons of liquid whole eggs in the walk-in refrigerator, which could lead to dripping and contamination. Additionally, plastic-handled scoops were stored in direct contact with food items such as brown sugar, powdered sugar, white sugar, and dry pasta, increasing the risk of cross-contamination. The Food Service Director acknowledged these issues, attributing them to staff negligence. Further observations revealed improper food handling practices by staff. A dietary cook used the same gloved hand to open an oven door and then handle a dinner roll, which was placed on a resident's lunch plate without changing gloves, creating an opportunity for cross-contamination. Additionally, two unlabeled plastic mugs containing a brown thickened liquid were found in a snack refrigerator, lacking proper labeling and dating as required by the US FDA 2022 Food Code. The Food Service Director was unaware of who placed the mugs in the refrigerator, highlighting a lapse in adherence to food safety protocols.
Inadequate Documentation of Resident Care by Provider
Penalty
Summary
The facility failed to ensure that the total program of care for three residents was adequately reviewed and documented during provider visits. Resident 4, who was admitted in 2020 with a diagnosis of neuralgia, had provider visits in March, May, and July 2024 conducted by a Gerontology Nurse Practitioner, Staff 29. However, the documentation from these visits lacked sufficient evidence that the resident's condition and total program of care were evaluated. Staff 29 admitted uncertainty about where the documentation was recorded in the electronic health record and could not provide additional information regarding her evaluations. Similarly, Resident 21, admitted in February 2023 with chronic pain and dementia, and Resident 23, admitted in May 2019 with dementia and hypertension, also had provider visit notes that were insufficient in documenting evaluations of their conditions and total programs of care. Staff 29 conducted these visits but again failed to provide comprehensive documentation. The facility's Administrator and Director of Nursing Services reviewed the notes and acknowledged that they were not comprehensive, indicating a systemic issue with documentation during provider visits.
Inaccurate Staffing Reports
Penalty
Summary
The facility failed to ensure the accuracy of the Direct Care Staff Daily Report (DCSDR) postings for 16 out of 27 days reviewed, which could lead to residents and visitors receiving inaccurate staffing information. The review of the DCSDR from August 1 to August 27, 2024, revealed discrepancies in the reported hours worked by Certified Nursing Assistants (CNAs) and Nursing Assistants (NAs) on specific dates. On August 29, 2024, the Staffing Coordinator (Staff 17) admitted to not fully understanding how to complete the DCSDR and failing to update the report to reflect schedule changes. The Administrator (Staff 1) expected the DCSDR to be accurate, indicating a lack of proper training or oversight in maintaining accurate staffing records.
Failure to Implement Enhanced Barrier Precautions and PPE Use
Penalty
Summary
The facility failed to implement appropriate Enhanced Barrier Precautions (EBP) and ensure the correct use of personal protective equipment (PPE) for three residents, leading to a risk of infection spread. Resident 146, admitted with an abscess of the lung and pneumonia, had Contact Precautions signage posted, but staff were observed entering the room without donning PPE. Staff expressed confusion about the required precautions, and the resident confirmed inconsistent PPE use by staff. Similarly, Resident 43, with an infected leg wound, did not have staff consistently wearing gowns during wound care, despite the presence of PPE containers outside the room. The Infection Preventionist was unaware of the gown requirement for EBP, indicating a lack of proper training and communication. Additionally, the facility's infection control practices were inadequate, as observed with the improper disposal of used PPE and the absence of a disposal container in one room. Resident 296, with an indwelling catheter, was not placed on EBP, contrary to the requirements. Staff confirmed the oversight, highlighting a systemic issue in the facility's infection control protocols. These deficiencies demonstrate a failure to adhere to established guidelines for preventing infection transmission, putting residents at risk.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. Resident 16, who was admitted with a severe cognitive impairment, was physically abused by Resident 13, who has moderate cognitive impairment and a history of behavioral issues. On the day of the incident, Resident 13, who was confused and agitated, believed that Resident 16 was interfering with their wheelchair and responded by hitting Resident 16 in the face, causing a small open area. Staff members witnessed the altercation and noted that Resident 13 was having a particularly bad day, exhibiting aggressive behavior towards both residents and staff. Interviews with staff and residents revealed that Resident 13 had a pattern of becoming angry without apparent reason, and on this occasion, they verbally and physically lashed out. Despite the incident, Resident 16 later reported feeling safe in the facility, although initially uncomfortable around Resident 13. The facility's investigation confirmed the altercation and the inappropriate behavior of Resident 13, highlighting a failure to adequately protect Resident 16 from abuse.
Failure to Maintain Resident Care Equipment
Penalty
Summary
The facility failed to ensure that resident care equipment was in good repair, specifically for a resident with multiple sclerosis who was cognitively intact and used a wheelchair. Observations over several days revealed that the resident's wheelchair had torn and cracked vinyl coverings on both armrests, with sharp, rough edges protruding. The resident reported using the wheelchair daily and described the armrests as uncomfortable and rough on their skin. Despite the facility's protocol for staff to report equipment in disrepair to maintenance and conduct nightly wheelchair inspections, the issues with the wheelchair were not noticed or reported by the staff responsible for the resident's care.
Failure to Conduct Significant Change MDS Assessment
Penalty
Summary
The facility failed to document and conduct a significant change Minimum Data Set (MDS) assessment for a resident who experienced notable changes in condition. The resident was admitted with diagnoses including stroke and depression and initially assessed as cognitively intact with a BIMS score of 14. Over time, the resident's condition changed significantly, including a seizure event and a new prescription for topiramate for epilepsy. Additionally, the resident was involved in a physical altercation with another resident and exhibited behavioral changes, such as increased cognitive impairment and incontinence, as noted in a subsequent quarterly MDS. Despite these significant changes, no significant change assessment was found in the resident's clinical record. Interviews with staff revealed that the resident exhibited behaviors such as verbal abuse and physical aggression, particularly after family visits. The facility's administrator and interim Director of Nursing Services confirmed that a significant change MDS should have been completed, indicating a lapse in the facility's assessment and documentation processes.
Failure to Complete PASARR I Screening Prior to Admission
Penalty
Summary
The facility failed to complete a PASARR I (Pre-Admission Screening/Resident Review) screening prior to the admission of a resident diagnosed with multiple sclerosis and major depressive disorder. This resident, who was cognitively intact and required substantial assistance with activities of daily living, was admitted in July 2024. Upon review, no evidence was found in the resident's health record to indicate that the PASARR I was completed before admission. The Social Services Director confirmed that the PASARR I was not added to the resident's electronic health record, despite the resident being in the facility for over a month. This oversight placed the resident at risk for inappropriate placement and lack of needed services.
Failure to Follow Professional Standards in Medication Management
Penalty
Summary
Facility staff failed to adhere to professional standards of practice regarding the diagnosis and treatment of a resident's condition. The resident, admitted with diagnoses including stroke and depression, did not have a documented history of seizure disorder or epilepsy. Despite this, the resident was prescribed topiramate, an anticonvulsant, following a seizure episode after starting olanzapine, an antipsychotic medication. The resident experienced multiple seizures and was later hospitalized for sepsis due to a UTI. The facility's records, including the comprehensive care plan and MDS assessments, did not reflect a diagnosis of seizure disorder or epilepsy, raising concerns about the appropriateness of the anticonvulsant prescription. Interviews with facility staff revealed uncertainty about the cause of the seizures, with a pharmacist consultant suggesting that the seizures could have been related to the resident's recent COVID-19 infection or sepsis. The resident reported experiencing muscle cramps that appeared as convulsions when not administered gabapentin timely. The facility's administrator and interim DNS acknowledged that the nurse practitioner should have consulted with the physician regarding the epilepsy diagnosis, indicating a lapse in communication and coordination of care for the resident.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was dependent on staff for personal care. Resident 13, admitted in November 2023 with a history of stroke and chronic pain, had a care plan indicating a self-care deficit requiring substantial assistance with ADLs, including grooming. However, a review of the Documentation Survey Report on August 26, 2024, showed no records of personal hygiene care being provided to the resident during the day or evening shifts. Observations on multiple occasions revealed a brown stain on the resident's face, which was confirmed by staff. The facility's administrator and interim director of nursing services acknowledged that staff were expected to clean the resident's face, indicating a lapse in meeting the resident's care needs.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement care plan interventions for a resident at risk for falls, leading to a deficiency. The resident, admitted in May 2019, had a history of a fall and was diagnosed with a fracture of the left lower leg, dementia, and high blood pressure. The resident's care plan, updated in March 2024, identified the risk for falls and included an intervention to place a fall mat at the side of the bed, revised in April 2024. However, observations in August 2024 revealed that the fall mat was not placed at the bedside as required by the care plan. Staff members, including CNAs and an RNCM, were unaware of the requirement for a fall mat, despite it being documented in the care plan. The RNCM confirmed the absence of the fall mat, acknowledging the oversight in implementing the care plan intervention, which placed the resident at risk for injury.
Failure to Provide Timely PICC Dressing Care
Penalty
Summary
The facility failed to obtain a physician order and provide appropriate PICC dressing care for a resident, identified as Resident 146, who was admitted with a lung abscess and pneumonia. The resident's admission orders included central venous access care per facility protocol, but there was no physician order or resident-specific protocol documented for PICC dressing care. During the period from admission to 12 days later, there was no documentation indicating that the PICC dressing care was provided. On observation, the resident's PICC dressing was found to have been changed on the 12th day after admission, with the resident confirming that it had not been changed since admission. A registered nurse (RN) acknowledged changing the dressing on that day after noticing it had not been changed since admission and confirmed the lack of documentation and physician order. Another RN confirmed that the facility protocol required PICC dressings to be changed every seven days, which was not adhered to in this case.
Failure to Ensure Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician, which was identified during a survey. The deficiency involved a resident who was admitted to the facility with diagnoses including a stroke and chronic pain. A review of the resident's clinical record revealed that there were no documented physician visits since the resident's admission. This was confirmed by the facility's Administrator and Social Services Supervisor during an interview.
Failure to Provide Prescribed Medications
Penalty
Summary
The facility failed to provide prescribed medications for one of the sampled residents, identified as Resident 147, who was admitted with a pelvis fracture. The physician's orders dated 8/22/24 included Preservision AREDs 2, psyllium oral capsules, and tolterodine tartrate, which were not available from 8/22/24 to 8/26/24. Staff 7, a CMA, confirmed that the medications were marked as unavailable on the MAR and admitted to not contacting the pharmacy or notifying the physician about the unavailability for five days. Staff 12, an RNCM, stated that medications should be available upon admission and that staff should check the cubex or contact the pharmacy if medications are unavailable. However, Staff 12 was unaware of the issue and expected staff to notify the pharmacy and physician within one day of recognizing the unavailability.
Failure to Implement Pharmacy Recommendations for Medication Order
Penalty
Summary
The facility failed to follow up on pharmacy recommendations for a resident admitted with insomnia. The resident was prescribed trazodone at bedtime for insomnia, with an additional tablet if not asleep within an hour. The pharmacist recommended discontinuing the current trazodone order and re-entering it with scheduled and PRN portions separated for proper administration charting. However, the June 2024 Medication Administration Record (MAR) showed that the trazodone order continued as previously prescribed, and the pharmacist's recommendations were not implemented. In July 2024, the pharmacist reiterated the same recommendation, and a handwritten note indicated it was done on July 15, 2024. Despite this, the July 2024 MAR revealed that the trazodone order remained unchanged until July 16, 2024, when it was added to the PRN section, indicating that the pharmacist's recommendations were not fully implemented.
Failure to Monitor Psychotropic Medications
Penalty
Summary
The facility failed to adequately monitor psychotropic medications for a resident, which placed them at risk for ineffective medication management. The resident was admitted with diagnoses including insomnia, depression, and pain, and was prescribed fluoxetine, trazodone, and olanzapine. The care plan required monitoring and documenting the side effects and effectiveness of these medications every shift. However, there was no documentation in the resident's clinical record to indicate that this monitoring occurred. Staff reported that when the facility switched systems for tracking clinical records, the monitoring of side effects was not included, and despite notifying management, it was not added. This lack of monitoring was confirmed by the facility's administrator and social services supervisor.
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Illustrative
What surveyors actually found near you
We read the 12 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
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Illustrative
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Nursing homes near The Dalles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Dalles Health And Rehabilitation | 0.9 mi | ★★★★★ | 1 | 0 |
| Oregon Veterans Home | 3.9 mi | ★★★★★ | 1 | 0 |
| Hood River Post Acute | 17.2 mi | ★★★★★ | 10 | 0 |
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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.