Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Hood River Post Acute during CMS and state inspections, most recent first.
Failure to document GDRs for psychotropic meds: four residents with diagnoses including schizophrenia, bipolar disorder, dementia with behavioral disturbance, and anxiety were receiving antipsychotic and other psychotropic medications as ordered, but their records showed no attempted GDRs and no physician documentation that GDRs were clinically contraindicated. The RNCM stated the residents were on an ECU and believed GDRs were not warranted due to their diagnoses, but could not provide the required documentation.
Failure to Obtain and Document Advance Directives: The facility failed to assist two residents with advance directives. One resident with HTN had a care plan stating full code and that an advance directive would be honored and kept in the chart, but no advance directive was found in the medical record. Another resident with asthma had a care plan noting the advance directive was reviewed, yet no advance directive was documented in the chart. The DNS stated the resident did not have an advance directive and referenced education about the difference between an advance directive and a POLST.
Failure to maintain privacy during tracheostomy suctioning. A resident with a trach, cerebral infarction, and locked-in state was observed receiving suctioning with the door fully open and visible from the hallway on multiple occasions. During care, the resident showed visible reactions including leg lifting, tremoring, and grimacing, while staff, other residents, and passersby looked into the room. The RT stated the resident reacted when the suction catheter went deeper, and the resident representative said the care should not have been visible to others. The LPN/RCM and DNS confirmed the door should have been closed to maintain privacy.
A resident with an indwelling suprapubic catheter repeatedly reported leakage at the stoma, leaving the bed and clothing wet and causing discomfort. The attending MD documented that leaking should prompt a urology referral for an exchange or different size, and a handwritten request for urology follow-up was placed in the record, but staff later confirmed the referral was not made. CNA and LPN staff stated the stoma leaked urine daily and they provided peri care and used absorbent pads to manage the ongoing leakage.
Failure to Maintain Nutritional Status: A resident admitted with malnutrition and Stage 3 pressure ulcers experienced significant weight loss, with the sacral wound worsening to Stage 4. Meal records showed frequent intake of 50% or less or meal refusal, and the resident repeatedly refused ordered protein and nutritional supplements. Staff confirmed the weight loss and that no interventions had been implemented in response to the decline.
A resident with a gastrostomy tube had EBP ordered, but no EBP signage or PPE was observed outside or inside the room, and staff were seen providing care using only gloves. A CNA confirmed EBP was not in place, and the DNS acknowledged that EBP was indicated due to the resident’s gastrostomy tube.
Failure to Send Discharge Medications With Resident: A resident with seizures and anxiety was discharged to an ALF without remaining doses of lacosamide and clonazepam, even though the chart noted medications were provided. Controlled substance records showed the meds stayed in the facility until later disposal, and staff confirmed the resident should have left with these scheduled medications.
Failure to Thoroughly Investigate Repeated Falls: A resident with Alzheimer’s disease and insomnia had repeated falls and floor-found incidents over several months, including witnessed falls and falls in the room and hallway. The fall investigations were completed late for several events and did not include root cause analysis, assessment of whether existing care plan interventions were effective, or documentation of additional interventions to prevent further falls or injuries.
A facility failed to store foods at appropriate temperatures, with a refrigerator consistently exceeding the required 41 degrees F. Despite recorded temperature discrepancies, no corrective action was taken by the Dietary Director, leading to an immediate jeopardy situation as raw meat stored at unsafe temperatures was planned for use in an upcoming meal.
The facility did not ensure that contact information for State agencies and the LTCO poster were accessible to residents in one of the two units observed. The postings were only available outside the locked enhanced care unit (ECU), and a resident reported being unaware of how to access this information and unable to leave the ECU without staff assistance. The administrator confirmed that ECU residents could not access the postings without help.
The facility failed to maintain sanitary laundry practices, as observed when a staff member delivered clean resident clothing using an uncovered laundry cart in two halls. The cart was left unattended during delivery, which was acknowledged by the Administrator as improper practice.
A facility failed to obtain consent before administering mirtazapine to a resident with dementia and a fracture, as revealed by a review of health records. The resident was prescribed the antidepressant for major depressive disorder, and the MARs showed daily administration from August 2023 through September 2024. However, there was no documentation indicating that the resident was informed of the medication's risks and benefits, which was confirmed by the DNS and Regional Nurse Consultant.
A facility failed to ensure a safe system for a resident's self-administration of medication. A resident with multiple sclerosis, initially assessed to self-administer multiple medications but later only approved for Ventolin, was left with four unidentified medications unattended by an RN. A CNA also observed medications left at the resident's bedside. The DNS was informed, but no further information was provided.
A resident with Schizoaffective disorder was restricted from accessing their cell phone during nighttime hours, despite being cognitively intact and valuing personal belongings. Staff were unaware of the reason for this restriction, and no documentation justified it. The facility administrator acknowledged that residents should maintain their cell phones unless a behavior care plan states otherwise.
The facility failed to ensure continuous access to personal funds for two residents, both cognitively intact, with one having borderline personality disorder and the other schizoaffective disorder. Access was restricted to the presence of CFL staff, available only during specific hours. Staff confirmed the limitation, and the administrator acknowledged the issue, stating residents should have constant access to their funds.
The facility failed to maintain a homelike environment and adequate hot water temperatures in the main shower room. Residents reported inconsistent and cold water temperatures, confirmed by staff and maintenance tests. The shower room was also in disrepair, with missing baseboards, damaged walls, and a missing drain cover, posing safety risks.
The facility failed to complete PASARR Level II evaluations for two residents, risking their access to specialized services. One resident with Schizoaffective disorder and cerebral palsy did not receive a Level II evaluation for serious mental illness, while another resident with anxiety and depression did not receive a follow-up Level II evaluation after a significant change in condition. The Social Services Director acknowledged the oversight, and the Administrator provided no additional information.
The facility failed to update care plans for two residents, leading to discrepancies in assistive device usage and weight monitoring. One resident was observed without a mobility bar, contrary to the care plan, while another was found without specified bed rails and had conflicting weight monitoring instructions. Staff confirmed the care plans were not updated to reflect current needs.
A resident with dementia and depression did not receive an individualized activity program as per their preferences, such as listening to music and participating in group activities. The facility's activity logs showed minimal engagement, and staff were unaware of the resident's interests beyond music. The Activities Director admitted to limited one-on-one activities, and the administrator acknowledged the deficiency without further information.
A resident with a history of trauma and a diagnosis of borderline personality disorder did not receive trauma-informed care, as their clinical record lacked documentation of trauma assessment or identification of triggers. The Social Services Director confirmed that trauma screenings and care plans were standard practice, but no evidence was found for this resident. The facility administrator acknowledged the deficiency.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended on two occasions. The incidents were confirmed by the DNS and an LPN, violating the facility's policy that requires carts to be locked when not in use or attended by authorized personnel.
A resident with cognitive impairment and a history of stroke and kidney failure sustained skin tears during a transfer when CNAs failed to use a hoyer lift as required by the care plan. The incident highlights a lapse in following prescribed interventions for residents at risk of falls.
A resident with alcohol-induced dementia was physically abused by another resident with Lewy body dementia, who was known for agitation and aggression. The incident occurred when staff heard yelling and found the victim on the ground after being hit. Both residents later could not recall the event due to cognitive impairments.
A resident with Lewy body dementia, known for exit-seeking behavior and high fall risk, eloped from the facility by following a UPS driver. Despite wearing a Wanderguard, the resident exited onto a snow-covered sidewalk and fell, resulting in pain in the left hip and arm. Staff interviews confirmed the resident's frequent attempts to leave and the regular activation of the Wanderguard alarm, indicating inadequate supervision and a failure to maintain a safe environment.
Failure to Document Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had gradual dose reductions attempted or documented as clinically contraindicated for 4 of 5 sampled residents reviewed for medications. Resident 8, admitted with paranoid schizophrenia and anxiety disorder, was receiving buspirone and perphenazine; Resident 9, admitted with bipolar disorder, was receiving olanzapine; Resident 4, admitted with antisocial personality disorder and dementia with behavioral disturbance, was receiving quetiapine fumarate; and Resident 71, admitted with bipolar disorder, was receiving olanzapine and Depakote. For each of these residents, the MDS indicated no GDR was attempted and no physician documentation showed that a GDR was clinically contraindicated. The residents’ MARs showed the psychotropic medications were administered as ordered over the reviewed periods, but their records did not contain documented evidence of GDR attempts or a documented rationale for why a GDR was not clinically contraindicated. Staff 3, the RNCM, stated the residents were on a specialized Enhanced Care Unit and believed residents on that unit would not warrant a GDR because of their diagnoses. Staff 3 also stated that psychotropic medications and changes in condition were reviewed monthly by the IDT, but was unable to provide the required GDR documentation for any of the four residents.
Failure to Obtain and Document Advance Directives
Penalty
Summary
The facility failed to assist residents to formulate advance directives for 2 of 2 sampled residents reviewed for advance directives. Resident 10 was admitted with diagnoses including hypertension, and the care plan dated 2/5/226 indicated the resident was full code, that the advance directive would be honored, and that it would be in the medical record at all times. However, review of the medical record found no evidence of an advance directive. Resident 14 was admitted with diagnoses including asthma, and a 2/10/26 Baseline Care Plan Person-Centered Care Planning Evaluation indicated the resident's advance directive had been reviewed with the resident. Review of the medical record also found no evidence of an advance directive. On 3/10/26 at 1:13 PM, the DNS stated Resident 14 did not have an advance directive and that education had been initiated regarding the difference between an advance directive and a POLST; the DNS also stated the expectation was for the RCM or Social Service Director to ensure that if a resident had an advance directive, it was obtained and scanned into the chart.
Failure to Maintain Privacy During Tracheostomy Suctioning
Penalty
Summary
The facility failed to ensure privacy was maintained when care was provided for one resident reviewed for dignity. The facility’s Resident Rights Policy stated employees shall treat all residents with kindness, respect, and dignity, and that residents have the right to privacy and confidentiality. The resident involved was admitted with diagnoses including cerebral infarction, tracheostomy, and locked-in state. The admission MDS indicated the resident was in a comatose state with an inability to communicate, and a physician order directed tracheostomy suctioning every six hours and as needed to prevent airway blockage. During observation, a respiratory therapist performed tracheostomy suctioning with the resident’s door fully open, leaving the resident visible from the main hallway. On two separate observations, the resident was seen reacting during suctioning with leg movements and strong tremoring, and other residents, staff, and passersby looked into the room while care was being provided. The respiratory therapist stated the resident’s legs lifted and shook when the suctioning tube went more than two inches deep and that the resident grimaced during the procedure. The resident representative stated the resident would not want care provided visible to others and was uncomfortable knowing suctioning was done with the door wide open. The LPN/Resident Care Manager and the DNS both confirmed the door should remain closed to maintain privacy during tracheostomy care.
Failure to Address Leaking Suprapubic Catheter
Penalty
Summary
The facility failed to ensure appropriate care and services were provided for a resident with an indwelling suprapubic catheter. The resident was admitted with acute and chronic respiratory failure with hypoxia, was cognitively intact, and was his/her own representative. The resident’s record showed an indwelling suprapubic catheter on the admission and quarterly MDS assessments, and the care plan directed the facility to follow up with urology consults as ordered. The facility’s policy stated catheter care included monitoring for signs of complications. The resident repeatedly reported that the suprapubic catheter leaked at the stoma and left the bed wet, and the attending physician documented that if the catheter was leaking, staff were to refer the resident to urology for an exchange or different size. A handwritten note requesting a urology referral was uploaded to the record, but staff later confirmed the referral was not made. Nursing and CNA staff stated the stoma leaked urine daily, peri care was routinely provided around the stoma, absorbent pads were placed below it, and the resident complained of feeling wet and uncomfortable because of the leakage.
Failure to Maintain Nutritional Status
Penalty
Summary
Provide enough food and fluids to maintain a resident’s health was not met for a resident admitted with a Stage 3 pressure ulcer to the sacral region and left heel and with moderate protein-calorie malnutrition. The resident’s care plan identified nutritional imbalance risk due to malnutrition, and weights showed a decline from 200 lbs to 190 lbs and then to 179.8 lbs over the course of the stay. Skin evaluations documented Stage 3 pressure ulcers on the left ankle and sacrum at admission, and a nutrition-at-risk evaluation started a protein supplement twice daily because of the wounds, with a physician order for a nutritional supplement twice daily. The resident’s sacral pressure ulcer later worsened to Stage 4. Nutrition-at-risk documentation noted the resident was refusing the nutritional supplement, and MARs showed refusals of the supplement after it was ordered. Meal intake records for the prior 30 days showed the resident ate 50% or less of meals or refused meals 37 times, and the resident was offered a health shake or Ensure six times and refused 13 times. Staff stated that when a resident consumed 50% or less of a meal, an alternate or meal replacement was offered, but also confirmed the resident had significant weight loss and no interventions had been implemented in response to the decline.
Failure to Implement EBP for Resident with Gastrostomy Tube
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were in place for 1 of 6 sampled hallways reviewed for EBP. Resident 55 was admitted in 2/2026 with diagnoses including gastrostomy status, and the 2/10/26 admission orders included EBP. However, on 3/9/26 and 3/10/26 between 8:37 AM and 3:38 PM, no EBP signage or PPE was observed inside or outside the resident’s room. On 3/9/26 at 2:32 PM and 3/10/26 at 1:34 PM, staff including a CNA were observed providing care to Resident 55 without PPE beyond gloves. The CNA stated that care for residents with tube feeding should include a gown, mask, and gloves, and confirmed EBP was not in place and PPE was not used beyond gloves. The DNS also acknowledged that EBP was not in place, signage was not posted, and EBP was indicated for Resident 55 due to the gastrostomy tube.
Failure to Send Discharge Medications With Resident
Penalty
Summary
The facility failed to ensure a safe discharge for one resident who had been admitted with diagnoses including seizures and anxiety. Physician orders dated 9/1/25 included lacosamide 200 mg twice daily for seizures and clonazepam 1 mg twice daily for anxiety. Progress notes showed the resident transitioned home to an assisted living facility on 9/15/25, and the note stated the resident was provided medications upon discharge. However, review of the Controlled Substance Log for 9/2025 showed 33 tablets of lacosamide and 24 tablets of clonazepam remained in the facility until they were disposed of on 11/9/25, indicating the medications were not provided at discharge. Staff interviews confirmed residents should leave with scheduled and PRN medications, including antiseizure and antianxiety medications, and an external facility staff member stated the resident was not provided the remaining doses and had to have the medications reordered. The resident stated being afraid after learning all medications did not arrive at the new facility, and the DNS confirmed the resident should have been provided the remaining doses upon discharge.
Failure to Thoroughly Investigate Repeated Falls
Penalty
Summary
The facility failed to thoroughly investigate repeated falls for Resident 83, who was admitted in 3/2025 with diagnoses including Alzheimer’s disease and insomnia. A public complaint alleged the facility failed to have interventions in place to mitigate the resident’s falls. The record shows multiple fall investigations across 2025 and early 2026, including incidents where the resident was found on the floor in the room or hallway, observed self-ambulating and falling, or witnessed falling to the floor. For each of the cited fall investigations, the facility did not include an analysis of the root cause of the fall, whether the care planned interventions were effective, or whether any additional interventions were put in place. The investigations identified by surveyors included falls on 3/21/25, 3/23/25, 3/24/25, 3/26/25, 3/27/25, 3/30/25, 4/8/25, 4/11/25, 4/27/25, 5/1/25, 5/16/25, 6/10/25, 6/18/25, 7/2/25, 7/9/25, 8/30/25, 9/13/25, 10/5/25, 10/19/25, 11/9/25, 11/12/25, 12/6/25, and 2/8/26. On 3/11/26, the DNS stated investigations were expected to be completed within five business days. The DNS also stated the fall investigations for several of the resident’s falls were completed late and were not thorough, because they were missing root cause analysis and missing interventions intended to help prevent further falls or injuries from falls. The resident’s record also showed the resident died on 2/24/26.
Failure to Maintain Safe Food Storage Temperatures
Penalty
Summary
The facility failed to store foods at appropriate temperatures, leading to a deficiency in food safety. During an inspection, it was observed that a kitchen refrigerator was not maintaining the required temperature of 41 degrees F or less, as per the U.S. Food and Drug Administration's Food Code 2022. The refrigerator was found to be at 45 degrees F on the first inspection and 49 degrees F on a subsequent inspection. This refrigerator contained various food items, including uncooked meat, which were stored at unsafe temperatures. Staff 8, the Dietary Director, acknowledged the refrigerator had issues staying cool for a few weeks but did not take corrective action when informed of the temperature discrepancies. The Refrigerator Temperature Log for September 2024 showed multiple instances where the refrigerator temperature exceeded the acceptable range. Despite these recorded temperatures, no action was taken to address the issue. Staff 8 mentioned the possibility of the refrigerator door not closing properly and speculated that the Maintenance Director might have been notified, although no records of such notification were provided. The Maintenance Director confirmed he was not informed of the issue until the day of the inspection. The facility's failure to maintain proper food storage temperatures was identified as an immediate jeopardy situation, as raw meat stored at unsafe temperatures was planned to be used for an upcoming meal.
Removal Plan
- All food was removed from the refrigerator and disposed.
- The refrigerator was taken out of service.
- New foods would be purchased to serve to residents.
- All kitchen refrigerators would be checked for correct temperatures.
- The Administrator would educate the Dietary Manager and all dietary staff on the importance of refrigerator temperatures and action that should occur immediately with any food temperature concerns. Education would include storage, thawing, cooking and danger zone temperatures as well as when to dispose of any food that is in question. If dietary staff does not answer, they will be educated prior to their shift.
- The Administrator would educate maintenance on the importance of placing a malfunctioning refrigerator out of service and action that should occur immediately with any food temperature concerns.
- The Administrator or designee would audit refrigerator temperature logs daily for one week, then weekly for three weeks and then monthly for two months.
- The findings would be brought to QAPI to ensure substantial compliance is met.
- The Administrator would be responsible to ensure compliance.
Failure to Provide Accessible Contact Information for State Agencies and LTCO
Penalty
Summary
The facility failed to ensure that contact information for pertinent State agencies and the required Long Term Care Ombudsman (LTCO) poster were accessible to residents in one of the two units observed for required postings. This deficiency was identified during an observation on September 23, 2024, at 11:00 AM, where the necessary postings were found only in a hallway outside of the facility's locked enhanced care unit (ECU) and not inside the ECU itself. On September 25, 2024, at 3:30 PM, a resident expressed that they had no knowledge of where to access the contact information for pertinent State agencies or the LTCO and expressed interest in knowing this information. The resident also mentioned being unable to leave the ECU without a staff escort. On the same day at 10:55 AM, the facility's administrator acknowledged the findings and confirmed that ECU residents could not access the required postings without staff assistance.
Inadequate Sanitary Laundry Practices
Penalty
Summary
The facility failed to ensure sanitary laundry services for two of the six halls reviewed for infection control, placing residents at risk for cross-contamination. On two separate occasions, Staff 20, responsible for laundry services, was observed delivering clean resident clothing using a small, uncovered laundry cart throughout the 400 and 500 Halls. The cart was left unattended while Staff 20 delivered clothing from room to room. This practice was acknowledged by Staff 1, the Administrator, who confirmed that clean resident clothing should be covered during delivery.
Failure to Obtain Consent for Antidepressant Medication
Penalty
Summary
The facility failed to obtain consent before administering antidepressant medication to a resident, which was identified during an interview and record review. Resident 21, who was admitted in August 2023 with diagnoses including a fracture and dementia, was prescribed mirtazapine for major depressive disorder as per the physician's order dated August 25, 2023. The medication administration records (MARs) from August 2023 through September 2024 indicated that the resident received mirtazapine daily. However, a review of the resident's health record revealed no documentation showing that the resident was informed in advance about the risks and benefits of mirtazapine. On September 25, 2024, both the Director of Nursing Services (DNS) and the Regional Nurse Consultant confirmed the absence of documentation and acknowledged that consent was not obtained from the resident or their representative before starting the medication.
Failure in Safe Medication Self-Administration
Penalty
Summary
The facility failed to ensure a safe system for a resident's self-administration of medication, specifically for a resident diagnosed with multiple sclerosis who was cognitively intact. Initially, the resident was assessed to self-administer multiple medications but later was only approved to self-administer Ventolin. Despite this, a registered nurse left four unidentified medications at the resident's bedside unattended, believing the resident was assessed to take medications independently. This was corroborated by a CNA who observed medications left at the resident's bedside in the evenings. The Director of Nursing Services was informed of these observations, but no further information was provided by the time of the report.
Resident's Right to Retain Personal Possessions Violated
Penalty
Summary
The facility failed to ensure that a resident was allowed to retain personal possessions, specifically a cell phone, which is a violation of the resident's right to be treated with respect and dignity. The resident, who was admitted with a diagnosis of Schizoaffective disorder, was cognitively intact and expressed the importance of taking care of personal belongings. Despite this, the resident was restricted from having access to their cell phone during nighttime hours, from 7:00 PM to 9:00 AM, since admission. The resident expressed dissatisfaction with this restriction, feeling upset about not being able to contact their mother at will. Staff members, including CNAs and the Enhanced Care Unit Program Supervisor, were unaware of the specific reasons for the restriction, although there was a concern mentioned about the roommate potentially taking the phone. However, no documentation in the resident's clinical record justified the restriction. The facility administrator acknowledged the findings and stated that residents should be able to maintain their cell phones unless a behavior care plan indicated otherwise, which was not present in this case.
Deficiency in Resident Access to Personal Funds
Penalty
Summary
The facility failed to ensure that residents had continuous access to their personal funds, affecting two residents. Resident 1, who was admitted in October 2017 with a diagnosis of borderline personality disorder and was cognitively intact, reported being able to access their money only during daytime hours. Staff interviews revealed that access to funds was dependent on the availability of staff from the Center for Living (CFL), who were present from approximately 9:00 AM to 7:00 PM. Staff members, including CNAs and the Enhanced Care Unit Program Supervisor, confirmed that residents could not access their money outside these hours, and an LPN admitted to not knowing how to access resident funds when CFL staff were unavailable. Similarly, Resident 9, admitted in July 2024 with schizoaffective disorder and also cognitively intact, reported being unable to access funds after 7:00 PM on weekdays and after 4:00 PM on weekends. The same staff members reiterated that residents had to wait for CFL staff to access their money. The facility administrator acknowledged these findings, stating that residents should have access to their money at all times. This deficiency placed residents at risk of not having access to their personal funds when needed.
Inadequate Hot Water and Unhomelike Shower Room Conditions
Penalty
Summary
The facility failed to maintain a homelike environment and provide adequate hot water temperatures in the main shower room, affecting the residents' comfort and safety. Observations and interviews revealed that the water temperature in the shower room was inconsistent and often too cold. A resident reported that the water was too cold, while another mentioned that the water would fluctuate between hot and cold. A CNA confirmed the issue, stating that she had to start the shower early to allow the water to warm up. The maintenance director tested the water temperature, which was found to be 87 degrees Fahrenheit, despite the hot water heater gauge reading 99 degrees Fahrenheit. The administrator also tested the water, which reached only 94 degrees Fahrenheit. Additionally, the shower room was observed to be in a state of disrepair, contributing to an un-homelike environment. Sections of baseboard were missing, exposing unfinished and uncleanable sheetrock. The partition wall had significant damage, and the ceiling appeared torn and potentially water-damaged. The vent was dirty, the light bulb was exposed, and the drain cover was missing, leaving a three-inch hole in the floor that posed a potential injury risk. The administrator confirmed the damage and the inadequate water temperatures, acknowledging the un-homelike state of the shower room.
Failure to Complete PASARR Level II Evaluations
Penalty
Summary
The facility failed to ensure that a PASARR Level II evaluation was completed for two residents who required it, placing them at risk of not receiving specialized services. Resident 9, admitted with diagnoses including Schizoaffective disorder and cerebral palsy, had a PASARR Level I indicating indicators of both serious mental illness and a developmental disability. However, the PASARR Level II was only requested for the developmental disability, not the serious mental illness. The Social Services Director was unsure why the PASARR Level II for the serious mental illness was not completed, and the Administrator acknowledged the findings without providing additional information. Resident 26, admitted with anxiety and depression, initially had a PASARR Level I indicating no serious mental illness or developmental disability. However, a PASARR Level II was requested in 2023 due to an increase in paranoid delusions. After a hospitalization in 2024, Resident 26's new PASARR Level I indicated serious mental illness, but no additional PASARR Level II was requested to address this change. The Social Services Director admitted that an additional PASARR Level II should have been requested following the resident's significant change of condition, but it was not done. The Administrator was informed of these findings and did not provide further information.
Failure to Update Care Plans for Assistive Devices and Weight Monitoring
Penalty
Summary
The facility failed to ensure care plans were revised to accurately reflect the needs of two residents, leading to potential unmet needs. Resident 14, admitted with dementia and parkinsonism, was observed without a mobility bar on the bed, despite the care plan indicating its necessity for enhanced bed mobility. Staff confirmed that the care plan had not been updated to reflect the resident's current needs, as the mobility bar was no longer required. Similarly, Resident 35, admitted with delusional disorders, depression, and edema, was found without the bilateral 1/4 inch rails specified in the care plan. Staff confirmed that the resident did not use these devices, and the care plan had not been updated. Additionally, there was a discrepancy in the care plan regarding the frequency of weight monitoring for Resident 35, with the care plan indicating daily weights, while a physician's order specified weekly weights. Staff acknowledged the care plan had not been revised to align with the physician's order.
Failure to Provide Individualized Activity Program
Penalty
Summary
The facility failed to provide an ongoing program to support individual activity interests and preferences for a resident diagnosed with dementia and depression. The resident, admitted in January 2021, was noted to have short and long-term memory loss and was severely impaired in decision-making. The resident's activity preferences included listening to music, participating in group activities, and spending time outdoors. However, the facility's activity logs indicated that the resident only received four one-to-one activities and did not participate in any group activities over a month-long period. Observations revealed the resident was often in bed or in a wheelchair at the nurse's station or in their room, with no music playing, which was one of their known interests. Staff interviews revealed that the resident was non-verbal and unable to make choices about activities, with staff unaware of any interests outside of music. The Activities Director admitted to not engaging in many one-on-one activities with the resident and was unable to specify the resident's favorite activities beyond listening to music. Despite attempting a sensory mat once, no further sensory activities were tried. The facility's administrator acknowledged the findings but did not provide additional information, indicating a lack of adherence to the facility's policy of assessing and addressing residents' activity preferences and needs.
Failure to Provide Trauma-Informed Care for a Resident
Penalty
Summary
The facility failed to provide trauma-informed care to a resident who was a trauma survivor, as evidenced by the lack of documentation and assessment of the resident's past trauma and potential triggers for re-traumatization. The resident, admitted in October 2017, had a diagnosis of borderline personality disorder and reported a history of childhood and teenage abuse. Despite being cognitively intact, the resident's clinical record did not reflect any assessment or identification of trauma history or triggers. During interviews, the Social Services Director acknowledged that residents were screened for trauma and care plans were developed for those who experienced trauma, including identifying possible triggers. However, there was no documentation indicating that the resident in question was ever screened for trauma. The facility administrator confirmed the findings of the investigation but did not provide any additional information.
Medication and Biologicals Security Lapse
Penalty
Summary
The facility failed to ensure that medications and biologicals were secured and accessible only to authorized personnel, as observed during a survey. On two separate occasions, medication and treatment carts were found unlocked and unattended. The first incident occurred on the 300 hall, where a treatment cart was left unlocked and unattended, confirmed by the Director of Nursing Services (DNS). The second incident took place on the 500 hall, where a medication cart was similarly left unlocked and unattended, confirmed by a Licensed Practical Nurse (LPN). The facility's Medication Storage Policy mandates that medication carts should remain locked when not in use or attended by authorized personnel, which was not adhered to in these instances.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to adhere to the care plan interventions for a resident who was at risk for falls due to muscle weakness. The resident, who was moderately impaired in cognition and had a history of stroke and kidney failure, was supposed to be transferred using a two-person hoyer lift. However, during a transfer from bed to wheelchair, the care plan was not followed, resulting in the resident sustaining two skin tears on the right forearm. The incident occurred when two CNAs, unfamiliar with the resident, attempted the transfer without using the hoyer lift as required. The skin tears were assessed and cleaned by an RN, measuring 1.5 cm each and horseshoe-shaped. The Director of Nursing Services confirmed that the care plan was not followed, emphasizing that the expectation was for care plans to be adhered to at all times.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident 101, who was cognitively intact, was admitted with alcohol-induced dementia. Resident 100, admitted with Lewy body dementia, was severely cognitively impaired and had a history of agitation and aggression. On the day of the incident, staff heard yelling and cursing from the shared room of Residents 100 and 101. Upon entering, staff observed Resident 101 on the ground and Resident 100 standing over them, having hit Resident 101 in the face over a misunderstanding about personal belongings. Staff interviews revealed that Resident 100 could be pleasant but also verbally aggressive, and had previously been instructed to intervene to protect others' safety. After the altercation, Resident 101 was initially scared but later could not recall the incident due to poor short-term memory. Resident 100 also could not remember the details of the event. The facility's failure to prevent this altercation placed residents at risk for abuse.
Failure to Prevent Elopement and Fall of a Resident with Dementia
Penalty
Summary
The facility failed to ensure adequate supervision and a safe environment for a resident with Lewy body dementia, who was at high risk for elopement and falls. The resident, admitted in July 2021, was known to exhibit exit-seeking behaviors and was equipped with a Wanderguard to monitor such tendencies. Despite these precautions, the resident frequently attempted to leave the facility, as noted in care plans and assessments. On November 30, 2022, the resident followed a UPS driver out of the facility, stepping onto a snow-covered sidewalk and subsequently falling, resulting in pain in the left hip and arm. Interviews with staff revealed that the resident consistently lingered near the facility's doors, often asking to go outside. Staff acknowledged the resident's persistent exit-seeking behavior and the frequent activation of the Wanderguard alarm. On the day of the incident, the weather conditions included snow and ice, which contributed to the resident's fall after exiting the facility. The incident highlights the facility's failure to provide adequate supervision and maintain a safe environment for the resident, who was at high risk for elopement and falls.
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 14 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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 Hood River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Columbia Basin Care Facility | 17.2 mi | ★★★★★ | 12 | 1 |
| The Dalles Health And Rehabilitation | 17.5 mi | ★★★★★ | 1 | 0 |
| Oregon Veterans Home | 20.9 mi | ★★★★★ | 1 | 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.