Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Oregon Veterans Home during CMS and state inspections, most recent first.
Failure to protect a resident from physical abuse by another resident. Two cognitively intact residents were involved in a physical altercation in the smoking area, during which one resident struck the other in the head with a cane, causing a scalp laceration that required staples and hospital transfer. The facility investigation reviewed video footage and concluded the act was willful and intended to cause harm.
The facility inaccurately coded MDS assessments for five residents, indicating they were receiving anticoagulant medications when they were not. Interviews with an RNCM and the DNS confirmed the inaccuracies, as no evidence in the clinical records supported the use of anticoagulants for these residents.
A resident with a history of agitation related to noise physically assaulted another resident over music being played in their shared room. The incident resulted in temporary redness and pain for the victim, who had heart failure and dementia. Staff intervened after hearing yelling, and the aggressor, who had dementia and anxiety disorder, later acknowledged the physical contact.
The facility failed to report allegations of sexual abuse involving two residents to the State Survey Agency. A resident with cognitive impairment was reportedly touched inappropriately by another resident during activities, witnessed by staff but not reported. The facility administrator was unaware of these incidents, which were not communicated to the State Survey Agency, placing residents at risk.
The facility failed to investigate allegations of abuse involving three residents, including inappropriate touching and an altercation. Incidents were reported to staff but not investigated in a timely manner, and the facility administrator was unaware of the issues until much later. The investigation into an altercation was incomplete, lacking staff interviews and a documented determination of abuse.
A resident with dementia and diabetes was administered Lactulose despite physician orders to withhold it if the resident had two loose stools the previous day. Staff confirmed administering the medication on multiple occasions when it should have been held, placing the resident at risk for adverse side effects.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a cognitively intact resident from physical abuse by another cognitively intact resident. Resident 26, admitted with depression and a BIMS of 14, was involved in a physical altercation with Resident 7, who was admitted with diagnoses including PTSD and depression and also had a BIMS of 14. A facility-reported incident stated that the altercation occurred in the smoking area and resulted in a bodily injury to Resident 26, who sustained a scalp laceration and was sent to the hospital. The emergency department record documented that Resident 26 was struck over the head with a cane and had a 1 cm scalp laceration requiring three staples. The facility investigation reviewed video footage and determined that Resident 7 entered the smoking area after Resident 26, moved within a foot of Resident 26, attempted to strike Resident 26's right arm, and then struck Resident 26 in the head with a cane, causing bleeding. The investigation concluded that Resident 7 acted with intent to cause physical harm and that the actions appeared willful. Resident 7 later confirmed involvement in the altercation and stated he/she caused Resident 26 to bleed and had a tendency to fight in response to interpersonal conflict. Resident 26 stated he/she did not know why Resident 7 struck him/her with the cane and could not recall whether a verbal altercation occurred first.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for five residents regarding the use of anticoagulant medications. Each of the five residents, who were admitted with various diagnoses including dementia, anxiety, heart failure, and stroke, were inaccurately documented as receiving anticoagulant medications in their MDS assessments. However, upon review of their clinical records, no evidence was found to support that these residents were actually receiving such medications. Interviews with Staff 6, a Registered Nurse Case Manager (RNCM), and Staff 2, the Director of Nursing Services (DNS), revealed that Staff 6 was responsible for completing the medication section of the MDS. Staff 6 acknowledged the inaccuracies in the MDS entries for all five residents, confirming that none of them were on anticoagulant medications. Staff 2 also confirmed the inaccuracies, acknowledging that the residents were not receiving anticoagulant medications as indicated in their MDS assessments.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, resulting in an altercation between two residents. Resident 76, who had a history of agitation related to noise, was triggered by music played by Resident 106. This led to Resident 76 physically assaulting Resident 106 by choking them and covering their mouth and nose. The incident was witnessed by staff who intervened, but not before Resident 106 sustained temporary redness to the neck and reported pain. Resident 76, who had been diagnosed with dementia and anxiety disorder, did not recall the incident initially but later acknowledged the physical contact when reminded of the details. Resident 106, who had heart failure and dementia, expressed anger but not fear towards Resident 76 following the incident. The altercation was documented in a Resident to Resident Conflict report, and the physical effects on Resident 106 were noted in subsequent wound evaluations and nursing notes.
Failure to Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of sexual abuse involving two residents to the State Survey Agency. Resident 54, who was admitted in April 2021 with diagnoses including diabetes and a leg fracture, was reportedly touched inappropriately by Resident 108 during an activity. This incident was witnessed by Staff 17, who reported it to Staff 23, but no evidence was found that the incident was reported to the State Survey Agency. The facility administrator was unaware of the incident and acknowledged that it was not reported as expected. Similarly, Resident 307, admitted in January 2024 with dementia and vascular Parkinsonism, was also reportedly touched inappropriately by Resident 108. Staff 17 witnessed this incident and reported it to other staff members, but again, there was no evidence of the incident being reported to the State Survey Agency. The facility administrator was not aware of this incident either and confirmed it was not reported. These failures placed residents at risk due to the lack of protective measures to prevent further abuse.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse involving three residents. Resident 54, who had cognitive impairment, was reportedly inappropriately touched by another resident during activities. This incident was witnessed by a staff member who reported it to a former RNCM, but the facility administrator was unaware of the incident until months later, and no investigation was conducted prior to that time. Similarly, Resident 307, who had moderately impaired cognition, was also reportedly touched inappropriately by the same resident. This incident was reported to other staff members, but again, the facility administrator was not informed, and no investigation was conducted until much later. Additionally, an altercation occurred between Resident 76 and Resident 106, where Resident 76 reportedly placed their hands around Resident 106's neck. The investigation into this incident was incomplete, as it did not include staff or witness statements, and there was no documented determination of whether abuse occurred. The RNCM responsible for the investigation acknowledged the oversight in not interviewing staff and failing to document a determination. These failures in investigation placed residents at risk and did not adhere to the facility's policy on abuse investigation.
Failure to Follow Physician Orders for Bowel Care
Penalty
Summary
The facility failed to adhere to physician orders regarding bowel care for a resident diagnosed with dementia and diabetes. The physician had prescribed Lactulose to be administered once daily for constipation, with specific instructions to withhold the medication if the resident experienced two loose stools the previous day. However, a review of the resident's bowel records and Medication Administration Records (MARs) for January, February, and March 2025 revealed that the medication was administered on several occasions when it should have been withheld according to the physician's orders. Interviews with facility staff, including two Certified Medication Aides (CMAs) and a Registered Nurse Case Manager (RNCM), confirmed that the medication was given despite the resident having two or more loose stools on the previous day. Both CMAs acknowledged their initials on the MARs and admitted to administering Lactulose when it should have been held. The RNCM also confirmed the administration of the medication on the identified dates and stated that the expectation was for all staff to follow the physician's orders. This oversight placed the resident at risk for adverse side effects of the medication.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 23 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 3.9 mi | ★★★★★ | 1 | 0 |
| Columbia Basin Care Facility | 3.9 mi | ★★★★★ | 12 | 1 |
| Hood River Post Acute | 20.9 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.