Above 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 The Dalles Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with mild cognitive impairment, poor safety awareness, and diabetic neuropathy, which reduced sensation in the feet, was known to slide out of bed at night. The bed was positioned too close to a baseboard heater, and the resident rolled out of bed and placed a foot directly on the heater. A CNA later found the resident on the floor with the foot on the heater, and assessment documented multiple small second-degree burns with blisters on the left foot and toes caused by direct contact with the heater.
A resident dependent on staff for ADL care and requiring two-person assistance for transfers fell from a mechanical lift when a CNA attempted a solo transfer. The lift's wheel caught on a metal strip, causing the resident to fall and sustain a forehead laceration requiring sutures. The CNA admitted to not following the care plan due to a busy night.
The facility did not conduct annual performance reviews for five CNAs, as confirmed by the DNS. This failure placed residents at risk of receiving care from potentially incompetent staff.
The facility failed to follow physician orders for two residents, leading to potential health risks. A resident with heart failure and COPD was not monitored for weight changes as ordered, and the physician was not notified of significant weight gains. Another resident with a history of GI bleed received incorrect medication dosages due to transcription errors, continuing aspirin and receiving the wrong Eliquis dosage. Staff acknowledged these oversights.
A resident with chronic heart failure and COPD had inaccurate medical records due to outdated physician orders and failure to notify the provider of significant weight changes. Additionally, insulin administration orders were not followed correctly, as high blood sugar levels were not reported to the physician as required. These issues placed residents at risk for inaccurate medical records.
A resident with moderate cognitive impairment was subjected to verbal abuse and disrespect by a former CNA, who attempted to force the resident into bed against their wishes, used profanity, and threw an object that hit the resident's hand. The incident was witnessed by another CNA and confirmed by the resident's spouse and the facility's administrator.
Resident Burn from Contact with Baseboard Heater Due to Inadequate Hazard Prevention
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was protected from accident hazards related to a baseboard heater, resulting in second-degree burns. The resident had diagnoses including stroke and diabetic neuropathy, a condition causing numbness in the hands and feet, and was care planned for impaired cognition and poor safety awareness, including sliding out of bed at night and fidgeting with items on the walls. The resident’s MDS showed mild cognitive impairment with a BIMS score of 13/15. Despite these known risks, the resident’s bed was positioned too close to a baseboard heater in the room. On the night of the incident, the resident rolled out of bed and placed their left foot on the baseboard heater. A CNA found the resident lying on the floor, whimpering, with the left foot resting on the heater. Due to the resident’s diabetic neuropathy, staff reported the resident would not have been aware of the injury as it was occurring. The CNA removed the resident’s foot from the heater and notified the charge nurse. Subsequent assessment and a Skin and Wound Assessment documented second-degree burns with multiple small blisters on the left foot and toes, each approximately 0.2 cm in length and width. The administrator and RN case manager acknowledged that the burns were caused by direct contact with the baseboard heater after the resident rolled out of bed.
Failure to Provide Two-Person Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that staff provided the required two-person assistance when transferring a resident using a mechanical lift, resulting in an accident. Resident 33, who was admitted to the facility with diagnoses including heart disease and memory loss, was dependent on staff for activities of daily living and required two-person assistance for transfers as per the care plan. On the night of the incident, Staff 25, a former CNA, attempted to transfer the resident alone due to a busy night and the inability to find assistance. During the transfer, the mechanical lift's wheel rolled over a metal strip on the floor, causing the lift to jerk and the sling to tilt, leading to the resident falling out of the sling and sustaining a laceration to the forehead that required sutures. Staff 25 attempted to prevent the fall by grabbing the resident's arm, inadvertently causing additional lacerations. The resident was assessed by Staff 8, an LPN, who managed the bleeding before the resident was transferred to the hospital for further evaluation. The hospital record confirmed the resident sustained a laceration to the forehead and an abrasion to the right forearm. Staff 25 acknowledged the failure to follow the care plan, which required two-person assistance, and admitted fault for the incident. The incident was reported to Staff 3, the Assistant Executive Director, who confirmed that the mechanical lift's wheel had caught on a metal divider, causing the accident.
Removal Plan
- Conduct a thorough investigation of the incident.
- Educate Staff 25 to follow the care plan and place on a probationary period.
- Provide staff education on proper use of two staff persons when using the mechanical lift and following resident care plans explicitly.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received annual performance reviews, affecting five randomly selected CNA staff members. During an interview and record review, it was revealed that Staff 6, Staff 10, Staff 14, Staff 23, and Staff 24 did not have their annual performance reviews completed. Staff 2, the Director of Nursing Services (DNS), confirmed that these reviews were not conducted. This oversight placed residents at risk of receiving care from potentially incompetent staff.
Failure to Follow Physician Orders for Weight Monitoring and Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders for two residents, leading to potential health risks. Resident 12, diagnosed with chronic heart failure and COPD, had specific physician orders for daily weight monitoring to manage heart failure. The orders required staff to notify the physician if the resident's weight increased by three pounds in 24 hours or fell below 195 pounds. However, during November and December 2024, there were multiple instances where Resident 12's weight increased by more than three pounds in a 24-hour period, and the physician was not notified. Staff members acknowledged the oversight, confirming that the physician was not informed of the weight variances as required. Resident 9, with a history of heart failure and gastrointestinal hemorrhage, was discharged from the hospital with specific medication orders to discontinue aspirin and adjust the dosage of Eliquis due to a history of GI bleed. Despite these orders, the resident received the incorrect dosage of Eliquis and continued to receive aspirin after it was supposed to be discontinued. The Director of Nursing Services confirmed that the hospital discharge orders were inaccurately transcribed, resulting in the resident receiving the wrong medication regimen.
Inaccurate Medical Records and Physician Notification Failures
Penalty
Summary
The facility failed to ensure complete and accurate medical records for a resident admitted with chronic heart failure and COPD. A physician order from April directed staff to monitor the resident's weight and notify the provider if it fell below 195 pounds. However, the resident's weight consistently remained below this threshold in November and December, without evidence of provider notification. Staff acknowledged the order was outdated, as the resident's weight averaged in the 180s, and the physician was aware of this status. Additionally, a physician order from July instructed staff to administer insulin based on a sliding scale and notify the physician if blood sugar levels exceeded 350. Despite four instances of blood sugar readings above this level in December, there was no documentation of physician notification. Staff clarified that the order intended for physician notification only if blood sugar levels exceeded 451, following the sliding scale protocol. These discrepancies in following physician orders and maintaining accurate records placed residents at risk for inaccurate medical records.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as evidenced by an incident involving a former CNA (Staff 7) and a resident with moderate cognitive impairment. On the night of the incident, Staff 7 attempted to force the resident out of their recliner and into bed, despite the resident's expressed preference to sleep in the recliner. When the resident refused, Staff 7 yelled at the resident, used profanity, and threw an object that hit the resident's hand. This behavior was witnessed by another CNA (Staff 6), who reported that Staff 7 had also removed the resident's blankets and thrown them back on the resident when they refused to go to bed. The resident expressed confusion and distress over the treatment received from Staff 7, who was not even assigned to the resident's hall that night but intervened regardless, claiming the assigned CNA was lazy. The resident's spouse, who visited daily, confirmed that the resident was angry but not fearful or depressed following the incident. The facility's administrator interviewed the resident the next day, who reiterated their desire not to receive care from Staff 7 again. The administrator confirmed that Staff 7 had been placed on administrative leave and subsequently terminated following an investigation that corroborated the resident's account of the incident. The resident's care plan indicated they had moderate cognitive impairment but were capable of making their needs and preferences known, which were disregarded by Staff 7 during the incident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 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
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 The Dalles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Columbia Basin Care Facility | 0.9 mi | ★★★★★ | 12 | 1 |
| Oregon Veterans Home | 3.9 mi | ★★★★★ | 1 | 0 |
| Hood River Post Acute | 17.5 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Dalles Health And Rehabilitation.
100% money-back within 48 hours.
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.