The Dalles Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at The Dalles Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 27, 2026

  Based on interview and record review, it was determined the facility failed to ensure a resident was free from sustaining a burn from a baseboard heater for 1 of 3 (#2) sampled residents revied for accidents. As a result, Resident 2 sustained second degree burns on her/his left foot and toes. Findings include:Resident 2 was admitted to the facility in 2025 with diagnosis including stroke and diabetic neuropathy (a condition that causes numbness to the hands and feet). Resident 2's 5/21/25 Care Plan indicated Resident 2 with impaired cognitive disturbance and safety awareness which included sliding out of bed at night and fidgeting with items on walls including keypads, fire alarms and picture frames.Resident 2's MDS identified the resident with a BIMS score of 13 out 15 indicating mild… […]

• Actual harm, isolatedF689Dec 20, 2024

  Based on interview and record review it was determined the facility failed to ensure staff provided two-person assistance when transferring a resident for 1 of 4 sampled residents (#33) reviewed for accidents. This failure resulted in Resident 33 falling from a mechanical lift and sustaining a laceration to the forehead which required sutures. Findings include: Resident 33 admitted to the facility in 4/2022 with diagnoses including heart disease and memory loss. A care plan dated 1/21/24 revealed Resident 33 was dependent on staff for her/his ADL care needs and required two-person assistance with a mechanical lift for transfers. […]

• Actual harm, isolatedF688Jul 15, 2022

  Based on observation, interview and record review it was determined the facility failed to prevent loss of range of motion and development of contractures for 1 of 1 sampled resident (#6) reviewed for contractures. This failure resulted in Resident 6 developing bilateral (both) ankle contractures, reduced range of motion of both hips and pain in the lower extremities. Findings include: Resident 6 was admitted to the facility in 2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Policy on the Restorative Program (RA) updated 3/2019 indicated the program's focus was on achieving and maintaining optimal physical, mental and psychosocial functioning of the resident and to attain and maintain each resident's practicable functioning. […]

• Actual harm, isolatedF686Mar 11, 2021

  Based on interview and record review it was determined the facility failed to follow physician's orders as a result a resident developed two pressure ulcers, unstageable due to eschar for 1 of 3 sampled residents (#2) reviewed for pressure ulcers. This placed residents at risk for pressure ulcers, delayed healing and inappropriate treatment. Findings include: The Minimum Data Set 3.0 User's Manual revealed eschar is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/edges of the wound. […]

• No harm, potential for more than minimal, patternF730Dec 20, 2024

  Based on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 5 of 5 randomly selected CNA staff (#s 6, 10, 14, 23 and 24) reviewed for staffing. This placed residents at risk for lack of care by competent staff. Findings include: On 12/18/24 at 10:00 AM, Staff 2 (DNS) was asked for the annual performance reviews for Staff 6, Staff 10, Staff 14, Staff 23 and Staff 24. On 12/18/24 at 12:52 PM, Staff 1 (Administrator) and Staff 2 were present for an interview. Staff 2 stated Staff 6, Staff 10, Staff 14, Staff 23 and Staff 24 did not have annual performance reviews completed. Staff 2 stated she did not provide annual performance reviews.