Cycle 1
Health 2024-09-27 · Fire 2024-09-27
14 health deficiencies
Top issue: Resident Rights (6 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Hood River, OR
Hood River Post Acute
1-star overall rating with 1-star inspections with $38,636 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
729 Henderson Road, Hood River, OR
(541) 386-2688
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1983-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.37
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.23
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.33
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.10
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.98
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
4.75
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
723
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.85
Composite VBP score used to determine payment impact.
Payment multiplier
1.0192
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.9
Baseline 19.39% · Performance 17.31% · Measure score 8.9 · Achievement 8.9 · Improvement 8.32
Healthcare-associated infections
4.37
Baseline 5.67% · Performance 6.53% · Measure score 4.37 · Achievement 4.37 · Improvement 0
Total nurse turnover
5.32
Baseline 51.35% · Performance 41.94% · Measure score 5.32 · Achievement 5.32 · Improvement 3.05
Adjusted total nurse staffing
7.35
Baseline 5.10 hours · Performance 5.17 hours · Measure score 7.35 · Achievement 7.35 · Improvement 0.47
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.81% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 3% · Lower 95% interval 5.34% |
| Discharge to community | 71.63% |
50.57%
21.1 pts better
|
Better than the National Rate · Eligible stays 90 · Observed rate 72.22% · Lower 95% interval 61.94% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 91 · Denominator 91 |
| Falls with major injury | 1.1% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 91 |
| Discharge self-care score | 40.32% |
53.69%
13.4 pts worse
|
Numerator 25 · Denominator 62 |
| Discharge mobility score | 54.84% |
50.94%
3.9 pts better
|
Numerator 34 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 91 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.53% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 3.77% · Lower 95% interval 3.88% |
| Staff COVID-19 vaccination coverage | 4.44% |
8.2%
3.8 pts worse
|
Numerator 4 · Denominator 90 |
| Staff flu vaccination coverage | 35.56% |
42%
6.4 pts worse
|
Numerator 32 · Denominator 90 |
| Discharge function score | 58.06% |
56.45%
1.6 pts better
|
Numerator 36 · Denominator 62 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 66 · Denominator 66 |
| Resident COVID-19 vaccinations up to date | 32.81% |
25.2%
7.6 pts better
|
Numerator 21 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.4
0.5 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.5
0.3 pts better
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.7% |
95.5%
7.8 pts worse
|
93.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 87.5% · Q3 82.6% · Q4 85.1% · 4Q avg 87.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
95.2%
0.1 pts better
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
2.4%
3.4 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 7.5% · Q3 6.5% · Q4 4.3% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.9% |
4.7%
1.2 pts worse
|
11.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.9% · Q3 10.8% · Q4 5.1% · 4Q avg 5.9% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
5.0%
3.8 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.8% |
12.5%
8.3 pts worse
|
19.6%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 28.2% · Q3 17.8% · Q4 15.2% · 4Q avg 20.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.0% |
14.7%
18.3 pts worse
|
16.7%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 33.3% · Q3 33.3% · Q4 33.3% · 4Q avg 33.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.6% |
24.1%
10.5 pts better
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 9.5% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.6% |
15.8%
6.8 pts worse
|
14.9%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 33.3% · Q3 19.0% · Q4 18.2% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
1.7%
0.6 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 2.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
2.0%
0.8 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.1% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.8% |
22.2%
6.6 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 28.7% · Q3 22.8% · Q4 30.7% · 4Q avg 28.8% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
6.5%
2.1 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 8.0% · Q4 8.2% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.3% |
85.4%
19.1 pts worse
|
81.7%
15.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.7% · Q2 68.6% · Q3 63.6% · Q4 57.6% · 4Q avg 66.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
15.1%
6.3 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 8.5% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.7%
0.9 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.5% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 68.0% |
81.2%
13.2 pts worse
|
79.7%
11.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 68.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.9% |
21.6%
1.7 pts better
|
23.9%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 16.0% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-31 · Fire 2020-01-31
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2018-05-11 · Fire 2018-05-11
9 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-27
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-09-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-09-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-06
F · Potential for more than minimal harm
2020-01-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-03-04
E · Potential for more than minimal harm
2020-01-31
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-03-04
D · Potential for more than minimal harm
2020-01-31
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-03-04
F · Potential for more than minimal harm
2018-05-11
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2018-06-19
F · Potential for more than minimal harm
2018-05-11
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2018-06-19
F · Potential for more than minimal harm
2018-05-11
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2018-06-19
F · Potential for more than minimal harm
2018-05-11
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2018-06-19
F · Potential for more than minimal harm
2018-05-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-06-19
F · Potential for more than minimal harm
2018-05-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2018-06-19
D · Potential for more than minimal harm
2018-05-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-06-19
Inspection history
Recent health citations
L · Immediate jeopardy
2024-09-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-06
E · Potential for more than minimal harm
2024-09-27
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2024-11-06
E · Potential for more than minimal harm
2024-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-09-27
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-09-27
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-09-27
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-09-27
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-09-27
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-09-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-09-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-09-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-09-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-09-27
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-09-27
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-06-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-18
E · Potential for more than minimal harm
2020-01-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2020-03-04
D · Potential for more than minimal harm
2020-01-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-12-23
D · Potential for more than minimal harm
2020-01-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-03-04
D · Potential for more than minimal harm
2020-01-31
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2020-03-04
D · Potential for more than minimal harm
2020-01-31
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2020-03-04
E · Potential for more than minimal harm
2018-05-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-06-19
D · Potential for more than minimal harm
2018-05-11
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2018-06-19
D · Potential for more than minimal harm
2018-05-11
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2018-06-19
D · Potential for more than minimal harm
2018-05-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-06-19
D · Potential for more than minimal harm
2018-05-11
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2018-06-19
D · Potential for more than minimal harm
2018-05-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2018-06-19
D · Potential for more than minimal harm
2018-05-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-06-19
D · Potential for more than minimal harm
2018-05-11
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2018-06-19
D · Potential for more than minimal harm
2018-05-11
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2018-06-19
Penalties and ownership
What sits behind the stars
$38,636
2024-09-27
Fine
Fine · fine $38,636
Fine
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Farrar, Chanda
Operational/Managerial Control · Individual
Gobbo, Robert
Operational/Managerial Control · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
5% Or Greater Indirect Ownership Interest · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
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2-star overall rating with 2-star inspections with $58,220 in total fines with 15 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
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The Dalles, OR
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#3
Oregon Veterans Home
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5-star overall rating with 5-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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