Cycle 1
Health 2024-12-20 · Fire 2024-12-20
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
The Dalles, OR
The Dalles Health & Rehabilitation Center
4-star overall rating with 4-star inspections with 4 recent health deficiencies
1023 W. 25th Street, The Dalles, OR
(541) 298-5158
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
121
Certified beds
Average residents
40
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Evergreen Healthcare Group
Operator or chain grouping
Approved since
1986-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
41 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.29
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.25
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
4.30
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.04
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
4.64
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 53% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
757
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
64.19
Composite VBP score used to determine payment impact.
Payment multiplier
1.0187
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.77
Baseline 20.32% · Performance 18.76% · Measure score 5.77 · Achievement 5.77 · Improvement 4.25
Healthcare-associated infections
8.28
Baseline 5.08% · Performance 5.36% · Measure score 8.28 · Achievement 8.28 · Improvement 0
Total nurse turnover
4.94
Baseline 26.32% · Performance 43.48% · Measure score 4.94 · Achievement 4.94 · Improvement 0
Adjusted total nurse staffing
6.68
Baseline 5.09 hours · Performance 4.98 hours · Measure score 6.68 · Achievement 6.68 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.06% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 5% · Lower 95% interval 6.09% |
| Discharge to community | 56.6% |
50.57%
6 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 52.94% · Lower 95% interval 47.95% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.75% |
95.27%
3.5 pts better
|
Numerator 79 · Denominator 80 |
| Falls with major injury | 2.5% |
0.77%
1.7 pts worse
|
Numerator 2 · Denominator 80 |
| Discharge self-care score | 45.61% |
53.69%
8.1 pts worse
|
Numerator 26 · Denominator 57 |
| Discharge mobility score | 54.39% |
50.94%
3.5 pts better
|
Numerator 31 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 1.25% |
2.29%
1 pts better
|
Numerator 1 · Denominator 80 · Adjusted rate 1.3% |
| Healthcare-associated infections requiring hospitalization | 5.36% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 0% · Lower 95% interval 2.64% |
| Staff COVID-19 vaccination coverage | 7.94% |
8.2%
0.3 pts worse
|
Numerator 5 · Denominator 63 |
| Staff flu vaccination coverage | 70.59% |
42%
28.6 pts better
|
Numerator 60 · Denominator 85 |
| Discharge function score | 54.39% |
56.45%
2.1 pts worse
|
Numerator 31 · Denominator 57 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 91.23% |
96.28%
5 pts worse
|
Numerator 52 · Denominator 57 |
| Resident COVID-19 vaccinations up to date | 37.25% |
25.2%
12.1 pts better
|
Numerator 19 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.4
0.1 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.5
1.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
95.5%
2.2 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.7% · Q3 100.0% · Q4 95.0% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.0% |
95.2%
0.8 pts better
|
95.5%
0.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.9% |
2.4%
4.5 pts worse
|
3.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.3% · Q3 5.0% · Q4 15.0% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.7%
4.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
5.0%
3.3 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.5% · Q3 5.0% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
12.5%
2.8 pts worse
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 22.7% · Q3 15.0% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.6% |
14.7%
7.1 pts better
|
16.7%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.6% · 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 | 28.7% |
24.1%
4.6 pts worse
|
16.3%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.9% |
15.8%
7.1 pts worse
|
14.9%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 36.4% · Q3 20.0% · 4Q avg 22.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
1.7%
1.1 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 10.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.0%
2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.4% |
22.2%
3.2 pts worse
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · 4Q avg 25.4% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
6.5%
6.5 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.7% |
85.4%
7.7 pts worse
|
81.7%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 80.4% · Q2 91.9% · Q3 85.4% · Q4 57.9% · 4Q avg 77.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.0% |
15.1%
4.1 pts better
|
12.0%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 9.6% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.7%
0.7 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 1.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.3% |
81.2%
1.1 pts better
|
79.7%
2.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.4% |
21.6%
9.2 pts better
|
23.9%
11.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 9.6% · Expected 18.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-05 · Fire 2023-10-05
7 health deficiencies
Top issue: Resident Rights (4 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-07-15 · Fire 2022-07-15
9 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-10-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-10
F · Potential for more than minimal harm
2022-07-15
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-08-24
F · Potential for more than minimal harm
2022-07-15
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-08-24
F · Potential for more than minimal harm
2022-07-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-08-24
F · Potential for more than minimal harm
2022-07-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-08-24
F · Potential for more than minimal harm
2022-07-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-24
F · Potential for more than minimal harm
2022-07-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-24
F · Potential for more than minimal harm
2022-07-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-08-24
F · Potential for more than minimal harm
2022-07-15
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-08-24
E · Potential for more than minimal harm
2022-07-15
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2022-08-24
Inspection history
Recent health citations
G · Actual harm
2024-12-20
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 2024-08-03
E · Potential for more than minimal harm
2024-12-20
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-20
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 2025-01-21
D · Potential for more than minimal harm
2024-05-17
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 2024-02-21
E · Potential for more than minimal harm
2023-10-05
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 2023-11-10
D · Potential for more than minimal harm
2023-10-05
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-05
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 2023-11-10
D · Potential for more than minimal harm
2023-10-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-05
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 2023-11-10
G · Actual harm
2022-07-15
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-08-24
E · Potential for more than minimal harm
2022-07-15
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-07-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-07-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-07-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-07-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-07-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-08-24
D · Potential for more than minimal harm
2022-07-15
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 2022-08-24
D · Potential for more than minimal harm
2022-07-15
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2022-08-24
Penalties and ownership
What sits behind the stars
Ownership
Couve Financial Services LLC
Operational/Managerial Control · Organization
Couve Healthcare Consulting LLC
Operational/Managerial Control · Organization
Curry, Danielle
Operational/Managerial Control · Individual
Nagle, Jordan
Operational/Managerial Control · Individual
Odenthal, Jason
Operational/Managerial Control · Individual
Perlman, Harold
Operational/Managerial Control · Individual
Pnw 12 Opco Management LLC
Operational/Managerial Control · Organization
Pnw 12 SNF Consulting LLC
Operational/Managerial Control · Organization
Spielman, Shimon
Operational/Managerial Control · Individual
Tennison, Jasen
Operational/Managerial Control · Individual
Tennison, Leana
Operational/Managerial Control · Individual
The Dalles SNF Operations LLC
Operational/Managerial Control · Organization
Yenowitz, Yitzchok
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Columbia Basin Care Facility
The Dalles, OR
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
Oregon Veterans Home
The Dalles, OR
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Hood River Post Acute
Hood River, OR
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
Jump out