Inspection Reports for Chehalem Post Acute

1900 E. Fulton Street, Newberg, OR, 97132

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Inspection Report Summary

The most recent inspection on August 13, 2025, identified deficiencies related to personal privacy, confidentiality of records, and administrative rules, all of which were corrected by the second revisit. Earlier inspections showed a pattern of deficiencies involving resident rights, abuse and neglect, staffing, medication management, infection control, and environmental issues, with some citations remaining uncorrected after revisits. Complaint investigations did not result in substantiated findings, and no fines, immediate jeopardy findings, or license actions were listed in the available reports. Prior focused infection control surveys repeatedly cited failure to report complete COVID-19 information to the CDC’s NHSN, and multiple surveys noted issues with abuse policies and accident hazards. The facility’s record shows ongoing challenges with compliance in several areas, though recent corrections indicate some progress in addressing cited deficiencies.

Deficiencies (last 3 years)

Deficiencies (over 3 years) 24.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

269% worse than Oregon average
Oregon average: 6.7 deficiencies/year

Deficiencies per year

32 24 16 8 0
2023
2024
2025

Inspection Report

Complaint Investigation
Capacity: 84 Deficiencies: 4 Date: Aug 13, 2025

Visit Reason
Complaint and re-licensure survey with 4 citations including issues with personal privacy/confidentiality of records and administrative rules. All deficiencies were corrected by the second revisit.

Findings
Complaint and re-licensure survey with 4 citations including issues with personal privacy/confidentiality of records and administrative rules. All deficiencies were corrected by the second revisit.

Deficiencies (4)
F0000 - INITIAL COMMENTS
F0583 - Personal Privacy/Confidentiality of Records
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Complaint Investigation
Capacity: 84 Deficiencies: 29 Date: Mar 28, 2025

Visit Reason
Complaint, licensure complaint, re-licensure, recertification, and state licensure survey with 35 citations. Deficiencies included issues with informed consent for psychotropic medications, privacy, environment, abuse policies, transfer/discharge notices, comprehensive care plans, medication management, staffing, infection control, and facility assessment. Many deficiencies were corrected by the first revisit, but several remained not corrected at the second revisit.

Findings
Complaint, licensure complaint, re-licensure, recertification, and state licensure survey with 35 citations. Deficiencies included issues with informed consent for psychotropic medications, privacy, environment, abuse policies, transfer/discharge notices, comprehensive care plans, medication management, staffing, infection control, and facility assessment. Many deficiencies were corrected by the first revisit, but several remained not corrected at the second revisit.

Deficiencies (29)
F0000 - INITIAL COMMENTS
F0552 - Right to be Informed/Make Treatment Decisions
F0583 - Personal Privacy/Confidentiality of Records
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0607 - Develop/Implement Abuse/Neglect Policies
F0623 - Notice Requirements Before Transfer/Discharge
F0656 - Develop/Implement Comprehensive Care Plan
F0658 - Services Provided Meet Professional Standards
F0684 - Quality of Care
F0689 - Free of Accident Hazards/Supervision/Devices
F0725 - Sufficient Nursing Staff
F0727 - RN 8 Hrs/7 days/Wk, Full Time DON
F0730 - Nurse Aide Peform Review-12 hr/yr In-Service
F0732 - Posted Nurse Staffing Information
F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records
F0758 - Free from Unnec Psychotropic Meds/PRN Use
F0761 - Label/Store Drugs and Biologicals
F0776 - Radiology/Other Diagnostic Services
F0777 - Radiology/Diag Srvcs Ordered/Notify Results
F0838 - Facility Assessment
F0865 - QAPI Prgm/Plan, Disclosure/Good Faith Attmpt
F0880 - Infection Prevention & Control
F0882 - Infection Preventionist Qualifications/Role
F0883 - Influenza and Pneumococcal Immunizations
F0887 - COVID-19 Immunization
M0000 - Initial Comments
M0183 - Nursing Services: Minimum CNA Staffing
M0185 - Bariatric Criteria and Services
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Capacity: 84 Deficiencies: 1 Date: Mar 27, 2025

Visit Reason
Federal Monitoring Survey with 1 citation (F0000 - INITIAL COMMENTS) not corrected at first visit.

Findings
Federal Monitoring Survey with 1 citation (F0000 - INITIAL COMMENTS) not corrected at first visit.

Deficiencies (1)
F0000 - INITIAL COMMENTS

Inspection Report

Complaint Investigation
Capacity: 84 Deficiencies: 6 Date: Jan 7, 2025

Visit Reason
Complaint, licensure complaint, and state licensure survey with 6 citations including issues with room change notification, abuse and neglect, accident hazards, and administrative rules. Several deficiencies were not corrected at second visit.

Findings
Complaint, licensure complaint, and state licensure survey with 6 citations including issues with room change notification, abuse and neglect, accident hazards, and administrative rules. Several deficiencies were not corrected at second visit.

Deficiencies (6)
F0000 - INITIAL COMMENTS
F0559 - Choose/Be Notified of Room/Roommate Change
F0600 - Free from Abuse and Neglect
F0689 - Free of Accident Hazards/Supervision/Devices
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Complaint Investigation
Capacity: 84 Deficiencies: 4 Date: Sep 19, 2024

Visit Reason
Complaint, licensure complaint, and state licensure survey with 4 citations including abuse and neglect issues. Some deficiencies corrected at first revisit but not corrected at second revisit.

Findings
Complaint, licensure complaint, and state licensure survey with 4 citations including abuse and neglect issues. Some deficiencies corrected at first revisit but not corrected at second revisit.

Deficiencies (4)
F0000 - INITIAL COMMENTS
F0600 - Free from Abuse and Neglect
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES

Inspection Report

Complaint Investigation
Capacity: 84 Deficiencies: 2 Date: Mar 15, 2024

Visit Reason
Complaint, licensure complaint, and state licensure survey with 2 citations (F0000 and M0000 - Initial Comments) not corrected at first visit.

Findings
Complaint, licensure complaint, and state licensure survey with 2 citations (F0000 and M0000 - Initial Comments) not corrected at first visit.

Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments

Inspection Report

Capacity: 84 Deficiencies: 1 Date: Feb 12, 2024

Visit Reason
Focused Infection Control survey with 1 citation for failure to report complete COVID-19 information to CDC's NHSN. Deficiency not corrected at first visit.

Findings
Focused Infection Control survey with 1 citation for failure to report complete COVID-19 information to CDC's NHSN. Deficiency not corrected at first visit.

Deficiencies (1)
F0884 - Reporting - National Health Safety Network

Inspection Report

Capacity: 84 Deficiencies: 1 Date: Jan 22, 2024

Visit Reason
Focused Infection Control survey with 1 citation for failure to report complete COVID-19 information to CDC's NHSN. Deficiency not corrected at first visit.

Findings
Focused Infection Control survey with 1 citation for failure to report complete COVID-19 information to CDC's NHSN. Deficiency not corrected at first visit.

Deficiencies (1)
F0884 - Reporting - National Health Safety Network

Inspection Report

Complaint Investigation
Capacity: 84 Deficiencies: 25 Date: Dec 4, 2023

Visit Reason
Complaint, licensure complaint, re-licensure, recertification, and state licensure survey with 26 citations covering a wide range of deficiencies including resident rights, abuse, staffing, medication management, environment, infection control, and policies. Some deficiencies were corrected at revisit, others remained uncorrected.

Findings
Complaint, licensure complaint, re-licensure, recertification, and state licensure survey with 26 citations covering a wide range of deficiencies including resident rights, abuse, staffing, medication management, environment, infection control, and policies. Some deficiencies were corrected at revisit, others remained uncorrected.

Deficiencies (25)
F0000 - INITIAL COMMENTS
F0565 - Resident/Family Group and Response
F0582 - Medicaid/Medicare Coverage/Liability Notice
F0584 - Safe/Clean/Comfortable/Homelike Environment
F0600 - Free from Abuse and Neglect
F0609 - Reporting of Alleged Violations
F0684 - Quality of Care
F0689 - Free of Accident Hazards/Supervision/Devices
F0693 - Tube Feeding Mgmt/Restore Eating Skills
F0695 - Respiratory/Tracheostomy Care and Suctioning
F0725 - Sufficient Nursing Staff
F0732 - Posted Nurse Staffing Information
F0755 - Pharmacy Srvcs/Procedures/Pharmacist/Records
F0756 - Drug Regimen Review, Report Irregular, Act On
F0757 - Drug Regimen is Free from Unnecessary Drugs
F0759 - Free of Medication Error Rts 5 Prcnt or More
F0761 - Label/Store Drugs and Biologicals
F0770 - Laboratory Services
F0806 - Resident Allergies, Preferences, Substitutes
F0812 - Food Procurement,Store/Prepare/Serve-Sanitary
F0842 - Resident Records - Identifiable Information
M0000 - Initial Comments
M0183 - Nursing Services: Minimum CNA Staffing
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Z0000 - General Comments

Inspection Report

Capacity: 84 Deficiencies: 1 Date: Oct 10, 2023

Visit Reason
Focused Infection Control survey with 1 citation for failure to report complete COVID-19 information to CDC's NHSN. Deficiency not corrected at first visit.

Findings
Focused Infection Control survey with 1 citation for failure to report complete COVID-19 information to CDC's NHSN. Deficiency not corrected at first visit.

Deficiencies (1)
F0884 - Reporting - National Health Safety Network

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