Chehalem Health & Rehab: 10-Month Infection Gap, OR
NEWBERG, OR - Chehalem Health & Rehab operated without a qualified infection preventionist for 298 days in 2024, according to a March 28, 2025 inspection by federal regulators that also identified multiple infection control violations placing residents at risk.
Critical Staffing Gap in Infection Control
The most serious violation discovered at Chehalem Health & Rehab was the facility's failure to maintain a qualified infection preventionist for nearly ten months. The nursing home operated without this critical position from January 5, 2024 through October 29, 2024 - a 298-day period during which residents faced heightened risks of healthcare-associated infections.
Federal regulations require nursing homes to designate a qualified infection preventionist responsible for implementing and maintaining comprehensive infection prevention and control programs. This position serves as the facility's frontline defense against the spread of dangerous pathogens, including multidrug-resistant organisms and respiratory illnesses that can be particularly devastating in elderly populations.
According to the inspection report, a registered nurse was asked to serve as the infection prevention nurse in 2024 but "did not receive education or training and was terminated from the facility on October 28, 2024." The facility's Director of Nursing acknowledged the significant gap in coverage during the survey.
The absence of a trained infection preventionist creates cascading risks throughout a nursing facility. Without proper oversight, basic infection control protocols may be inconsistently implemented, staff may not receive adequate training on best practices, and emerging infection threats may go unrecognized until outbreaks occur. Elderly residents with compromised immune systems are particularly vulnerable to these lapses.
Improper Personal Protective Equipment Disposal
Inspectors identified dangerous violations in the handling of contaminated personal protective equipment (PPE) for residents requiring enhanced barrier precautions. Two residents with indwelling catheters and colostomy devices were placed on these special precautions to prevent the spread of multidrug-resistant organisms, but staff consistently violated CDC guidelines for PPE disposal.
The Centers for Disease Control and Prevention specifically requires that contaminated PPE be disposed of in trash bins located inside patient rooms, near the exit, before staff leave the room. This protocol prevents contaminated materials from being carried into hallways where they can expose other residents and staff.
However, at Chehalem Health & Rehab, multiple staff members told inspectors they disposed of used PPE gowns in garbage bins located in the hallway outside residents' rooms. One certified nursing assistant stated that disposing PPE outside the room "was okay since the resident did not have covid," demonstrating a fundamental misunderstanding of infection control principles.
Enhanced barrier precautions are implemented when residents harbor organisms that pose transmission risks beyond standard pathogens. Indwelling catheters and colostomy devices create particularly high-risk situations because they bypass the body's natural barriers against infection. Improper PPE disposal in these situations can facilitate the spread of antibiotic-resistant bacteria throughout the facility.
The facility's own Infection Preventionist observed the violations during the survey and "acknowledged staff were to place used PPE in the garbage bin located inside the resident's room," confirming that staff were not following established protocols.
Hand Hygiene Failures During Meal Service
Inspectors documented multiple instances of staff failing to perform proper hand hygiene during meal distribution, one of the most critical times for preventing cross-contamination between residents. During an 18-minute observation period, a certified nursing assistant repeatedly violated the facility's own hand hygiene policy while delivering meals to residents.
The violations included retrieving meal trays without sanitizing hands after exiting residents' rooms, handling contaminated coffee cups and then preparing fresh coffee for another resident without hand hygiene, and moving meal carts between halls without proper sanitization. When questioned, the staff member "acknowledged she did not complete hand hygiene between resident rooms" despite knowing the requirements.
Hand hygiene is considered the single most important intervention for preventing healthcare-associated infections. During meal service, staff move rapidly between residents who may have varying levels of immune compromise and different infectious risks. Failure to maintain proper hand hygiene during this process creates an ideal environment for pathogen transmission.
The facility's hand hygiene policy specifically requires sanitization "before and after direct resident contact," "before and after assisting a resident with meals," and "after handling soiled equipment or utensils." These requirements exist because meals represent a high-risk activity where contaminated hands can directly introduce pathogens into residents' digestive systems.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
CHEHALEM POST ACUTE in NEWBERG, OR was cited for violations during a health inspection on March 28, 2025.
The absence of a trained infection preventionist creates cascading risks throughout a nursing facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.