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.
Missing Water Management Program
Perhaps most concerning from a systemic perspective, Chehalem Health & Rehab had no water management program in place to prevent the growth of waterborne pathogens like Legionella bacteria. The facility's Administrator stated he "was not aware of the requirement for the facility to have a water management program" and confirmed no prevention plan existed.
Federal guidelines require healthcare facilities to develop comprehensive water management programs that identify and control areas where dangerous bacteria can proliferate in building water systems. Legionella bacteria, which causes Legionnaires' disease, thrives in warm water environments commonly found in healthcare facilities' plumbing systems, cooling towers, and hot water tanks.
Elderly residents are at particularly high risk for severe Legionnaires' disease, which can cause pneumonia with mortality rates exceeding 25% in vulnerable populations. The bacteria spreads through aerosolized water droplets from sources like showers, faucets, and cooling systems.
The facility had a Legionnaire's Disease Policy that referenced conducting annual risk assessments and developing water management programs, but the March 2025 Facility Assessment contained no evidence these activities had been completed. The Maintenance Director confirmed that no water management program was in place.
Additional Issues Identified
The inspection revealed several other infection control deficiencies beyond the major violations. A resident who consented to receive a pneumococcal vaccination in late 2024 never received the immunization despite verbal consent, leaving them vulnerable to serious pneumococcal infections that can cause pneumonia, meningitis, and bloodstream infections.
Additionally, facility staff failed to obtain proper consent from a healthcare decision-maker for a COVID-19 vaccination for a cognitively impaired resident. Federal regulations require facilities to ensure that residents or their authorized representatives provide informed consent after receiving education about recommended vaccines.
These vaccination failures represent missed opportunities to protect vulnerable residents from serious respiratory illnesses. Pneumococcal disease and COVID-19 can be particularly severe in elderly populations, making vaccination compliance a critical component of infection prevention strategies.
The inspection findings highlight the interconnected nature of infection control in nursing homes, where lapses in one area can compound risks throughout the facility. The absence of a qualified infection preventionist likely contributed to the multiple protocol violations documented during the survey, emphasizing the importance of maintaining properly trained infection control leadership in long-term care settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chehalem Health & Rehab from 2025-03-28 including all violations, facility responses, and corrective action plans.
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