Chehalem Health & Rehab

F-F882.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 33 385199 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385199 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chehalem Post Acute 1900 E. Fulton Street Newberg, OR 97132

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47005 potential for actual harm 1. Based on observation, interview and record review it was determined the facility failed to ensure proper Residents Affected - Some hand hygiene was completed during meals for 2 of 3 halls reviewed for dining. This placed residents at risk for cross contamination. Findings include:

The 8/1/24 Hand Hygiene Policy and Procedure indicates effective hand hygiene reduces the incidence of healthcare-associated infections. All members of the healthcare team will comply with current Centers of Disease Control and Prevention hand hygiene guidelines.

The procedure included:

3. Hand hygiene is the primary means of preventing the transmission of infection and should be performed as soon as possible after hands become contaminated and frequently during the working day. The following is list of some situations that require hand hygiene:

c. Before and after direct resident contact;

f. Before and after eating or handling food;

g. Before and after assisting a resident with meals;

s. After handling soiled equipment or utensils;

On 3/19/25 between the hours of 12:11 PM and 12:29 PM, during the lunch meal in the west and east hall

the following observations were made:

-12:15 PM Staff 3 (CNA) was observed retrieving a meal tray from a delivery cart located in the west hall and entered room [ROOM NUMBER]. Staff 3 retrieved another tray from the delivery cart and entered room [ROOM NUMBER] without sanitizing her hands after exiting the resident's room and before retrieving another meal tray.

-12:19 PM Staff 3 was observed delivering a meal tray to room [ROOM NUMBER]. Staff 3 retrieved used coffee cups from the resident's bedside table and threw away the cups. Staff 3 made coffee for room [ROOM NUMBER] and did not sanitize her hands after retrieving the dirty cups and making coffee for another resident.

-12:25 PM Staff 3 was observed pushing the meal delivery cart from the west hall to the east hall. Staff 3 retrieved a meal tray and delivered the tray to room [ROOM NUMBER]. Staff 3 retrieved another tray from

the delivery cart and entered room [ROOM NUMBER] without sanitizing hands after moving the cart or

before retrieving or delivering the meal tray.

On 3/19/25 at 12:29 PM Staff 3 stated she was supposed to sanitize her hands before touching each meal tray and before and after exiting a resident rooms. Staff 3 acknowledged she did not complete hand hygiene between resident rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 33 385199 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385199 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chehalem Post Acute 1900 E. Fulton Street Newberg, OR 97132

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 3/19/25 at 1:02 PM Staff 2 (DNS) stated staff were to complete hand hygiene each time they went in and out of a resident's room and passed each meal tray. Level of Harm - Minimal harm or potential for actual harm 48830

Residents Affected - Some 2. Based on interview and record review it was determined the facility failed to develop and implement a water management program and conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens and illness. This placed all residents at risk for exposure to water-borne pathogens. Findings include:

The Centers for Medicare and Medicaid Services Center for Clinical Standards and Quality/Safety and Oversight Group letter 17-30, revised on 7/6/18, on Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease stated, Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water.

A review of the facility 9/2024 Legionnaire's Disease Policy revealed the following:

-The center completes Legionella Risk Assessment to determine risk for Legionella outbreaks annually.

-The center develops and reviews their Water Management Program annually.

-During routine inspections of control areas, the center mitigates areas of concern via developed center specific plans.

A review of the 3/19/25 Facility Assessment revealed no evidence a risk assessment was completed to prevent the growth and spread of water-borne pathogens in the facility's main water system.

On 3/28/25 at 8:29 AM Staff 37 (Maintenance Director) stated the facility did not have a water management program in place.

On 3/28/25 at 12:11 PM Staff 1 (Administrator) stated he was not aware of the requirement for the facility to have a water management program. Staff 1 confirmed the facility did not have a prevention plan or system in place for the prevention of a spread of water-borne pathogens, such as Legionella, in the facility's main water system.

3. Based on observation, interview and record review it was determined the facility failed to follow CDC (Centers for Disease Control and Prevention) Infection Control Guidelines related to Enhanced Barrier Precautions for 2 of 10 sampled residents (#s 2 and 10) reviewed for infection control. This placed residents at risk for exposure and cross contamination. Findings include:

The CDC's 4/2/24 implementation of Nursing Home PPE guidelines for prevention of spread of Multidrug-Resistant Organisms (MDROs) included a trash bin was to be placed inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 33 385199 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385199 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chehalem Post Acute 1900 E. Fulton Street Newberg, OR 97132

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 a. Resident 10 was admitted to the facility in 9/2024 with diagnoses including Multiple Sclerosis and use of a colostomy. Level of Harm - Minimal harm or potential for actual harm A 3/14/25 care plan indicated Resident 10 was on enhanced barrier precautions related to an indwelling catheter and a colostomy. Staff were to follow the guidelines posted next to the door. Residents Affected - Some

On 3/25/25 at 9:25 AM Resident 10's room was observed to have signage posted on the resident's door that stated the resident was on enhanced barrier precautions. A plastic storage bin with PPE in the drawers was observed outside of the resident's room along with a garbage bin located next to it which contained a used PPE gown.

On 3/25/25 at 9:30 AM Staff 4 (CNA) stated used PPE was either thrown away in the garbage bin inside Resident 10's bathroom or the garbage bin right outside of the room in the hallway.

On 3/25/25 at 9:32 AM Staff 5 (CNA) stated Resident 10 was on enhanced barrier precautions due to a catheter and a colostomy. Staff 5 stated after direct care was provided for Resident 10, used PPE was always placed in the garbage bin located outside of the resident's room.

On 3/25/25 at 9:37 AM Staff 6 (CNA) stated Resident 10 was on enhanced barrier precautions and when direct care was provided, PPE was to be worn. Staff 6 stated used PPE was placed in the garbage bin located outside of the resident's room and that was okay since the resident did not have covid.

b. Resident 2 was admitted to the facility in 9/2024 with diagnoses including neurogenic bladder (when nerves that control bladder function are damaged or impaired, leading to a loss of normal bladder control) and dementia.

A 3/14/25 care plan indicated Resident 2 was on enhanced barrier precautions related to an indwelling catheter. Staff were to follow the guidelines posted next to the door.

On 3/25/25 at 9:43 AM Resident 2's room was observed to have signage posted on the resident's door that stated the resident was on enhanced barrier precautions. A plastic storage bin with PPE in the drawers was observed outside of the resident's room along with a garbage bin located next to it that contained a used PPE gown.

On 3/25/25 at 9:47 AM Staff 8 (LPN) stated all used PPE was placed in the garbage bin outside of the resident's room.

On 3/25/25 at 9:54 AM Staff 7 (Infection Preventionist) observed the used PPE gowns inside the garbage bins. Staff 7 acknowledged staff were to place used PPE in the garbage bin located inside the resident's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 33 385199 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385199 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chehalem Post Acute 1900 E. Fulton Street Newberg, OR 97132

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 34702

Residents Affected - Many Based on interview and record review it was determined the facility failed to have a qualified and trained infection preventionist in place for 1 of 1 facility reviewed for infection prevention and control. This placed residents at risk for inadequate infection control. Findings include:

On 3/28/25 surveyors requested documentation to indicate the facility had an infection preventionist in place.

On 3/28/25 at 10:56 AM Staff 2 (DNS) provided documentation to indicate Staff 51 (Former Infection Preventionist) was employed until 1/5/24 and Staff 7 (Infection Preventionist) started on 10/29/24.

On 3/25/25 at 11:55 AM Staff 25 (RN) stated she worked at the facility in 2024 and was asked by Staff 2 to be the infection prevention nurse, but did not receive education or training and was terminated from the facility on 10/28/24. Staff 25 stated there was no infection preventionist working at the facility since January 2024.

On 3/28/25 at 10:56 AM Staff 2 acknowledged the facility did not have a certified infection preventionist from 1/5/24 through 10/29/24 (298 days).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 33 385199 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385199 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chehalem Post Acute 1900 E. Fulton Street Newberg, OR 97132

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or 48830 potential for actual harm Based on interview and record review it was determined the facility failed to administer a pneumococcal Residents Affected - Few vaccine for 1 of 5 sampled residents (#24) reviewed for immunizations. This placed residents at risk for contracting communicable illnesses. Findings include:

A review of the facility 9/1/2024 Influenza and Pneumococcal Immunizations policy indicated it was the policy of the center to offer the Influenza and Pneumococcal immunizations to residents in accordance with federal regulations and current CDC (Centers for Disease Control and Prevention) guidelines.

Resident 24 was admitted to the facility in 6/2024 with diagnoses including diabetes and heart failure.

A review of the 1/18/25 Quarterly MDS indicated Resident 24 was cognitively intact.

A review of Resident 24's clinical record revealed an undated pending consent for Prevnar 20 (a type of Pneumococcal vaccination).

On 3/26/25 at 1:33 PM and on 3/28/25 at 10:12 AM Staff 7 (Infection Preventionist) stated she recalled talking with Resident 24 in October or November 2024 to educate and offer a pneumococcal vaccination that

the resident was eligible for. Staff 7 stated Resident 24 provided verbal consent, however Staff 7 never followed up and Resident 24 was not administered the vaccination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 33 385199 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 385199 B. Wing 03/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Chehalem Post Acute 1900 E. Fulton Street Newberg, OR 97132

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm 48830

Residents Affected - Few Based on interview and record review it was determined the facility failed to obtain resident representative consent for a Covid-19 vaccine for 1 of 5 sampled residents (#40) reviewed for immunizations. This placed residents at risk for a lack of informed education and consent and at risk for contracting communicable illnesses. Findings include:

A review of the facility's 9/1/24 Covid-19 Vaccination policy and procedure indicated residents were offered recommended Covid-19 vaccinations upon admission and as eligible per CDC (Centers for Disease Control and Prevention) recommendations. Consent for approved vaccines were obtained prior to or at the time of vaccination.

Resident 40 was admitted to the facility in 4/2023 with diagnoses including dementia and adult failure to thrive.

A review of the 8/5/24 Quarterly MDS indicated Resident 40's cognition was severely impaired.

A review of Resident 40's clinical record revealed Witness 5 (Family Member) was Resident 40's Power of Attorney and Healthcare Decision maker.

A review of Resident 40's immunization list revealed on 10/16/24 the resident was educated, offered and refused a Covid-19 vaccination. There was no indication Witness 5 was contacted for education and consent.

On 3/26/25 at 1:24 PM Staff 7 (Infection Preventionist) acknowledged Resident 40's cognition was impaired, and Resident 40's resident representative was not contacted for education or consent for a Covid-19 vaccination.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 33 385199