Chehalem Post Acute
1900 E. Fulton Street, Newberg, OR 97132 · Yamhill County · (503) 538-2108
84 certified beds, about 77 residents a day · For profit - Corporation · Medicare and Medicaid since 1989
Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
3 of 5
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385199 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on March 28, 2025, inspectors cited 24 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 58 health citations since October 2022, 3 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 2 fines totaling $54,581 in the last three years; the largest was $39,793, and the latest is dated January 7, 2025.
Nurses and nurse aides worked 4.63 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.31 of those hours.
70.9% of nursing staff left within the year CMS measured (Oregon average 47.4%).
CMS links it to PACS Group, an affiliated group of 275 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
710/22
2012/23
109/24
301/25
2403/25
108/25
201/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 58 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
32D
16E
5F
Potential for minimal harm
0A
1B
1C
January 15, 2026Complaint inspection · 2 citations
- D Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide written advance notice to a resident/responsible party prior to room changes for 2 of 3 sampled residents (#s 11 and 12) reviewed for resident rights. This placed residents at risk for potential adjustment difficulties and delayed family communication related to changes in room location.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure dependent residents received showers for 2 of 3 sampled residents (#12 and 16) reviewed for ADLs. This placed residents at risk for a lack of personal hygiene and loss of dignity.
August 13, 2025Complaint inspection · 1 citation
- E Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident records were kept private for 1 of 1 sampled facility record system reviewed for privacy. This placed residents at risk for lack of privacy.
March 28, 2025Standard inspection, Complaint inspection · 24 citations
- F Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a registered nurse was available for at least eight consecutive hours for 6 of 79 days reviewed for RN coverage. This placed residents at risk for delayed nursing assessments.
- F Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on interview and record review, it was determined the facility failed to conduct and complete a comprehensive facility wide assessment to care for its residents competently during day to day operations. This placed residents at risk for unidentified and unmet needs.
- F Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program that implemented action plans to correct identified quality deficiencies. This failed practice placed all residents at risk for not receiving the care and services for optimal resident outcomes.
- F Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Inspectors wroteBased 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.
- E Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure privacy was provided during care and resident records were kept private for 2 of 2 sampled residents (#s 37 and 45) and 1 of 1 sampled facility record system reviewed for privacy. This placed residents at risk for lack of privacy.
- E Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review it was determined the facility failed to implement their policies and procedures for screening potential employees to prevent abuse for 3 of 3 sampled new employees (#s 8, 9 and 10) reviewed for employee screening. This placed residents at risk for abuse.
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 1 resident council and 4 of 4 sampled residents (#s 13, 16, 37 and 38) reviewed for concerns with staffing. This placed residents at risk for delayed and unmet care needs.
- E Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure performance reviews were completed at least once every 12 months for 3 of 3 CNAs (#s 29, 30 and 31) reviewed for staffing. This placed residents at risk for a lack of care by competent staff.
- E Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain and administer medication to residents timely to ensure the provision of routine medications for 10 of 17 sampled residents (#s 15, 22, 33, 34, 35, 44, 53, 62, 166, 167) reviewed for medications. This placed residents at risk for adverse medication side effects.
- E Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure medications and biologicals were secured for 1 of 3 medication carts and 1 of 3 treatment carts reviewed for safe medication storage. This placed residents at risk for unauthorized access to medications.
- E Provide and implement an infection prevention and control program.
Inspectors wrote1. Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene was completed during meals for 2 of 3 halls reviewed for dining. This placed residents at risk for cross contamination.
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to inform residents and/or resident's responsible party of the risks and benefits, and to ensure consent was obtained, for the use of psychotropic medications for 2 of 5 sampled residents (#s 22 and 30) reviewed for unnecessary medications. This placed residents at risk for lack of informed consent of psychotropic medications.
- D 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.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure resident rooms were clean and in good repair for 2 of 3 sampled residents (#s 37 and 54) reviewed for environment. This placed residents at risk for lack of a homelike environment.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review it was determined the facility failed to develop a person-centered comprehensive care plan related to bowel care for 1 of 1 sampled resident (#16) reviewed for constipation. This placed residents at risk for lack of personal preferences being honored.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure Staff 32 (LPN) adhered to professional standards for medication management. This placed residents at risk for adverse side effects of medication.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to clarify insulin orders with the physician, monitor and provide bowel medications as ordered and failed to identify medication discrepancies for 3 of 7 sampled residents (#s 22, 39 and 114) reviewed for medications. This placed residents at risk for not receiving medications.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assess a resident's fall for 1 of 2 sampled residents (#53) reviewed for falls. This placed residents at increased risk for injury from falls.
- D 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from unnecessary psychotropic medication for 1 of 6 sampled residents (#53) reviewed for unnecessary medication. This placed residents at risk for adverse side effects.
- D Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide timely diagnostic services for 1 of 2 sampled residents (#164) reviewed for lab services. This placed residents at risk for undiagnosed care needs.
- D Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Inspectors wroteBased on interview and record review it was determined the facility failed to notify the ordering physician of the results of a critical lab value for 1 of 2 sampled residents (#53) reviewed for accidents. This placed residents at risk for delayed treatment.
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on interview and record review it was determined the facility failed to administer a pneumococcal vaccine for 1 of 5 sampled residents (#24) reviewed for immunizations. This placed residents at risk for contracting communicable illnesses.
- D 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.
Inspectors wroteBased 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.
- C Post nurse staffing information every day.
Inspectors wroteBased on interview and record review it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for required staff postings. This placed residents and the public at risk for incomplete and inaccurate staffing information.
- B Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure transfer notices with appeal rights were provided in writing to residents and their representatives for 1 of 1 sampled resident (#31) reviewed for hospitalization. This placed residents at risk for lack of information regarding their options and rights.
January 7, 2025Complaint inspection · 3 citations
- G Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to protect the resident's right to be free from physical abuse by another resident for 1 of 3 sampled residents (#14) reviewed for abuse. This failure resulted in Resident 13 deliberately kicking Resident 14's walker which resulted in Resident 14 losing her/his balance. Resident 14 fell to the floor and received a head laceration with contusion (bruise) and a fractured hip which required surgery. This placed residents at risk for physical harm.
- D Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide advance written notice to a resident or their responsible party prior to a room change for 1 of 4 sampled residents (#10) reviewed for resident rights. This placed residents at risk for potential adjustment difficulties related to room changes.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow care plan interventions when transferring for 1 of 4 sampled residents (#7) reviewed for accidents. This failure put residents at risk for injury.
September 19, 2024Complaint inspection · 1 citation
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review it was determined the facility failed to protect the resident's right to be free from verbal and physical abuse by a resident for 1 of 7 sampled residents (#3) reviewed for abuse. This placed residents at risk for isolation.
December 4, 2023Standard inspection, Complaint inspection · 20 citations
- J Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure supervision and safety interventions were in place to prevent smoking related accidents, and failed to ensure smoking materials were stored in a safe manner for 1 of 2 sampled residents (#27) reviewed for smoking safety. This placed the resident at increased risk for personal injury from fires. This failure, determined to be an Immediate Jeopardy situation, placed Resident 27 at increased risk for personal injury from fire.
- E Honor the resident's right to organize and participate in resident/family groups in the facility.
Inspectors wroteBased on interview and record review it was determined the facility failed to promptly respond to grievances and recommendations from the resident council for 2 of 2 months reviewed. This placed residents at risk for unresolved quality of life and care issues.
- E 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.
Inspectors wrote3. On 11/27/23 at 12:27 PM Resident 37's room was observed to have a loose doorknob plate and a plastic kick plate on the front left edge of the door that was jagged, sharp and peeling away from the door. On 11/27/23 at 12:27 PM Witness 5 (Family Member) stated she was concerned about the loose doorknob plate and the plastic kick plate on the front left edge of the door that was jagged, sharp and peeling away from the door. She stated she complained to staff about the issues several times. On 11/28/23 at 12:26 PM Staff 15 (Maintenance Director) observed Resident 27's room and acknowledged the loose doorknob plate and plastic kick plate on the front left edge of the door was jagged, sharp and peeling away from the door. 4. On 12/4/23 at 12:00 PM the carpet in the hallways was observed to have dark brown or black spots throughout the facility. [...]
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 1 of 4 halls reviewed for staffing. This placed residents at risk for delayed and unmet care needs.
- E Post nurse staffing information every day.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Reports (DCSDR) were correct and complete for 15 of 27 days reviewed for staff postings. This placed residents and the public at risk for incorrect staffing information.
- E Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals for 2 of 2 treatment carts and 1 of 1 medication room, and failed to ensure medication carts were properly secured during a random observation. This placed residents at risk for reduced efficacy of medication and unauthorized access to medications.
- E Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on interview and record review it was determined the facility failed to offer residents a menu to accommodate their preferences for 2 of 2 sampled residents (#s 8 and 10) reviewed for food choices. This placed residents at risk for not having food preferences honored and weight loss.
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview it was determined the facility failed to store and handle food in a sanitary manner for 1 of 1 facility kitchen reviewed for sanitary food storage and handling. This placed residents at risk for food-borne illness and contamination.
- D Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents recieved informed Advance Beneficiary Notification (ABN) information for 1 of 3 sampled residents (#44) reviewed for discharge. This placed residents at risk for financial hardship.
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review it was determined the facility failed to protect the resident's right to be free from verbal abuse by a resident for 2 of 9 sampled residents (#s 14 and 35) reviewed for abuse. This placed residents at risk for abuse.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review it was determined the facility failed to report the results of an abuse investigation to the State Survey Agency within five business day to the State Agency for 2 of 9 sampled residents (#s 21 and 201) for abuse. This placed residents at risk for continued abuse.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 1 sampled resident (# 8) reviewed for insulin. This placed residents at risk for adverse side effects of medication.
- D Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received appropriate care and services for a feeding tube for 1 of 1 sampled resident (#42) reviewed for feeding tubes. This placed residents at risk for complications related to the use of a feeding tube including infection.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure a CPAP (Continuous Positive Airway Pressure, assists to keep breathing airways open while sleeping) mask was in good repair for 1 of 1 sampled resident (#14) reviewed for respiratory care. This placed residents at risk for lack of respiratory care.
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident narcotic drug records were accurate for 1 of 1 sampled resident (#28) reviewed for narcotic medication. This placed residents at risk for inaccurate clinical records related to narcotics and drug diversion.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure pharmacist recommendations were considered for 2 of 5 sampled residents (#s 4 and 12) reviewed for medication. This placed residents at risk for unnecessary medication.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident's use of Dilantin (seizure medication) was monitored for toxicity levels for 1 of 5 sampled residents (#4) reviewed for unnecessary medications. This placed residents at risk for adverse medication side effects and toxicity.
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to maintain a medication error rate of less than 5 percent. There were three errors in 25 opportunities resulting in a 12 percent error rate for 1 of 2 sampled residents (#12) reviewed for medication administration. This placed residents at risk for adverse medication side effects.
- D Provide timely, quality laboratory services/tests to meet the needs of residents.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete laboratory monitoring as ordered for 1 of 1 sampled resident (#37) reviewed for lab orders. This placed residents at risk for worsening conditions.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure records were accurate and complete for 1 of 1 sampled resident (#37) reviewed for lab orders. This placed residents at risk for inaccurate medical records.
October 21, 2022Standard inspection · 7 citations
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow care plan interventions, failed to assess for care plan effectiveness, failed to identify and implement new fall interventions and failed to provide adequate supervision needed to prevent falls for 1 of 1 sampled resident (#12) reviewed for falls. This failure resulted in the resident having 17 falls in nine months, one with serious injury which required emergency medical services and treatment at the hospital.
- F Provide and implement an infection prevention and control program.
Inspectors wrote1. 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 potentially hazardous microorganisms. This placed residents at risk for water borne infections.
- E 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.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure the building was maintained in good repair for 12 of 40 resident rooms (#s 17, 20, 29, 30, 35, 36, 39, 40, 41, 42, 43 and 44) reviewed for environment. This placed residents at risk for an unhomelike environment.
- D Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 1 of 1 sampled residents (# 29) reviewed for self-administration of medications. This placed residents at risk for adverse medication side effects.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders related to insulin for 1 of 5 sampled residents (#29) reviewed for unnecessary medications. This placed residents at risk for low blood sugar.
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review it was determined the facility failed to accurately and consistently assess a pressure ulcer for 1 of 2 sampled residents (#11) reviewed for pressure ulcers. This placed residents at risk for worsening or delayed healing of pressure ulcers.
- D Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure resident care equipment was maintained in safe operating condition for 2 of 6 residents (#s 13 and 29) reviewed for environment. This placed residents at risk for accidents.
Fire safety inspections
37 fire safety citations on file: 21 on March 28, 2025, 13 on December 4, 2023, 3 on October 21, 2022.
Every fire safety citation37 citations
- F Conduct risk assessment and an All-Hazards approach.
- F Develop Emergency Preparedness policies and procedures.
- F Establish policies and procedures including evacuation.
- F Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
- F Keep aisles, corridors, and exits free of obstruction in case of emergency.
- F Install emergency lighting that can last at least 1 1/2 hours.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Properly select, install, inspect, or maintain portable fire extinguishes.
- F Meet other general requirements that are deficient.
- F Have simulated fire drills held at unexpected times.
- F Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- F To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency.
- F Have power receptacles that are properly grounded.
- F Have generator or other power source capable of supplying service within 10 seconds.
- D Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- D Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- D Provide properly protected cooking facilities.
- D Ensure proper usage of power strips and extension cords.
- D Have proper medical gas storage and administration areas.
- F Address subsistence needs for staff and patients.
- F Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have simulated fire drills held at unexpected times.
- F Ensure proper usage of power strips and extension cords.
- E To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- D Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- D Provide properly protected cooking facilities.
- D Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- D Meet other general requirements.
- F Conduct testing and exercise requirements.
- E Have properly located and lighted "Exit" signs.
- D To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| January 7, 2025 | Fine | $14,788 |
| December 4, 2023 | Fine | $39,793 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.63 | 5.03 | 3.86 |
| Registered nurses | 0.31 | 0.72 | 0.69 |
| All nursing staff on weekends | 4.23 | 4.51 | 3.42 |
| Nurse aides | 3.38 | ||
| Licensed practical nurses | 0.94 | ||
| Nursing staff turnover (share who left in a year) | 70.9% | 47.4% | 45.8% |
| Registered nurse turnover | 69.2% | 51.6% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.26 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.80 on weekdays and 4.23 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 31.6% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.17 in April to June 2025 to 4.63 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.63 | 0.31 | 4.80 | 4.23 | 31.6% | 0 of 90 | 77 |
| Oct to Dec 2025 | 4.60 | 0.25 | 4.77 | 4.16 | 36.8% | 0 of 92 | 74 |
| Jul to Sep 2025 | 4.92 | 0.46 | 5.11 | 4.44 | 25.1% | 0 of 92 | 65 |
| Apr to Jun 2025 | 5.17 | 0.47 | 5.32 | 4.80 | 30.2% | 1 of 91 | 59 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 11.2 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 4.7 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.4 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.3 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 19.8 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.6 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 16.1 | 13.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 22.6 | 21.4 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.3 | 16.1 | 12.0 |
Owners and operators
Legal business name: CHEHALEM SNF HEALTHCARE LLC. CMS links this home to PACS Group, a group of 275 nursing homes averaging 2.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Truist Bank | 5% or greater security interest | Organization | 09/01/2024 | |
| Apt, Frederick | Operational/managerial control | Individual | 05/10/2024 | |
| Jergensen, Joshua | Operational/managerial control | Individual | 05/10/2024 | |
| Mitchell, John | Operational/managerial control | Individual | 05/10/2024 | |
| Morris, Christopher | Operational/managerial control | Individual | 09/01/2024 | |
| Nyssen, Sara | Operational/managerial control | Individual | 09/01/2024 | |
| Park, Trevor | Operational/managerial control | Individual | 10/09/2024 | |
| Newberg 1900 Realty LLC | Adp of the SNF | Organization | 09/01/2024 | |
| Providence Administrative Consulting Services Inc | Adp of the SNF | Organization | 09/01/2024 | |
| Morris, Christopher | Adp of the SNF | Individual | 05/30/2025 | |
| Park, Trevor | Adp of the SNF | Individual | 05/30/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 12 problems in this area, most recently on January 15, 2026: "Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 11 problems in this area, most recently on January 15, 2026: "Provide care and assistance to perform activities of daily living for any resident who is unable."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 8 problems in this area, most recently on March 28, 2025: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist."
- How many nurses and aides work each shift, nights and weekends included?Inspectors cited 6 problems in this area, most recently on March 28, 2025: "Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 4.23 hours per resident per day, below the Oregon average of 4.51.
- How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.
Other nursing homes nearby
- Marquis Newberg Newberg, 1 mi · 5 of 5 stars · 12 citations
- Marquis Wilsonville Post Acute Rehab Wilsonville, 9.3 mi · 5 of 5 stars · 10 citations
- Avamere Rehabilitation of King City Tigard, 10.1 mi · 4 of 5 stars · 33 citations
- Marquis Tualatin Post Acute Rehab Tualatin, 10.4 mi · 5 of 5 stars · 11 citations
- Tigard Rehabilitation and Care Tigard, 11.3 mi · 1 of 5 stars · 44 citations
- French Prairie Nursing & Rehabilitation Center Woodburn, 11.6 mi · 1 of 5 stars · 62 citations
- Life Care Center of McMinnville McMinnville, 12.4 mi · 4 of 5 stars · 32 citations
- Evan Terrace Post Acute McMinnville, 13 mi · 1 of 5 stars · 60 citations
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is Chehalem Post Acute's Medicare star rating?
- CMS rates Chehalem Post Acute 1 out of 5 stars overall, with 1 for health inspections, 3 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Chehalem Post Acute get at its last inspection?
- 24 health deficiencies at the standard inspection on March 28, 2025. The Oregon average is 9.2.
- Has Chehalem Post Acute been fined?
- Yes. CMS lists 2 fines totaling $54,581 in the last three years.
- Does Chehalem Post Acute accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Chehalem Post Acute?
- CMS lists 11 owners and managers, and links the home to PACS Group. Legal business name: CHEHALEM SNF HEALTHCARE LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.