Saint Helens Post Acute
75 Shore Drive, Saint Helens, OR 97051 · Columbia County · (503) 397-2713
92 certified beds, about 80 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1991
Special Focus Facility candidate CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
1 of 5
Staffing
4 of 5
Quality measures
5 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385222 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on April 27, 2026, inspectors cited 19 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 76 health citations since September 2023, 2 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $14,613 in the last three years; the largest was $14,613, and the latest is dated October 17, 2025.
Nurses and nurse aides worked 4.21 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.49 of those hours.
58.5% of nursing staff left within the year CMS measured (Oregon average 47.4%).
CMS links it to Kalesta Healthcare Group, an affiliated group of 19 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.
2609/23
202/24
211/24
2101/25
104/25
110/25
111/25
303/26
1904/26
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 76 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
1K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
45D
19E
9F
Potential for minimal harm
0A
0B
1C
April 27, 2026Standard inspection, Complaint inspection · 19 citations
- F Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Inspectors wroteBased on interview and record review it was determined the facility failed to transmit resident assessments in the required timeframe for 20 of 20 residents (#s 20, 26, 36, 49, 53, 55, 56, 62, 64, 66, 73, 76, 78, 83, 106, 107, 108, 109, 110 and 111) reviewed for resident assessments. This placed residents at risk for inaccurate records.
- F Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide an effective pest control program for 1 of 1 facility reviewed for environment. This placed residents at risk for exposure to household pest and increased health risks.
- F Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of annual in-service training for 5 of 5 randomly selected staff members (#s 11, 24, 27, 28 and 29) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care.
- 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, interview and record review it was determined the facility failed to provide a comfortable and homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for an unsatisfying experience and living in an unkept environment.
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to monitor and assess resident skin conditions, administer psychotropic medications and insulin timely for 3 of 5 residents (#s 49, 82 and 94) reviewed for skin conditions, pain and insulin. This placed residents at risk for worsening skin conditions, increased anxiety and complications related to uncontrolled blood sugars.
- E Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure facility staff had the appropriate competencies to work with residents with substance use disorders for 1 of 1 facility reviewed for substance use disorder training. This placed residents at risk for diminished physical, mental and psychosocial well-being.
- E Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide therapy services as ordered for 4 of 4 sampled residents (#s 8, 50, 82 and 95) reviewed for rehabilitation services. This placed residents at risk for a decline in functional abilities and diminished quality of life.
- D Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to complete an accurate assessment prior to initiating restraint use and did not conduct ongoing assessments for 1 of 1 sampled residents (#50) reviewed for restraints. This placed residents at risk for unnecessary restraint use and reduced self-mobility.
- D Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide meaningful activities for dependent residents for 1 of 1 sampled resident (#43) reviewed for activities. This placed residents at risk for lack of social interaction and isolation.
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement interventions to prevent skin breakdown for 1 of 4 sampled residents (#8) reviewed for pressure ulcers. This placed residents at risk for the development of pressure ulcers and skin breakdown.
- D Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide appropriate wheelchair positioning and head/neck support for 1 of 1 sampled resident (#50) reviewed for mobility and positioning. This placed residents at risk for decreased range of motion and pain.
- 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 ensure staff followed the care plan related to smoking safety and liquid modifications for 2 of 2 sampled residents (#s 9 and 67) reviewed for smoking and dietary modifications. This placed residents at risk for injury.
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review it was determine the facility failed to ensure residents received appropriate pain management for 1 of 2 sampled residents (#94) reviewed for pain. This placed residents at risk for increased pain.
- D Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure appropriate provisions for dialysis care were implemented and timely post-dialysis assessments were completed for 1 of 1 sampled resident (#7) reviewed for dialysis. This placed residents at risk for delayed treatment.
- D Provide care or services that was trauma informed and/or culturally competent.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents who were trauma survivors received trauma-informed care for 3 of 3 sampled residents (#s 8, 41 and 49) reviewed for trauma-informed care. This placed residents at risk for re-traumatization and a decrease in their quality of life.
- D Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to identify and ensure a resident with a diagnosed substance use disorder and/or mental health disorder received necessary behavioral health care and services for 2 of 2 sampled residents (#s 9 and 49) reviewed for smoking and dementia care. This placed residents at risk for unaddressed behavioral and emotional needs and a decrease in their quality of life.
- 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 ensure a medication error rate of less than five percent during medication administration for 2 of 10 sampled residents (#s 74 and 82) reviewed for medication administration. The facility's medication administration error rate was 11.11%. This place residents at risk for subtherapeutic dosing and uncontrolled blood sugars.
- D Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure a functional and comfortable environment for 1 of 1 resident rooms reviewed for lighting. This placed residents at risk for diminished quality of life and quality of care.
- C Post nurse staffing information every day.
Inspectors wroteBased on interview and record review it was determined the facility failed to the ensure the Direct Care Staff Daily Report (DCSDR) postings were accurate and complete for 28 of 49 days reviewed for staffing. This placed residents and the public at risk for inaccurate and incomplete staffing information.
March 10, 2026Complaint inspection · 3 citations
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interview the facility failed to report an allegation of abuse and neglect within the required time frame to the State Agency for 2 of 2 sampled residents (#4 and #7) reviewed for abuse and neglect. This placed residents at risk for abuse.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to have evidence a thorough investigation was completed to prevent potential abuse for 1 of 2 sampled residents (#7). This placed residents at risk for 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 follow physician's orders for medication administration for 1 of 3 sampled residents (#1) reviewed for quality of care. This placed residents at risk for unmet medication needs.
November 21, 2025Complaint inspection · 1 citation
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement airborne precautions for 1 of 3 sampled residents (#1) reviewed for infection control. This placed residents at risk for exposure to infection.
October 17, 2025Complaint inspection · 1 citation
- 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 Resident 3 for 1 of 5 (#2) sampled residents for abuse. This failure to prevent abuse resulted with Resident 2 experiencing severe pain.
April 1, 2025Complaint inspection · 1 citation
- 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 resident records were accurate for 1 of 3 sampled residents (# 5) reviewed for medical records. This placed residents at risk for inaccurate health records.
January 21, 2025Standard inspection, Complaint inspection · 21 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 an RN was available for at least eight consecutive hours per day seven days per week for 4 of 68 days reviewed for staffing. This placed residents at risk for lack of timely RN assessments and care.
- F Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on interview and record review the facility failed to implement a Quality Assessment and Performance Improvement (QAPI) program which identified quality deficiencies, developed and implemented action plans to correct identified quality of care deficiencies. The facility failed to initiate a QAPI review related to abuse, investigations, timely reporting and immunizations. This placed residents at risk of not receiving care and services for optimal resident outcomes.
- F Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure effective systems were in place to identify problems, and take action to improve and monitor its performance for 1 of 1 facility reviewed for quality assessment and assurance. This failure placed residents at risk for worsening care.
- E Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observations and interviews the facility failed to ensure the state survey inspection results were readily accessible for 1 of 1 facility reviewed for resident council. This placed residents and the public at risk of not being informed of the facility's survey history.
- E Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interviews and record review it was determined the facility failed to implement written policies and procedures to thoroughly investigate all alleged violations, retain documents showing that all alleged violations were thoroughly investigated, to further prevent abuse and failed to establish coordination with the QAPI program regarding alleged staff and resident abuse for 3 of 7 sampled residents (#s 19, 23 and 202) reviewed for abuse. This placed residents at risk for verbal and physical abuse by staff.
- E Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record review it was determined the facility failed to report allegations of verbal and physical abuse within the mandated timeframe for 3 of 7 sampled residents (#s 19, 23, and 202) reviewed for abuse. This placed residents at risk for verbal and physical abuse from staff.
- E Respond appropriately to all alleged violations.
Inspectors wroteBased on interviews and record review it was determined the facility failed to thoroughly investigate alleged physical and verbal abuse from staff for 3 of 7 sampled residents (#s 16, 19 and 202) reviewed for abuse. This placed residents at risk for physical and verbal abuse from staff.
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wrote2. A facility Wound Documentation-Wound Rounds Policy dated 9/2023 indicated at the time of a new admission or readmission the resident would have a head-to-toe skin assessment by the wound nurse, charge nurse or designee within eight hours of admission. If a skin issue was noted the area would be entered in wound rounds which includes, but is not limited to, measurements, drainage and wound descriptors. The nurse's note was completed to document findings and summarize the initial assessment or findings. A care plan would be initiated. Skin check frequency would be indicated on the TAR weekly and was to be completed by a licensed staff. If skin issues were noted, orders would be written and transferred to the TAR as appropriate. [...]
- 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 and interview it was determined the facility failed to ensure expired medications were removed from 1 of 1 medication storage rooms and 3 of 4 medication carts reviewed for medication storage. This put residents at risk for reduced efficacy of medications.
- 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, interviews and record review it was determined the facility failed to ensure dishwasher temperatures were monitored daily to ensure the dishwasher functioned properly during an influenza outbreak for 1 of 1 dishwasher reviewed for the kitchen. This placed residents at risk for communicable diseases, un-sanitized dishware and utensils.
- E 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 for 1 of 1 sampled facility. This placed residents at risk for lack of quality of care and reduced quality of life.
- E Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents understood the meaning of an arbitration agreement (disputes are resolved with a neutral party and not in court) for 3 of 3 sampled residents (#s 44, 201, 300) reviewed for arbitration. This placed residents at risk for being uninformed of their legal rights.
- E 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 ensure vaccines were offered for 2 of 5 sampled residents (#s 8 and 301) reviewed for immunizations. This placed residents at risk for respiratory infections.
- E 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 ensure residents received risk and benefit of the COVID-19 vaccine information for 2 of 5 sampled residents (#s 8, and 301) reviewed for immunizations. This placed residents at risk for lack of information regarding vaccines.
- E Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure a functional and comfortable environment for 1 of 3 shower rooms reviewed for environment. This placed residents at risk for an uncomfortable bathing experience.
- 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 provide documentation that Notification of Medicare Non-Coverage (NOMNC) letters were provided in a timely manner for 1 of 3 sampled residents (# 205) reviewed for liability and appeal notices. This placed residents at risk of being uninformed of their right to appeal.
- D Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from misappropriation for 1 of 1 resident (#50) reviewed for misappropriation. This placed residents at risk for lack of medication efficacy and loss of property.
- 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 observation, interviews and record review it was determined the facility failed to ensure a comprehensive care plan addressed dental needs for 1 of 1 sampled resident (#28) reviewed for dental. This placed residents at risk for unmet dental needs.
- D Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide appropriate treatment and services to prevent further decreases in range of motion for 1 of 1 sampled resident (# 37) reviewed for rehab and restorative services. This placed residents at risk for decreased range of motion and a decreased physical condition.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide adequate incontinence care for 1 of 1 sampled resident (#8) reviewed for incontinence care. This placed residents at risk for unmet incontinence needs. Resident 8 was admitted to the facility in 7/2014 with diagnoses including traumatic brain injury and contractures of the left and right ankles. Resident 8's care plan revised on 12/9/21 indicated the resident had an ADL self-care performance deficit and needed frequent checks. Resident 8 had an alteration in bowel elimination and incontinence. Resident 8 needed to be checked every two hours and provided with peri care after each incontinent episode. Resident 8's Annual MDS dated [DATE] identified the resident was always incontinent of both bowel and bladder and required staff assistance with toileting. [...]
- D Provide or obtain dental services for each resident.
Inspectors wroteBased on observation, interviews and record review it was determined the facility failed to ensure prompt routine and emergency dental services were obtained for 1 of 1 sampled resident (#28) reviewed for dental. This placed residents at risk for unmet dental needs.
November 12, 2024Complaint inspection · 2 citations
- D 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 provide a written discharge notice to the resident and failed to notify the resident's representative of a discharge for 1 of 1 sampled resident (#2) reviewed for discharge. This placed residents at risk for lack of information regarding discharge and for their representatives being notified.
- 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 ensure residents received adequate supervision to prevent an elopement for 1 of 3 sampled residents (#2) reviewed for accidents. This placed residents at risk for elopement from the facility.
February 22, 2024Complaint inspection · 2 citations
- 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 provide risk & benefit information for psychotropic medications for 1 of 3 sampled residents (#1) reviewed for medications. This placed residents at risk for being uninformed of medications.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, it was determined the facility failed to thoroughly investigate for potential injuries of unknown cause and failed to rule out potential abuse or neglect without adequate documentation for 1of 3 sampled residents (#1) reviewed for abuse and accidents. This placed residents at risk for abuse and neglect.
September 12, 2023Standard inspection, Complaint inspection · 26 citations
- K Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wrote1. Based on observation, interview and record review it was determined the facility failed to ensure a safe environment related to smoking for 4 of 4 sampled residents (#s 6, 16, 17 and 36) reviewed for smoking. This deficient practice was determined to be an immediate jeopardy (IJ) situation and placed all residents at risk for serious harm, serious injury or death and constituted substandard quality of care.
- F 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 the facility failed to provide sufficient nursing staff to ensure residents attained and maintained their highest practicable mental, physical and psychosocial well-being for 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs.
- F Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 1 of 1 facility reviewed for binding arbitration agreements. This placed residents at risk of being uninformed regarding their legal rights.
- F Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and record review it was determined the facility's Quality Assessment and Assurance Committee (QAA) failed to systematically identify and correct deficiencies in the areas of smoking, assessments, care plans, quality of care, accidents and staffing. This placed residents at risk for accidents, injuries and unmet care needs.
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow Physician Orders for 6 of 12 sampled residents (#s 1, 15, 17, 25, 30 and 33) reviewed for position and mobility, bowel care, activities, edema and unnecessary medications. This placed residents at risk for worsening medical conditions and hospitalization.
- E Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 4 sampled CNAs (#s 18, 23, 28 and 30) reviewed for staffing. This placed residents at risk for lack of care by competent staff.
- E Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure consultations from a qualified dietitian or other clinically qualified nutrition professional for 1 of 1 facility reviewed for qualified dietary staff. This placed residents at risk for unmet dietary needs.
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents were treated in a dignified manner for 3 of 3 sampled residents (#s 1, 15 and 96) reviewed for dignity. This placed residents at risk for a decreased quality of life.
- 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 resident (#96) reviewed for self-administration of medications. This placed residents at risk for adverse medication side effects.
- D Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident request for a medical appointment was honored for 1 of 2 sampled residents (#33) reviewed for choices. This placed residents at risk for unmet medical needs.
- D Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain copies of advance directives for 2 of 4 sampled residents (#s 27 and 40) reviewed for advance directives. This placed residents at risk of not having their health care decisions honored.
- 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 and interview it was determined the facility failed to maintain a comfortable homelike environment for 1 of 3 sampled residents (#96) reviewed for dignity. This placed residents at risk for an unkempt environment.
- 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 an incident of potential abuse to the State Agency within the required timeframe for 2 of 7 sampled residents (#s 1 and 17) reviewed for accidents. This placed residents at risk for abuse.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to thoroughly investigate the contributing factors of a fall for 1 of 7 sampled residents (#1) reviewed for accidents. This placed residents at risk for abuse and further injury.
- D Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review it was determined the facility failed to comprehensively assess cognition, mood, activities and discharge for 2 of 3 sampled residents (#s 25 and 30) reviewed for activities and care planning. This placed residents at risk for unassessed needs.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure accurate assessments for 1 of 2 sampled residents (#15) reviewed for food. This placed residents at risk for inaccurate assessments.
- 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 observation, interview and record review it was determined the facility failed to implement care plan interventions in the area of ADLs for 1 of 2 sampled residents (#11) who were reviewed for position and mobility. This placed residents at risk for potential injury.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure care plans were revised to accurately reflect care needs for 2 of 8 sampled resident (#s 11 and 15) reviewed for unnecessary medications, pressure ulcers and position and mobility. This placed residents at risk for incorrect care and unmet needs.
- 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 provide the necessary services to maintain grooming assistance and hand hygiene for 2 of 5 sampled residents (#s 25 and 40) reviewed for ADLs. This placed residents at risk of unmet grooming and hygiene needs.
- D Provide activities to meet all resident's needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activities program for 2 of 2 sampled residents (#s 11 and 25) reviewed for activities. This placed residents at risk for a decline in psychosocial well-being and diminished quality of life.
- D Ensure the activities program is directed by a qualified professional.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide a qualified professional to direct the activities program for 1 of 1 facility reviewed for activities. This placed residents at risk for unmet physical, mental and psychosocial needs.
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to manage pain for 1 of 1 sampled resident (#27) reviewed for pain management. This placed residents at risk of increased pain.
- 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 wrote2. Resident 17 was admitted to the facility in 10/2021 with diagnoses including depression. A 4/15/23 Pharmacy Recommendation revealed the following: - Resident 17 received bupropion (an antidepressant medication) 150mg daily for depression and duloxetine (an antidepressant medication) 60mg daily for depression. - Resident 17 received these antidepressants since 10/24/21. - Consider a dose reduction of one of the medications unless contraindicated to reduce either at this time. - If dual therapy was to continue, the prescriber should document an assessment of risk versus benefit, indicating that the medications continue to be valid therapeutic interventions. No pharmacy recommendations were made for Resident 17 in 6/2023, 7/2023 or 8/2023. Resident 17's 8/2023 Physician Orders included an order for bupropion 150mg daily for depression and duloxetine 30mg daily for depression. [...]
- D Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide adaptive equipment for 1 of 2 sampled residents (#30) reviewed for nutrition. This placed residents at risk for decreased independence and weight loss.
- D 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 kitchen reviewed. This placed residents at risk for foodborne illnesses.
- D Keep all essential equipment working safely.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure resident care equipment was maintained in proper operating condition for 1 of 6 sampled residents (#196) reviewed for environment. This placed residents at risk for an unhomelike environment.
Fire safety inspections
29 fire safety citations on file: 8 on April 27, 2026, 4 on December 15, 2025, 5 on January 21, 2025, 1 on June 5, 2024, 11 on September 12, 2023.
Every fire safety citation29 citations
- F Conduct testing and exercise requirements.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Properly provide smoke detection systems in areas open to corridors.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Properly select, install, inspect, or maintain portable fire extinguishes.
- F Have simulated fire drills held at unexpected times.
- F To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F Have generator or other power source capable of supplying service within 10 seconds.
- F Develop and maintain an Emergency Preparedness Program (EP).
- F Establish emergency prep training and testing.
- F Have simulated fire drills held at unexpected times.
- D Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- F Develop Emergency Preparedness policies and procedures.
- F Establish policies and procedures including evacuation.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have simulated fire drills held at unexpected times.
- E To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D Meet other general requirements that are deficient.
- F Address patient/client population and determine types of services needed.
- F Address subsistence needs for staff and patients.
- F Establish procedures for tracking staff and patients during an emergency.
- 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 Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- F Have generator or other power source capable of supplying service within 10 seconds.
- D Provide properly protected cooking facilities.
- D Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| October 17, 2025 | Fine | $14,613 |
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) | 4.21 | 5.03 | 3.86 |
| Registered nurses | 0.49 | 0.72 | 0.69 |
| All nursing staff on weekends | 3.93 | 4.51 | 3.42 |
| Nurse aides | 2.96 | ||
| Licensed practical nurses | 0.76 | ||
| Nursing staff turnover (share who left in a year) | 58.5% | 47.4% | 45.8% |
| Registered nurse turnover | not reported | 51.6% | 42.9% |
| Administrators who left | not reported |
CMS expects 3.04 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 4.32 on weekdays and 3.93 on weekends, 9% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 45.1% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 1.10 in April to June 2025 to 4.21 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 | 4.21 | 0.49 | 4.32 | 3.93 | 45.1% | 2 of 90 | 80 |
| Oct to Dec 2025 | 4.05 | 0.49 | 4.19 | 3.70 | 31.8% | 0 of 92 | 72 |
| Jul to Sep 2025 | 4.00 | 0.34 | 4.13 | 3.65 | 14.4% | 8 of 92 | 54 |
| Apr to Jun 2025 | 1.10 | 0.11 | 1.09 | 1.13 | 18.7% | 63 of 91 | 44 |
| 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 | 10.5 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 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 | 2.3 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.5 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 8.8 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 3.3 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 14.6 | 13.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 13.8 | 21.4 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 12.1 | 16.1 | 12.0 |
Owners and operators
Legal business name: MAVERICKS BEACH, LLC. CMS links this home to Kalesta Healthcare Group, a group of 19 nursing homes averaging 2.4 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Kalesta Healthcare Group, LLC | 5% or greater direct ownership interest | Organization | 100% | 06/01/2025 |
| Clawson, Scott | 5% or greater indirect ownership interest | Individual | 44% | 06/01/2025 |
| Williams, Ryan | 5% or greater indirect ownership interest | Individual | 44% | 06/01/2025 |
| Clawson, Scott | Indirect ownership interest | Individual | 06/01/2025 | |
| Clawson, Scott | Corporate officer | Individual | 06/01/2025 | |
| Williams, Ryan | Corporate officer | Individual | 06/01/2025 | |
| Johansen, Julie | Operational/managerial control | Individual | 09/13/2023 | |
| Sanchez, Stephen | Operational/managerial control | Individual | 10/20/2015 | |
| Johansen, Julie | Adp of the SNF | Individual | 06/01/2025 | |
| Sanchez, Stephen | Adp of the SNF | Individual | 06/01/2025 |
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 you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 23 problems in this area, most recently on April 27, 2026: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 11 problems in this area, most recently on April 27, 2026: "Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 10 problems in this area, most recently on April 27, 2026: "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."
- When is the care plan meeting, and can family attend it?Inspectors cited 7 problems in this area, most recently on April 27, 2026: "Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.93 hours per resident per day, below the Oregon average of 4.51.
Other nursing homes nearby
- Woodland Convalescent Center Woodland, 4.3 mi · 2 of 5 stars · 22 citations
- Avalon Care Center - Scappoose Scappoose, 7.6 mi · 3 of 5 stars · 18 citations
- Salmon Creek Post Acute & Rehabilitation Vancouver, 12.9 mi · 3 of 5 stars · 48 citations
- Brookfield Health and Rehab of Cascadia Battle Ground, 14.5 mi · 3 of 5 stars · 40 citations
- Bridge Crest Post Acute Vancouver, 15.7 mi · 2 of 5 stars · 58 citations
- The Oaks at Timberline Vancouver, 16.6 mi · 5 of 5 stars · 14 citations
- Americana Health and Rehabilitation Longview, 19.3 mi · 4 of 5 stars · 20 citations
- Vancouver Specialty and Rehab Care Vancouver, 19.5 mi · 4 of 5 stars · 25 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 Saint Helens Post Acute's Medicare star rating?
- CMS rates Saint Helens Post Acute 2 out of 5 stars overall, with 1 for health inspections, 4 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Saint Helens Post Acute get at its last inspection?
- 19 health deficiencies at the standard inspection on April 27, 2026. The Oregon average is 9.2.
- Has Saint Helens Post Acute been fined?
- Yes. CMS lists 1 fine totaling $14,613 in the last three years.
- Does Saint Helens 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 Saint Helens Post Acute?
- CMS lists 10 owners and managers, and links the home to Kalesta Healthcare Group. Legal business name: MAVERICKS BEACH, 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.