Chehalem Post Acute

In the surveyor’s words

From the most serious findings on record at Chehalem Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 4, 2023

  Based 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. […]

• Actual harm, isolatedF600Jan 7, 2025

  Based 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. Findings include: The facility's 8/2024 Abuse-Screening, Training, Identification, Investigation, Reporting and Protection policy and procedure stated Abuse is the willful infliction of injury resulting in physical harm, pain or mental anguish. […]

• Actual harm, isolatedF689Oct 21, 2022

  Based 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. Findings include: Resident 12 was admitted to the facility in 2/2021 with diagnoses including diabetes, dementia and stroke with right side [CONDITION(S)] (weakness or paralysis). […]

• No harm, potential for more than minimal, widespreadF727Mar 28, 2025

  Based 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. Findings include: A review of the Direct Care Staff Daily Reports revealed the following dates with no RN coverage: -7/20/24 -9/16/24 -9/28/24 - 1/4/25 -1/5/25 -2/15/25 On 3/26/25 at 8:19 AM and 12:00 PM Staff 1 (Administrator) acknowledged the identified dates without the required RN coverage.

• No harm, potential for more than minimal, widespreadF838Mar 28, 2025

  Based 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. Findings include: The 3/19/25 Facility Assessment was reviewed. The assessment was not comprehensive and failed to accurately include information on the following: - How the facility assessment was used to address staffing needs and competencies. - The percentage of transmission based precautions in the facility. - The number of ADL assistance based on the average census. - The ethnic, cultural and religious makeup of the facility resident population. - The high usage of agency staff. […]