Mt. Tabor Health: Infection Control Failures - OR
Federal inspectors documented the violation during a November complaint investigation at the 120-bed facility on Southeast Powell Boulevard. The incident involved a resident admitted in October with gastroesophageal reflux disease and a gastric feeding tube inserted directly into their abdomen.
Enhanced Barrier Precautions require nursing staff to wear both gowns and gloves when providing care to residents with feeding tubes and other medical devices. The Centers for Disease Control and Prevention established these expanded protective equipment requirements specifically because residents with indwelling devices face heightened infection risks.
Signage posted outside the resident's room clearly indicated Enhanced Barrier Precautions were required. Despite this warning, Staff 20, who serves as the facility's interim director of nursing services, and Staff 25, a licensed practical nurse, violated the protocols on November 17.
At 3:12 PM that day, inspectors observed both nurses handling the resident's feeding tube and assessing the pump connected to the gastric tube. Neither wore the required protective gown. They used only gloves.
The violation occurred during what infection control experts classify as "high-contact resident care activities" — precisely the situations where Enhanced Barrier Precautions provide critical protection. The gastric tube, which bypasses the resident's natural digestive barriers, creates a direct pathway for bacteria and other pathogens to enter the body.
When confronted by inspectors three days later, the interim nursing director acknowledged the protocol breach. On November 20, Staff 20 admitted that neither she nor the licensed practical nurse had worn gowns while accessing the resident's gastric tube.
The admission came during a federal inspection triggered by complaints about the facility's infection control practices. Mt. Tabor Health & Rehabilitation, which opened in 1965, has faced previous scrutiny over its adherence to basic safety protocols.
Enhanced Barrier Precautions represent a relatively recent expansion of infection control requirements. The CDC developed these guidelines after research demonstrated that residents with wounds, catheters, feeding tubes and similar medical devices experience higher rates of healthcare-associated infections.
The precautions require gowns and gloves during any care activity involving significant contact with these high-risk residents. This includes wound care, device maintenance, and assistance with activities of daily living for residents who cannot maintain proper hygiene independently.
For residents with gastric feeding tubes, the enhanced precautions are particularly crucial. These devices, inserted surgically through the abdominal wall, create permanent openings that can harbor bacteria. Without proper protective equipment, healthcare workers can inadvertently transfer pathogens between residents or introduce new infections.
The inspection report classified the violation as causing "minimal harm or potential for actual harm" to residents. However, infection control experts note that such breaches can have cumulative effects, particularly in facilities serving medically complex populations.
Mt. Tabor Health & Rehabilitation serves residents requiring skilled nursing care, many with multiple chronic conditions and medical devices. The facility's Medicare database profile shows it provides care for residents with feeding tubes, catheters, and complex wound care needs — all populations requiring Enhanced Barrier Precautions.
The November inspection focused specifically on infection control practices after complaints were filed against the facility. Inspectors reviewed protocols for two residents but found violations affecting the resident with the gastric feeding tube.
Federal inspectors noted that the facility's own signage system worked correctly, clearly marking which residents required enhanced precautions. The breakdown occurred at the bedside level, where experienced nursing staff — including the interim director overseeing infection control facility-wide — failed to follow established protocols.
The resident affected by the violation had been living at Mt. Tabor Health & Rehabilitation for just over a month when the incident occurred. Their gastroesophageal reflux disease necessitated the feeding tube, making proper infection control during care activities essential for preventing complications that could require hospitalization or more invasive interventions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mt. Tabor Health & Rehabilitation from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Mt. Tabor Health & Rehabilitation in PORTLAND, OR was cited for violations during a health inspection on November 20, 2025.
Federal inspectors documented the violation during a November complaint investigation at the 120-bed facility on Southeast Powell Boulevard.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.