Mt Angel Health: Glucometer Disinfection Failure - OR
The nurse worked across all units of the facility.
Inspectors from the Centers for Medicare and Medicaid Services documented the lapse at Mt Angel Health and Rehabilitation during a visit on June 3, 2026. The facility's own policy, updated in December 2025, required staff to clean shared glucometers after each individual patient use with EPA-approved disinfectant wipes. The manufacturer of the facility's 2017 Evencare G2 glucometer said the same thing in its manual, adding one specific requirement: the wipe had to be left wet on the surface for two full minutes to ensure disinfection actually occurred.
At 11:33 that morning, inspectors watched Staff 5, a licensed practical nurse serving as Resident Care Manager, return to the medication cart after checking the blood glucose of Resident 81, a diabetic patient admitted to the facility in November 2025. She placed the glucometer directly into the cart drawer. She did not wipe it. She did not disinfect it at all.
Eighteen minutes later, at 11:51 AM, the nurse explained herself. She said she used alcohol pad wipes to clean the glucometers after blood glucose checks. She said the EPA disinfectant wipes were harsh on the device. She preferred the alcohol pads.
She also said she occasionally worked on all units within the facility.
The Director of Nursing Services, reached by inspectors at 12:39 PM the same day, confirmed that staff were required to use EPA-approved disinfectant wipes. There was no ambiguity in the policy. The nurse knew what the policy said. She had simply decided, on her own, that she preferred something else, and had apparently been doing it that way long enough to describe it as her routine.
The distinction between an alcohol pad wipe and an EPA-approved disinfectant wipe is not a matter of preference. Alcohol pads are not approved for disinfecting shared glucometers used on multiple patients. The concern is bloodborne pathogen transmission. A glucometer punctures the skin to draw blood. If the device is not properly disinfected between uses, blood from one resident can remain on or in the device when it is used on the next. That is the mechanism by which bloodborne infections spread in clinical settings, and it is why the two-minute wet-contact requirement exists. A wipe dragged across a surface and immediately removed does not achieve disinfection.
The nurse worked across every unit in the facility.
CMS classified the violation as having the potential for actual harm, affecting some residents. It did not rise to the level of immediate jeopardy, the agency's most serious designation. That classification reflects the absence of a documented infection linked to the glucometer. It does not mean nothing happened. It means inspectors could not prove it did.
What inspectors could prove was that a nurse responsible for managing resident care had, by her own account, been cleaning a shared blood-drawing device the wrong way, with a product that does not meet disinfection standards, and had done so as a matter of routine preference. She said the correct wipes were harsh on the glucometer. The glucometer is a piece of equipment. Resident 81 is a person whose blood was on it.
The facility's plan of correction was not included in the inspection record made available. For information on how Mt Angel Health and Rehabilitation intends to address the deficiency, CMS directed inquiries to the facility or the Oregon state survey agency.
The nurse said she occasionally worked on all units.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mt Angel Health and Rehabilitation from 2026-06-05 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
MT ANGEL HEALTH AND REHABILITATION in MOUNT ANGEL, OR was cited for violations during a health inspection on June 5, 2026.
The nurse worked across all units of the facility.
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.