Mt Angel Health And Rehabilitation
MT ANGEL HEALTH AND REHABILITATION in MOUNT ANGEL, OR — inspection on June 5, 2026.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
reviewed, and revised by a team of health professionals.
for 1 of 1 sampled resident (#3) reviewed for hospice.
This placed residents at risk for unmet hospice
dementia, bipolar and heart failure.The 8/14/25 Significant Change MDS indicated Resident 3 was on hospice status.Review of Resident 3's care plan referred to hospice and/or end of life in the following manner:-For ADL care hospice helped with bathing, dated 2/13/26. -For psychosocial well-being hospice was identified as one service to provide consultation, date initiated 7/3/25. -For activities, hospice was identified and indicated the resident often declined, date initiated 2/19/26. -Use of anti-anxiety medication related to end of life, dated 9/12/25.
The Care Plan did not indicate Resident 3's terminal illness as a focus area with interventions including hospice services or interventions related to end of life.On 6/4/26 at 9:30 AM Staff 2 (DNS) stated her expectation was for a terminal illness to be captured with interventions including hospice services on a resident's care plan.
Staff 2 acknowledged Resident 3's care plan was not revised to reflect her/his terminal illness and hospice status.
385018 06/05/2026
MT Angel Health and Rehabilitation 540 South Main Street Mount Angel, OR 97362
-Docusate Sodium, one tablet every Tuesday, Thursday, Saturday and Sunday for constipation.
-Milk of Magnesia as needed for constipation. -Fleet enema, one application every 24 hours as needed for constipation. -Bisacodyl rectal suppository, one application as needed for constipation. If no BM (bowel movement) on day four notify the provider.
A review of Resident 19's bowel records indicated the resident did not have a bowel movement from 5/10/26 through 5/20/26 (11 days) and 5/28/26 through 6/3/26 (7 days).
A review of Resident 19's 5/2026 MAR revealed the resident received milk of magnesia on 5/16/26 (day 7) and one suppository on 5/21/26 (day 12) and no additional PRN bowel medication was provided.
A review of Resident 19's 6/2026 MAR revealed the resident received milk of magnesia on 6/2/26 (day 5) and no additional PRN bowel medication was provided.
On 6/2/26 at 9:17 AM Resident 19 stated she/he had not had a bowel movement in over seven days which caused discomfort in her/his abdomen.
On 6/4/26 at 9:28 AM Staff 7 (CNA) stated Resident 19 went 22 shifts without a bowel movement.
On 6/4/26 at 9:53 AM Staff 6 (LPN) stated Resident 19 was often on alert for not having a bowel movement.
Staff 6 stated Resident 19 was on a scheduled bowel care regimen.
Staff 6 was not able to provide additional information related to the lack of PRN bowel medications provided to the resident.
On 6/4/26 at 11:58 AM Staff 2 (DNS) acknowledged Resident 19 did not receive bowel care interventions in a timely manner and went 11 and 7 days without having a bowel movement.
385018 06/05/2026
MT Angel Health and Rehabilitation 540 South Main Street Mount Angel, OR 97362
During interviews on 6/3/26 at 11:24 AM and 6/4/26 at 10:56 AM, Resident 17's hands were observed to be curled up into a fist. Resident 17 was unable to extend her hand. Resident 17 was not wearing her/his hand splint and the splint was observed on top of the resident's bedside table. Resident 17 stated she allowed staff to apply the splint. On 6/4/26 at 12:54 PM, Staff 8 (CNA) stated Resident 17's hand contractures were stiff and difficult to manage.
Staff 8 stated Resident 17 allowed staff to apply the hand splint.
Staff 8 stated she did not offer to apply the brace during her shift because she forgot. On 6/5/26 at 9:28 AM, Staff 9 (LPN) stated Resident 17 used bilateral hand splints to prevent further decrease to range of motion.
Staff 9 stated Resident 17 tolerated the splint and allowed staff to apply the hand splints.
Staff 9 stated staff did not tell her they were unable to apply the hand splint during the day.
On 6/5/26 at 10:13 AM, Staff 10 (RN Resident Care Manager) stated he was unsure of why Resident 17 did not wear the hand splint consistently and acknowledged the splints should be worn.
sufficient and competent nurse staffing.
This placed residents at risk for a lack of competent staff.
receive their annual performance evaluations: -Staff 11 (CNA), hire date was 12/2019 and a performance review was not completed.-Staff 12 (CNA), hire date was 8/2013 and a performance review was not completed.-Staff 13 (CNA), hire date was 1/2019 and a performance review was not completed. On 6/4/26 at 4:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) confirmed annual performance reviews were not completed for Staff 11, Staff 12 and Staff 13.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
385018 06/05/2026
MT Angel Health and Rehabilitation 540 South Main Street Mount Angel, OR 97362
residents at risk for exposure to blood-borne pathogens.
Findings include: The 12/2025 facility
disinfectant wipes. A 2017 Evencare G2 glucometer Manufacturer Manual indicated, Disinfect common use glucometers with the use of approved disinfectant wipes.
The glucometer was to be wiped with the disinfecting wipe and left wet for two minutes to ensure disinfection. Resident 81 was admitted to the facility in 11/2025 with diagnoses including diabetes.On 6/3/26 at 11:33 AM, Staff 5 (LPN Resident Care Manager) was observed to return to the medication cart after checking Resident 81's CBG, and place the glucometer in the drawer.
Staff 5 did not disinfect the glucometer. On 6/3/26 at 11:51 AM, Staff 5 stated she used alcohol pad wipes to clean the glucometers after she checked residents CBG.
Staff 5 stated EPA disinfectant wipes were harsh on the glucometer and she preferred to use alcohol pad wipes to clean the glucometers.
Staff 5 stated she occasionally worked on all units within the facility. On 6/3/26 at 12:39 PM, Staff 2 (DNS) stated staff were to use approved EPA disinfectant wipes to disinfect the glucometers.
385018 06/05/2026
MT Angel Health and Rehabilitation 540 South Main Street Mount Angel, OR 97362
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.