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Complaint Investigation

Mt. Tabor Health & Rehabilitation

February 24, 2026 · Portland, OR · 6040 Se Belmont Street
Citations 1
CMS Rating 2/5
Beds 120
Provider ID 385141
Healthcare Facility
Mt. Tabor Health & Rehabilitation
Portland, OR  ·  View full profile →
Inspection Summary

Mt. Tabor Health & Rehabilitation in PORTLAND, OR — inspection on February 24, 2026.

Found 1 citation. 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.

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Inspection Findings

FF0698
Quality of Life and Care Deficiencies

transportation for dialysis treatments for 1 of 3 sampled residents (#1) reviewed for dialysis care.

Findings include: Resident 1 was admitted to the facility in 12/2025, with diagnosis including acute kidney failure, dependence on renal dialysis and metabolic encephalopathy. Resident 1's Care Plan dated 11/22/25 documented the resident received dialysis, was to be transported to dialysis center three days a week (Tuesday, Thursday and Saturday) and would be free from complications secondary to requiring dialysis. Resident 1's Progress Note dated 12/24/25 noted Resident 1 received a dialysis treatment at the hospital on [DATE] and did not receive treatment on 12/25/25.

There was no documentation of her/his treatment on 12/27/25. In an interview on 2/19/26 at 12:22 PM, Staff 11 (Receptionist) stated she or nursing staff will assist with dialysis transportation planning.

Staff 11 stated she was unable to set up Resident 1's dialysis transportation over the holiday in December. In an interview on 2/20/26 at 3:11 PM, Witness 1 (Family Member) stated she received a call from the dialysis center on 12/29/25 which inquired why Resident 1 was not at dialysis.

Witness 1 stated she went to the facility and requested staff send Resident 1 to the ER for dialysis.

Witness 1 stated dialysis was completed on 12/29/25.

Witness 1 stated Resident 1 was very sick and had not admitted to the facility in that state. In an interview on 2/24/26 at 11:25 AM, Staff 29 (LPN) stated evening shift staff informed her Resident 1's transportation to dialysis needed to be scheduled.

Staff 29 stated Resident 1 missed her/his dialysis treatment.

Staff 29 stated Resident 1 was supposed to receive dialysis on 12/27/25 but she/he never received it. In an interview on 2/24/26 at 2:54 PM, Staff 2 (DNS) acknowledged Resident 1 missed dialysis due to no transportation being scheduled.

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

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PORTLAND, OR, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Mt. Tabor Health & Rehabilitation or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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