Mt. Tabor Health & Rehabilitation
Portland, Oregon · CCN 385141
26 surveys since 2009. The first finding at harm level was recorded in 2014.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 128
- Surveys
- 26
- Harm or worse
- 8
- Immediate jeopardy
- 6
Findings at the most serious level CMS records.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 120
- Ownership
- For profit - Corporation
- Chain
- HILL VALLEY HEALTHCARE
- County
- Multnomah
- Medicare-certified since
- 1978
CMS ratings
- Overall
- 2
- Health inspection
- 2
- Staffing
- 3
- Quality measures
- 3
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded more weighted findings than most of its peer group.
Weighted by harm level, against 26 for-profit facilities of 100–127 beds in Oregon.
Last survey on record
Jul 10, 2026
122 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.85 | 4.88 |
| Registered-nurse hours per resident day | 0.49 | — |
| Annual nurse turnover | 70.8% | 47.1% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D3272.7% | E1227.3% | F— |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6843×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F6893×
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F8123×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F5842×
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
- F6092×
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
In the surveyor’s words
From the most serious findings on record at Mt. Tabor Health & Rehabilitation, in the surveyor’s own words.
- Immediate jeopardy, widespreadF867Apr 14, 2021
Based on interview and record review it was determined the facility failed to ensure a program of systematic identification, analysis and action was in place related to medication administration and nursing competencies for 1 of 1 QAA (quality assurance and assessment) reviewed for QAA. This failure resulted in Staff 5 (Former Staff/RN) administering an incorrect medication on [DATE] to Resident 1 which she/he was allergic to and resulted in Resident 1's [DATE] respiratory distress, hospitalization and [DATE] death. This was determined to be an Immediate Jeopardy (IJ) situation. […]
- Immediate jeopardy, patternF726Apr 14, 2021
Based on interview and record review it was determined the facility failed to ensure Staff 5 (Former Staff/RN) had the appropriate skills and competencies necessary to care for resident needs related to medication administration. This failure resulted in Resident 1 receiving Resident 2's [MEDICATION(S)] (narcotic pain medication). Resident 1 had an allergy to [MEDICATION(S)]. Resident 1 experienced respiratory distress, hospitalization and death. This constituted an immediate jeopardy situation. Findings include: a. […]
- Immediate jeopardy, isolatedF658Apr 14, 2021
Based on interview and record review it was determined the facility failed to ensure Staff 5 (RN) administered medications per the current standard of practice and Staff 2 (DNS) failed to ensure nursing staff assigned to residents had the skills, experience and knowledge to provide care and services to meet resident needs. These failures resulted in Resident 1's hospitalization and death. This constituted an immediate jeopardy situation. Findings include: -Staff 2 failed to ensure nurse competency training was completed, reported and documented during Staff 5 as well as additional nursing staff orientations. -Staff 2 failed to investigate report and document medication errors and identify and investigate missing narcotic medication. […]
- Immediate jeopardy, isolatedF760Apr 14, 2021
Based on interview and record review it was determined the facility failed to ensure a resident was free from a significant medication error for 1 of 1 sampled resident (#1) reviewed for significant medication error. This failure resulted in Resident 1 receiving Resident 2's [MEDICATION(S)] (narcotic pain medication). Resident 1 had an allergy to [MEDICATION(S)] which resulted in Resident 1 experiencing respiratory distress, hospitalization and death. This constituted an immediate jeopardy situation. […]
- Actual harm, isolatedF686Aug 2, 2022
Based on interview and record review, it was determined the facility failed to assess and monitor a facility acquired pressure ulcer for 1 of 4 sampled residents (#203) reviewed for pressure ulcers. As a result, Resident 203's pressure ulcer worsened from a Stage 2 (partial-thickness loss of skin; shallow open ulcer) to Stage 3 (full-thickness loss of skin; subcutaneous fat may be visible in the ulcer) to Unstageable (full thickness skin and tissue loss and wound bed is obscured by slough or eschar), and became septic (infected with microorganisms, especially harmful bacteria). Resident 203 was admitted to the hospital and died . […]
Read 28 findings in full →The most serious and the most recent: 28 of 128 on record.
Every survey on record
FindingsAt actual harm or above
- Jul 10, 2026Complaint6 findings
- Feb 24, 2026Complaint1 finding
- Nov 20, 2025Complaint4 findings
- Jun 6, 2025Standard and complaint10 findings
- Apr 11, 2024Complaint2 findings
- Feb 23, 2024Standard and complaint11 findings
- Nov 18, 2022Standard10 findings
- Aug 2, 2022Complaint3 findings · 1 harm
Show the 18 earlier surveys
- Dec 7, 2021Standard4 findings
- Apr 14, 2021Complaint12 findings · 4 harm
- Nov 14, 2019Complaint2 findings
- Nov 14, 2018Standard10 findings
- Jun 27, 2018Complaint2 findings
- Mar 26, 2018Complaint3 findings · 1 harm
- Jun 30, 2017Standard7 findings
- Jun 9, 2017Complaint4 findings
- Jan 6, 2017Complaint1 finding
- Oct 27, 2016Complaint1 finding
- May 20, 2016Standard and complaint3 findings
- Mar 14, 2016Complaint1 finding
- Apr 21, 2015Standard4 findings
- Feb 5, 2014—12 findings · 2 harm
- Apr 12, 2013—1 finding
- Jul 3, 2012—9 findings
- Feb 15, 2011—4 findings
- Dec 4, 2009—1 finding
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
- Avamere Crestview of PortlandPortland7 harm findings
- Green Valley Rehabilitation Health CenterEugene3 harm findings
- Avamere Rehabilitation of Oregon CityOregon City6 harm findings
- Highland House Nursing & Rehabilitation CenterGrants Pass3 harm findings
- South Hills Rehabilitation CenterEugene7 harm findings
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