Inspection Reports for Avamere Rehabilitation of Lebanon
350 S. 8th, OR, 97355
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Inspection Report
Complaint Investigation
Capacity: 84
Deficiencies: 58
Nov 14, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from 2022 to 2025 with detailed deficiency history and enforcement actions.
Findings
Across multiple inspections from 2022 to 2025, the facility exhibited numerous deficiencies including inadequate staffing, failure to complete timely assessments, insufficient infection control practices, failure to follow care plans, and issues with resident rights and safety. Many deficiencies were corrected over time, but some remained uncorrected at the time of the most recent inspections.
Complaint Details
Multiple complaint investigations were conducted, including allegations of inadequate staffing, abuse, neglect, failure to follow care plans, and unsafe discharge planning. Investigations revealed failures in timely and thorough investigations, failure to notify residents or responsible parties, and ongoing staffing shortages impacting care.
Deficiencies (58)
| Description |
|---|
| F0000 - INITIAL COMMENTS |
| F0572 - Notice of Rights and Rules: Resident rights were not reviewed during Resident Council meetings. |
| F0628 - Discharge Process: Failure to provide written notice of transfer or bed-hold policy and notify Ombudsman for multiple residents. |
| F0636 - Comprehensive Assessments & Timing: Failure to complete timely comprehensive assessments for residents. |
| F0676 - Activities Daily Living (ADLs)/Mntn Abilities: Failure to assess and provide communication services and therapies timely. |
| F0677 - ADL Care Provided for Dependent Residents: Failure to provide scheduled showers and document care for dependent residents. |
| F0684 - Quality of Care: Failure to follow physician orders and provide wound care leading to infection. |
| F0689 - Free of Accident Hazards/Supervision/Devices: Failure to secure smoking materials and supervise smoking areas. |
| F0730 - Nurse Aide Peform Review-12 hr/yr In-Service: Failure to complete timely annual staff performance reviews. |
| F0740 - Behavioral Health Services: Failure to document and address resident behavioral changes and needs. |
| F0761 - Label/Store Drugs and Biologicals: Medication and treatment carts left unlocked, risking resident safety. |
| F0791 - Routine/Emergency Dental Srvcs in NFs: Failure to follow up on dental referrals for residents. |
| F0814 - Dispose Garbage and Refuse Properly: Exterior refuse containers uncovered, risking pest infestation. |
| F0838 - Facility Assessment: Facility assessment lacked documentation of staffing and resident/staff feedback. |
| F0880 - Infection Prevention & Control: Failure to follow infection control practices including hand hygiene and PPE use. |
| M0000 - Initial Comments |
| M0183 - Nursing Services: Minimum CNA Staffing: Failed to maintain CNA staffing ratios on multiple dates. |
| M9999 - STATE OF OREGON ADMINISTRATIVE RULES |
| F0585 - Grievances: Failure to timely notify resident of grievance resolution regarding missing money. |
| F0602 - Free from Misappropriation/Exploitation: Theft investigation and reimbursement for missing resident phone. |
| F0725 - Sufficient Nursing Staff: Inadequate CNA staffing on multiple dates causing unmet resident needs. |
| F0657 - Care Plan Timing and Revision: Failure to revise care plans for residents with contractures, feeding assistance, and substance use. |
| F0679 - Activities Meet Interest/Needs Each Resident: Failure to assess and provide meaningful activities for residents. |
| F0685 - Treatment/Devices to Maintain Hearing/Vision: Failure to replace hearing aids timely. |
| F0690 - Bowel/Bladder Incontinence, Catheter, UTI: Failure to provide adequate catheter care and supplies. |
| F0695 - Respiratory/Tracheostomy Care and Suctioning: Failure to obtain orders for oxygen and document tubing changes. |
| F0698 - Dialysis: Failure to provide proper dialysis care and monitor access site and weights. |
| F0727 - RN 8 Hrs/7 days/Wk, Full Time DON: Failed to staff RN for eight consecutive hours on multiple days. |
| F0732 - Posted Nurse Staffing Information: Failed to post accurate and complete staffing information. |
| F0756 - Drug Regimen Review, Report Irregular, Act On: Failed to address pharmacy recommendations for medications. |
| F0757 - Drug Regimen is Free from Unnecessary Drugs: Failed to monitor anticoagulant and psychotropic medications. |
| F0803 - Menus Meet Resident Nds/Prep in Adv/Followed: Failed to follow recipes and therapeutic diet standards. |
| F0804 - Nutritive Value/Appear, Palatable/Prefer Temp: Failed to maintain proper food flavor and temperature. |
| F0805 - Food in Form to Meet Individual Needs: Failed to provide physician ordered diets leading to aspiration risk. |
| F0806 - Resident Allergies, Preferences, Substitutes: Failed to honor resident food preferences (lactose intolerance). |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to ensure sanitation of ice machine and dishwasher chemical monitoring. |
| F0925 - Maintains Effective Pest Control Program: Failed to control pests leading to maggot infestation and flies in dining areas. |
| F0947 - Required In-Service Training for Nurse Aides: Failed to ensure CNA staff received required annual in-service training. |
| F0580 - Notify of Changes (Injury/Decline/Room, etc.): Failed to notify provider of resident refusals for blood glucose and orthostatic blood pressure checks. |
| F0600 - Free from Abuse and Neglect: Failed to ensure residents were free from abuse and harassment by other residents. |
| F0610 - Investigate/Prevent/Correct Alleged Violation: Failed to timely investigate allegations of abuse. |
| F0656 - Develop/Implement Comprehensive Care Plan: Failed to develop person-centered care plans for residents. |
| F0660 - Discharge Planning Process: Failed to contact referral agencies at time of discharge for resident. |
| F0677 - ADL Care Provided for Dependent Residents: Failed to provide necessary personal hygiene care for dependent residents. |
| F0680 - Infection Prevention & Control: Failed to correctly use PPE and maintain infection control standards. |
| F0684 - Quality of Care: Failed to assess, treat and follow physician orders for skin wounds. |
| F0725 - Sufficient Nursing Staff: Failed to provide sufficient nursing staff to meet resident needs. |
| F0730 - Nurse Aide Peform Review-12 hr/yr In-Service: Failed to complete annual CNA performance reviews. |
| F0732 - Posted Nurse Staffing Information: Failed to post accurate staffing information. |
| F0756 - Drug Regimen Review, Report Irregular, Act On: Failed to address pharmacy recommendations timely. |
| F0757 - Drug Regimen is Free from Unnecessary Drugs: Failed to monitor psychotropic medications for side effects. |
| F0803 - Menus Meet Resident Nds/Prep in Adv/Followed: Failed to follow recipes and therapeutic diet standards. |
| F0804 - Nutritive Value/Appear, Palatable/Prefer Temp: Failed to maintain proper food temperatures and flavor. |
| F0805 - Food in Form to Meet Individual Needs: Failed to provide physician ordered diets leading to aspiration risk. |
| F0806 - Resident Allergies, Preferences, Substitutes: Failed to honor resident food preferences. |
| F0812 - Food Procurement,Store/Prepare/Serve-Sanitary: Failed to maintain sanitation of ice machine and dishwasher chemical monitoring. |
| F0925 - Maintains Effective Pest Control Program: Failed to control pests leading to maggot infestation and flies in dining areas. |
| F0947 - Required In-Service Training for Nurse Aides: Failed to ensure CNA staff received required annual in-service training. |
Report Facts
Inspections on page: 10
Total deficiencies: 70
Licensing violations: 20
Abuse violations: 0
Notices: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jonathan Hutchinson | Administrator | Named in multiple findings related to facility management and staffing |
| Staff 1 | Administrator | Named in multiple inspection findings and interviews regarding facility operations and deficiencies |
| Staff 3 | Regional Director of Quality Assurance | Named in infection control and medication cart security findings |
| Staff 6 | Resident Care Manager - LPN | Named in multiple findings related to care planning and documentation |
| Staff 14 | Social Services Director | Named in findings related to discharge process and behavioral health services |
| Staff 27 | Activities Director | Named in findings related to resident rights and activities |
| Staff 29 | LPN | Named in wound care and infection control findings |
| Staff 30 | Medical Records | Named in medication order documentation findings |
| Staff 23 | Regional Nurse Consultant | Named in multiple findings and interviews regarding care and staffing |
| Staff 9 | CNA | Named in infection control and abuse findings |
| Staff 24 | CNA | Named in staffing and performance review findings |
| Staff 25 | CNA | Named in staffing and performance review findings |
| Staff 18 | LPN | Named in staffing and care findings |
| Staff 32 | LPN RCM | Named in care planning and abuse findings |
| Staff 40 | HR Director | Named in employee reference check findings |
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