Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Avamere Rehabilitation Of Lebanon
LEBANON, OR · 84 certified beds · Last Life Safety survey July 19, 2024
CMS Certification Number 385168 · first certified January 1986
Ownership
Operated by AVAMERE · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within OR
14 citations — more than 64% of the 128 certified nursing homes in OR. Compared within OR rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 3.7. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (October 2025 to December 2025), and past the point by which nine in ten OR facilities have been surveyed. This facility’s last Life Safety survey was July 2024. Facilities in OR are typically surveyed 15–17 months after the last one (median 16), measured over 188 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 14 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 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.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
How that compares
Compared with the median facility in OR, and nationally. Surveyors differ markedly between states, so the OR figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in OR | 11 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 15, 2022 | 4 |
| March 24, 2023 | 6 |
| June 18, 2024 | 1 |
| July 19, 2024 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2024-06-18 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2022-02-15 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2024-07-19 |
| K-0753 | Have restrictions on the use of highly flammable decorations. | 1 | 2023-03-24 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2022-02-15 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2023-03-24 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2024-07-19 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 1 | 2023-03-24 |
What the citations cover
- Miscellaneous Deficiencies 6
- Smoke Deficiencies 5
- Emergency Preparedness Deficiencies 2
- Egress Deficiencies 1
| Category | Citations |
|---|---|
| Miscellaneous Deficiencies | 6 |
| Smoke Deficiencies | 5 |
| Emergency Preparedness Deficiencies | 2 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 19, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (August 30, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (August 30, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 30, 2024) |
June 18, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 30, 2024) |
March 24, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 1, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 1, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (May 1, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 1, 2023) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (May 1, 2023) |
| K-0932 | Meet other general requirements. | Deficient, Provider has date of correction (May 1, 2023) |
February 15, 2022 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (April 4, 2022) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 4, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 4, 2022) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (April 4, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.