350 S. 8th, Lebanon, OR 97355 · Linn County · (541) 259-1221
84 certified beds, about 61 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1986
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385168 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on September 8, 2025, inspectors cited 14 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 60 health citations since March 2023, 1 was rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $20,303 in the last three years; the largest was $20,303, and the latest is dated June 18, 2024.
Nurses and nurse aides worked 4.50 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.53 of those hours.
42.3% of nursing staff left within the year CMS measured (Oregon average 47.4%).
CMS links it to Avamere, an affiliated group of 27 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 60 health citations on file.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide sufficient staffing to meet resident needs in a timely manner for 3 of 4 sampled residents (#s 1, 2 and 5) reviewed for call light times. This placed residents at risk for unmet needs.
Inspectors wroteBased on interview and record review, it was determined the facility failed to reduce the risk of a potential accident hazard for 1 of 3 sampled residents (#1) reviewed for accidents. This placed residents at risk for accidents.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain lab samples for 1 of 3 sampled residents (#10) reviewed for change of condition. This placed residents at risk for a delay in treatment.
Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure dependent residents received ADL assistance for bathing for 1 of 3 sampled residents (#7) reviewed for ADLs. This placed residents at risk for unmet needs.
Inspectors wroteBased on interview, and record review, it was determined the facility failed to obtain orders and provide treatment for non-pressure skin wounds for 1 of 3 sampled residents (#2) reviewed for change of condition. This placed residents at risk for worsening wounds.
Inspectors wroteBased on interview and record review it was determined that facility failed to demonstrate active involvement of staff and residents to determine staffing needs for 1 of 1 facility assessment. This placed residents at risk for inadequate staffing to meet resident needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow appropriate infection control practices during a COVID-19 outbreak for 2 of 2 halls reviewed for infection control. This placed residents at risk for exposure to the COVID-19 virus and other infectious disease.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were informed of their rights both orally and in writing on an ongoing basis for 1 of 1 facility reviewed for Resident Council. This placed residents at risk for not being informed of their rights.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide residents with a written bed hold notification, including reserved bed hold payment, at the time of transfer to the hospital and notify the Ombudsman for 4 of 4 sampled residents (#s 10, 11, 67, and 69) reviewed for hospitalization and discharge. This placed residents at risk for lack of knowledge regarding their choices and potential financial responsibilities.
Inspectors wroteBased on observation and interview the facility failed to provide covered refuse containers for 3 of 4 exterior refuse containers observed. This placed residents at risk for pest infestations.
Inspectors wroteBased on observation, interview and record review the facility failed to comprehensively assess 1 of 3 resident (#11) reviewed for positioning and hospitalization. This placed resident at risk for unassessed needs.
Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to coordinate the appropriate services to address communication needs for 1 of 1 sampled resident (#6) reviewed for communication. This placed residents at risk for ineffective communication and unmet needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide bathing and shower care for 1 of 3 sampled residents (#16) reviewed for ADLs. This placed residents at risk for poor hygiene.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow physician orders for 1 of 4 sampled residents (# 49) reviewed for infection control. This placed residents at risk for wound infections.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to implement care plan interventions related to smoking safety for 1 of 2 sampled residents (#37) reviewed for accidents. This placed residents at risk for increased smoking hazards and avoidable accidents.
Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure annual performance reviews for CNA staff were completed for 2 of 5 sampled CNA staff (#s 24 and 25) reviewed for staffing. This placed residents at risk due to lack of competent staff.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to timely address a new identified behavior for 1 of 2 sampled residents (#2) reviewed for mood and behavior. This placed residents at risk for lack of emotional and behavioral health needs.
Inspectors wroteBased on observation and interview it was determined the facility failed to ensure treatment carts were locked and secured appropriately for 2 of 2 treatment carts observed during random observations for medication and treatment cart storage. This placed residents at risk for unsafe access to stored medications.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow up on dental services for 1 of 2 sampled residents (#11) reviewed for dental care. This placed residents at risk for lack of dental services.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide adequate staffing to meet resident needs for 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to respond timely to a resident's grievance for 1 of 2 sampled residents (#8) reviewed for missing property. This placed residents at risk for unresolved concerns.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's cell phone was not stolen for 1 of 2 sampled residents (#3) reviewed for missing property. This placed residents at risk for loss of property.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow resident rights for 1 of 3 sampled residents (# 2) reviewed for resident rights. This placed residents at risk for lack of dignity.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure physician ordered diets were provided as ordered for 3 of 5 sampled residents (#s 3, 39 and 57) reviewed for nutrition. This deficient practice was determined to be an immediate jeopardy situation. Resident 57 was provided food not prepared according to their physician ordered diet texture, and this resulted in a severe coughing episode and risk of choking and/or aspiration. Staff were aware the food they were providing the resident was not appropriate.
Inspectors wroteBased on observation and interview it was determined the facility failed to follow recipes to meet menu and therapeutic standards for 1 of 1 kitchen. This place residents at risk for lack of meal satisfaction and compromised nutrition.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure proper flavor and food temperatures were maintained for meals served for 1 of 5 sampled resident (#27) and 1 of 1 facility kitchen reviewed for dining services. This placed residents at risk for food that was not palatable, safe, or appetizing.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure sanitation processes were followed for 1 of 1 observed kitchen. This placed residents at risk for food borne illnesses.
Inspectors wroteBased on observation and interview it was determined the facility failed to provide a clean homelike environment for 7 of 10 sampled residents (#s 6, 19, 27, 29, 37, 46 and 58) and 1 of 2 halls (North) reviewed for environment. This placed residents at risk for an unclean and unhomelike environment.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to meet the needs of residents for 1 of 8 sampled residents (#16) and 2 of 2 halls (North and 2nd South) reviewed for staffing. This placed residents at risk for unmet needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to staff a registered nurse for eight consecutive hours per day 7 days per week for 34 out of 126 days reviewed for staffing. This placed residents at risk for unmet assessment needs.
Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to post accurate and complete staffing information for 1 of 1 facility reviewed for staffing. This placed residents and visitors at risk for incomplete and inaccurate staffing information.
Inspectors wroteBased on observation, interviews and record review it was determined the facility failed to ensure resident rooms were free from pests for 1 of 10 sampled residents (#36) and 1 of 3 dining rooms reviewed for environment. This placed residents at risk for pest infestation.
Inspectors wroteBased on interview and record review it was determined the facility failed to have a system in place to ensure CNA staff received 12 hours of in-service training annually for 5 of 5 randomly selected staff members (#s 6, 7, 8, 9, and 10) reviewed for evidence of in-service training. This placed residents at risk for lack of competent staff.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide risk and benefit information related to the use of antipsychotic medications to residents/responsible parties prior to administration for 1 of 5 sampled residents (#10) reviewed for medications. This placed resident responsible parties at risk for lack of informed consent.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure care conferences were completed for 1 of 5 sampled residents (#15) reviewed for ADLs. This placed residents at risk for unmet needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to include a resident in shower schedule decisions for 1 of 4 sampled residents (#36) reviewed for choices. This placed residents at risk for lack of independent choices.
Inspectors wroteBased on interview and record review it was determined the facility failed to notify provider of CBG check and orthostatic blood pressure refusals for 1 of 5 sampled residents (# 17) reviewed for medications. This placed residents at risk for unmet needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 1 resident (#46) reviewed for abuse. This placed residents at risk for abuse.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to investigate allegations of abuse for 1 of 1 sampled resident (#46) reviewed for abuse. This placed residents at risk for abuse.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to revise care plan interventions for 3 of 13 sampled residents (#s 10, 17 and 24) reviewed for ADLS, medications, positioning and mobility. This placed residents at risk for unmet needs.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure dependent residents received required assistance with ADLs for 3 of 6 sampled residents (#s 16, 24, and 40) reviewed for ADLs. This placed resident at risk for unmet needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to assess and provide meaningful activities for 2 of 2 sampled resident (#s 36 and 42) reviewed for activities. This placed residents at risk for lack of social interaction.
Inspectors wroteBased on interview and record review it was determined the facility failed to implement bowel care, notify the physician and follow physician orders for 2 of 8 sampled residents (#s 17 and 33) reviewed for skin, change of condition, and medications. This placed residents at risk for unmet needs.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to replace hearing aids in a timely manner for 1 of 3 sampled residents (#40) reviewed for sensory needs. This placed residents at risk for a decline in hearing and impaired communication.
Inspectors wroteBased on interview and record review it was determined the facility failed to implement pressure ulcer treatments and care plans for 2 of 2 sampled residents (#s 1 and 3) reviewed for pressure ulcers and incontinent care. This placed residents at risk for pressure ulcers.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure a resident's environment remained free from accident hazards for 1 of 1 sampled resident (#66) reviewed for accidents, and respond to changes in condition in a timely manner for 1 of 1 sampled resident (#65) reviewed for change of condition. This placed residents at risk for injury and untimely care needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide adequate catheter care for 1 of 2 sampled residents (#14) reviewed urinary catheter. This placed residents at risk for urinary infections.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to obtain orders for oxygen for 2 or 2 sampled residents (#s 30 and 63) reviewed for respiratory care. This placed residents at risk for unmet respiratory needs.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure residents received proper dialysis care and services after dialysis for 1 of 1 sampled resident (#55) reviewed for dialysis. This placed residents at risk for dialysis complications.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 1 of 5 sampled CNA staff (#9) reviewed for staffing. This placed residents at risk for a lack of competent staff.
Inspectors wroteBased on interview and record review it was determined the facility failed to address pharmacy recommendations for 2 of 5 sampled residents (#s 10 and 17) reviewed for medications. This placed residents at risk for adverse medication side effects.
Inspectors wroteBased on interview and record review it was determined the facility failed to monitor anticoagulant medication for 1 of 5 sampled residents (#27) reviewed for medications. This placed residents at risk for adverse side effects of medications.
Inspectors wroteBased on interview and record review it was determined the facility failed to consistently monitor residents on psychotropic medications and ensure residents did not receive unnecessary medications for 3 of 5 sampled residents (#10, 17 and 27) reviewed for psychotropic medications. This placed residents at risk for receiving unnecessary psychotropic medications.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents' food preferences were honored for 1 of 1 sampled resident (#27 ) reviewed for nutrition. This placed residents at risk for unmet needs.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow infection control standards for 1 of 2 sampled residents (#30) and 2 of 2 unsampled residents (#s 6 and 11) reviewed for respiratory care. This placed residents at risk for exposure and contraction of infectious diseases.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 2 of 2 halls (200 and 400) reviewed for staffing. This placed residents at risk for delayed and unmet care needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete a comprehensive dementia assessment for 2 of 3 sampled residents (#s 2 and 47) reviewed for dementia. This place residents at risk for unassessed needs.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide diabetic nail care for 1 of 4 sampled residents (# 51) reviewed for ADLs. This placed residents at risk for lack of nail care.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure proper food temperatures for 3 of 9 sampled residents (#s 33, 46 and 218) reviewed for food. This placed residents at risk for cold food and impaired nutrition.
Inspectors wroteBased on observation and interview it was determined the facility failed to maintain the ice machine reviewed for 1 of 1 kitchen. This placed residents at risk for contamination.
14 fire safety citations on file: 3 on July 19, 2024, 1 on June 18, 2024, 6 on March 24, 2023, 4 on February 15, 2022.
| Date | Penalty | Amount or length |
|---|---|---|
| June 18, 2024 | Fine | $20,303 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.50 | 5.03 | 3.86 |
| Registered nurses | 0.53 | 0.72 | 0.69 |
| All nursing staff on weekends | 4.07 | 4.51 | 3.42 |
| Nurse aides | 3.31 | ||
| Licensed practical nurses | 0.66 | ||
| Nursing staff turnover (share who left in a year) | 42.3% | 47.4% | 45.8% |
| Registered nurse turnover | 42.9% | 51.6% | 42.9% |
| Administrators who left | 2 |
CMS expects 3.69 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.67 on weekdays and 4.07 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 2.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.69 in April to June 2025 to 4.50 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.50 | 0.53 | 4.67 | 4.07 | 2.2% | 0 of 90 | 61 |
| Oct to Dec 2025 | 4.55 | 0.50 | 4.77 | 3.99 | 4.2% | 0 of 92 | 59 |
| Jul to Sep 2025 | 4.54 | 0.46 | 4.82 | 3.82 | 3.7% | 0 of 92 | 59 |
| Apr to Jun 2025 | 4.69 | 0.32 | 4.96 | 4.02 | 1.4% | 6 of 91 | 55 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Oregon, all employers | |||
| CNAs (nursing assistants) | $23.96 | $22.83 to $28.40 | 14,800 |
| LPNs and LVNs | $38.69 | $35.11 to $43.60 | 4,260 |
| Registered nurses | $62.02 | $51.55 to $64.63 | 39,730 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 16.3 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.2 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.6 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.3 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 24.2 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.3 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 10.8 | 13.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 24.6 | 21.4 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 17.9 | 16.1 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.3 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.9 | 2.4 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Avamere Rehabilitation of Lebanon's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (63.5% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
63.5% this home
Better than the national rate
US median of homes 51.5% · Oregon: 52 better, 3 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 116 eligible stays.
9.9% this home
No different from the national rate
US median of homes 10.7% · Oregon: 3 better, 0 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 113 eligible stays.
5.5% this home
No different from the national rate
US median of homes 7.1% · Oregon: 0 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 59 eligible stays.
80.5% this home
Median of homes: Oregon59.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 41 residents counted.
1.9% this home
Median of homes: Oregon0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 52 residents counted.
4.8% this home
Median of homes: Oregon2.6% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 52 residents counted.
100.0% this home
Median of homes: Oregon98.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 37 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: LEBANON CARE CENTER, LLC. CMS links this home to Avamere, a group of 27 nursing homes averaging 3 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Bruns, Maureen | Contracted managing employee | Individual | 08/01/2020 | |
| Hutchinson, Jonathan | W-2 managing employee | Individual | 03/01/2024 | |
| Kofstad, Mary | Corporate officer | Individual | 02/13/2024 | |
| Simpson, Andrew | Corporate officer | Individual | 06/01/2024 | |
| Avamere Health Services LLC | Operational/managerial control | Organization | 01/01/2017 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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