Avamere Rehabilitation: Missed Shower Days - OR
Federal inspectors found that Resident 16 at Avamere Rehabilitation Of Lebanon received showers on July 8, 15 and 22, but missed scheduled bathing on July 11, 18 and 29. The resident's care plan required two staff members to assist with bathing due to their medical conditions.
The resident was admitted July 5 with diagnoses including metabolic encephalopathy, a temporary or permanent brain dysfunction caused by problems with the body's metabolism. Their admission assessment indicated complete dependence on staff assistance for bathing and showering.
Bath and shower task logs for July showed blank entries for the three missed days. No progress notes from July 5 through July 30 documented that staff offered the resident alternative showering opportunities when scheduled baths were missed or refused.
Staff 8, a certified nursing assistant, told inspectors September 4 that there were times when staff would get too busy to chart tasks performed on residents. She said after completing a shower task, she would document it as finished.
The facility's expectation was for residents to receive baths or showers twice weekly, according to Staff 6, the resident care manager and licensed practical nurse. She told inspectors September 8 that blank entries in the bath and shower logs indicated the task was not completed.
Staff 6 later provided documentation stating that on July 11, Resident 16's bath or shower was not completed due to being short-staffed.
The missed showers placed residents at risk for poor hygiene, inspectors determined. The facility failed to provide adequate bathing care for the resident who required two-person assistance due to their respiratory and neurological conditions.
Inspectors reviewed three residents for activities of daily living and found the bathing deficiency affected one resident. The violation was classified as minimal harm or potential for actual harm.
The resident's July 13 assessment confirmed their dependence on staff assistance for all bathing activities. Despite this documented need and the facility's twice-weekly bathing schedule, gaps in care occurred when staffing levels dropped.
No evidence existed that supervisors followed up on missed bathing days or ensured alternative arrangements for the resident's hygiene needs. The blank documentation entries revealed a pattern of incomplete care that went unaddressed for weeks.
Staff members' admission that they were too busy to document completed tasks raised questions about what other care might have been provided but not recorded, or missed entirely during understaffed shifts.
The inspection occurred September 8 following a complaint about the facility's care practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avamere Rehabilitation of Lebanon from 2025-09-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Avamere Rehabilitation Of Lebanon in LEBANON, OR was cited for violations during a health inspection on September 8, 2025.
The resident's care plan required two staff members to assist with bathing due to their medical conditions.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.