Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rehabilitation Center Of Lisbon during CMS and state inspections, most recent first.
A resident with intact cognition and multiple conditions including prior fracture, CVA, DM, CKD, and history of TIA was care-planned as a fall risk, requiring one-person assistance with transfers and ambulation using a wheeled walker and gait belt, and not to be left unattended in a wheelchair in the room. Despite these interventions and posted signage instructing staff not to leave the resident unattended and to use the call light, surveyors observed the resident repeatedly propelling herself in a wheelchair from the dining area to her room, entering and using the bathroom alone, and independently transferring from the wheelchair to a recliner while pushing the wheelchair and walking with a stooped posture. The resident had a documented unwitnessed fall after self-ambulating in the room without using the call light, and staff interviews confirmed the required assistance level and fall-prevention measures that were not consistently implemented.
Multiple residents experienced significant medication errors when staff failed to follow physician orders, verify the correct resident, and accurately transcribe and implement hospital discharge instructions. A resident with severe cognitive impairment received another resident’s full set of morning medications. Another resident with chronic pain was given PRN oxycodone too soon after a prior dose and again in place of a scheduled MS Contin dose during the same shift by an LPN. A third resident with heart failure, ESRD, and diabetes had hospital orders to discontinue and change several medications, including Farxiga, Augmentin, Lasix, and to add Midodrine with BP parameters, but facility staff continued some discontinued drugs, delayed starting the replacement antibiotic, and administered Midodrine without the ordered BP hold parameters or documented BP checks.
The facility failed to ensure proper PPE use when handling soiled laundry. A laundry aide was observed wearing gloves but not a gown while sorting linens. The Environmental Supervisor confirmed that only gloves are used for general laundry, while gowns and goggles are used for isolation laundry. The Administrator was unsure of PPE requirements for general laundry, despite facility guidelines stating that gloves and gowns should be available.
Failure to Implement Care-Planned Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement established fall-prevention interventions for a resident assessed as at risk for falls. The resident had intact cognition with a BIMS score of 15/15 and diagnoses including fracture with multiple trauma, CVA, muscle wasting and atrophy, Type 2 DM, CKD, history of TIA, and a history of fall with left hip fracture and repair. The care plan, revised on multiple dates, identified that the resident required supervision or touching assistance with transfers and walking, assistance of one staff member for transfers and ambulation to and from the bathroom using a wheeled walker and gait belt, and specific fall-prevention interventions. These interventions included not leaving the resident unattended in a wheelchair in the room, assisting with ambulation and transfers as needed, and having a sign in the room instructing use of the call light. Despite these care-planned interventions, observations on several dates showed the resident propelling herself in a wheelchair from the dining room to her room, entering and using the bathroom independently, and transferring herself from the wheelchair to a recliner without staff assistance. On one occasion, the resident was observed ambulating independently from the bathroom while pushing the wheelchair backwards with a stooped posture before sitting in a recliner. The resident had a documented unwitnessed fall in her room after self-ambulating to get a blanket without using the call light, stating she thought she could do it herself. A sign instructing staff not to leave the resident unattended in a wheelchair in the room was present, and staff interviewed acknowledged that the resident required one-person assistance with a walker and gait belt and that interventions included not leaving her unattended in the wheelchair in her room. The facility’s fall policy required that, based on assessment, interventions be implemented and placed on the care plan, but the observed practices did not align with the care-planned interventions for this resident.
Multiple Medication Administration and Transcription Errors Affecting Several Residents
Penalty
Summary
The deficiency involves multiple failures to ensure residents were free from significant medication errors, including wrong-resident administration, incorrect timing and drug selection, and failures to correctly transcribe and implement hospital discharge orders and medication parameters. One resident with severe cognitive impairment and multiple serious diagnoses, including GI hemorrhage, heart failure, anemia, and orthostatic hypotension, was given another resident’s entire set of morning medications. These medications included multiple cardiac, anticoagulant, antidepressant, GI, diuretic, antihypertensive, and other agents that were not ordered for this resident. The error was identified and documented as a medication error, and it was noted that the morning medications had been administered by an LPN. Another resident with osteoarthritis, anemia, HTN, and heart failure, and with intact cognition, had PRN opioid pain medication administered in violation of the ordered dosing interval and in place of a scheduled extended-release opioid. On one day, an LPN administered oxycodone 10 mg at 7:44 a.m. and again at 10:27 a.m., despite a prior dose at 5:41 a.m., even though the order specified administration every 6 hours PRN. Documentation showed that the 7:43–7:44 a.m. dose was ineffective with a follow-up pain score of 7, and an incident report identified that the PRN medication was given only 2.5 hours after the last dose. During the same shift, the same LPN documented holding the resident’s scheduled MS Contin 15 mg dose and instead administered another PRN oxycodone dose in place of the ordered scheduled morphine ER, contrary to the physician’s order. A third resident with moderate cognitive impairment, heart failure, ESRD, Type 2 DM, and non-Alzheimer’s dementia experienced multiple medication transcription and administration errors related to hospital discharge instructions. Hospital documentation directed discontinuation of Jardiance, but the facility MAR showed the resident was on Farxiga, and there was no documentation that staff clarified this discrepancy between 1/5 and 1/15. A later hospital discharge summary ordered Farxiga to be stopped, yet the MAR showed Farxiga was administered for several days after the resident’s return before being discontinued. Hospital records also ordered Augmentin to be stopped and changed to Amoxil, but the MAR showed Augmentin was continued and only later discontinued, with Amoxil started afterward. Additionally, hospital orders directed that Lasix 60 mg be held until restarted by a provider due to low BP, but the MAR showed Lasix 60 mg was started and continued after the resident’s return. Further, hospital documentation ordered initiation of Midodrine 5 mg TID for syncope, and a provider later added parameters to hold the medication if systolic BP was greater than 140. The MAR did not include these hold parameters, and Midodrine was administered three times daily over multiple days without documentation that BP was checked to ensure it was within the ordered parameters. Staff interviews confirmed that the Midodrine order on the MAR lacked hold parameters and that BP checks prior to administration were not documented. The DON stated that medication errors related to this resident’s Farxiga, Tramadol, and Amoxicillin were identified during a provider visit, and that the failure to implement Midodrine parameters was identified later. Facility policy required staff to read and follow transcribed physician orders on the EMAR, verify patient identity, and administer medications according to the ordered frequency and procedure, but the described events show these steps were not consistently followed for the residents involved.
Inadequate PPE Use in Laundry Handling
Penalty
Summary
The facility failed to use appropriate personal protective equipment (PPE) when laundering soiled items, as observed during a survey. Staff B, a laundry aide, was seen wearing gloves but not a gown while sorting soiled linens on the sorting counter. The Environmental Supervisor explained that soiled laundry arrives in plastic bags in a covered yellow cart and is sorted into bins, with items from isolation rooms placed in a separate red bin. The supervisor noted that only gloves are worn during the sorting of general soiled laundry, while a gown and goggles are used for isolation laundry. The Administrator/Infection Preventionist expected staff to wear an apron or gown for isolation laundry but was unsure about the requirements for general soiled laundry. The facility's Infection Prevention and Control Program (IPCP) Guidelines, revised in September 2022, state that gloves and gowns should be available for workers in the laundry area while sorting linens.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 227 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lisbon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hallmark Care Center | 1.7 mi | ★★★★★ | 11 | 0 |
| Mechanicsville Specialty Care | 7.2 mi | ★★★★★ | 4 | 0 |
| Solon Nursing Care Center | 9.8 mi | ★★★★★ | 0 | 0 |
| Silver Oak Nursing And Rehabilitation Center Llc | 12.1 mi | ★★★★★ | 14 | 0 |
| Linn Manor Care Center | 12.6 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rehabilitation Center Of Lisbon.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.