Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Evercare Of Lebanon during CMS and state inspections, most recent first.
A cognitively intact male resident with a documented history of sexually inappropriate behavior was observed by a CNA with his hand inside the brief of a severely cognitively impaired, nonverbal female resident who was bedbound and dependent for all ADLs. The CNA had just applied a tightly secured brief, later found loose after the incident, and saw the male resident remove his hand from the front of the brief when confronted. Although the facility’s abuse policy required mandatory, immediate reporting and investigation of suspected sexual abuse, the CNA did not report the event as abuse, assuming others were aware, and facility leadership only addressed the male resident’s placement without treating the incident as a reportable allegation. The male resident had prior psychiatric documentation of hypersexual behavior and boundary violations, but his care plan lacked interventions for sexual behaviors, and the observed incident was not timely reported to the Administrator or external authorities as required.
A cognitively intact male resident with bipolar and schizoaffective disorders, and a documented history of impulsive and sexually inappropriate behaviors, was not care planned for sexual behaviors and was allowed access to other residents. A nonverbal, terminally ill female resident with severe dementia and total ADL dependence was found in bed with this male resident standing against her bed rail; a CNA observed him remove his hand from the front of her brief, which she had previously secured tightly, and then noted the brief was loose. The CNA did not immediately report the incident, believing others were aware. In a later interview, the male resident admitted to sexually abusing her. In a separate event, the same male resident reported physically fighting another severely cognitively impaired male resident who had entered his room and bed, stating the other resident was hurt. The facility’s abuse policy affirms zero tolerance for abuse and requires reporting of resident‑to‑resident altercations caused by willful actions resulting in injury or mental anguish, yet surveyors found the facility failed to protect residents from resident‑to‑resident abuse by this known high‑risk resident.
A facility failed to prevent misappropriation of alprazolam for two residents with severe cognitive impairment. Staff discovered that the pharmacy had sent two cards of medication for each resident, but only one card was accounted for on file, and the missing doses could not be located. An LPN signed for the delivery, narcotics counts were inconsistent, and the residents were unable to report whether they had missed any medication.
A facility was unable to account for alprazolam for two residents after a discrepancy was found in the narcotic count and the expected medication cards were missing. One resident had severe cognitive impairment, multiple psychiatric and medical diagnoses, and was confused during survey; the other resident also had severe cognitive impairment and was wandering on the locked dementia unit. Staff reported the count records were not available, the medication totals did not match, and the facility could not determine who took the meds.
A resident with a history of elopement and cognitive impairment exited a secured memory care unit without staff intervention after an exit alarm was misattributed to a malfunctioning door. Staffing shortages and miscommunication delayed the response, resulting in the resident being missing for over two hours before being found unharmed in a nearby residential area.
A resident eloped from a locked memory care unit when only one CNA was present on the hall, as the other CNA was on break and the LPN was covering multiple areas. Staff interviews and observations revealed that alarms were not promptly responded to due to staffing shortages and communication issues, and a nurse was observed sleeping during a shift. These deficiencies affected the facility's ability to provide adequate care and supervision for all residents.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that the environment was not maintained safely and supervision was lacking, but does not provide further specifics.
The facility did not provide the required RN coverage for at least eight consecutive hours per day, seven days a week, as only the DON was employed as an RN and no other RNs were scheduled or present. This deficiency affected all residents in the facility, which had a census of 75 to 78 residents.
The facility did not maintain RN coverage for at least eight consecutive hours daily, as required. Several dates were identified without an RN on duty, particularly on weekends. Staff interviews confirmed the shortage, and the Administrator acknowledged the issue, citing recruitment efforts and an RN's health concerns as contributing factors.
The facility failed to follow its Legionella Policy, with the Maintenance Director not performing required weekly water checks and lacking training. Additionally, a CNA did not adhere to hand hygiene protocols during incontinent care for a resident with multiple medical conditions, including COPD and bilateral amputations. These deficiencies in infection control practices posed a risk to all 54 residents.
The facility failed to feed residents with dignity, affecting four residents who were dependent on staff for eating assistance. A CNA was observed standing over a resident while feeding, and other residents were referred to as "feeders" within earshot, contrary to the facility's policy on maintaining dignity during meals.
The facility failed to implement and follow care plan interventions to prevent falls, resulting in multiple incidents. A resident with cognitive impairment experienced falls due to improper placement of assistive devices and incomplete 15-minute checks. Another resident, dependent on staff for mobility, attempted self-transfers without adequate assistance, leading to repeated falls. Additionally, a resident with osteoporosis and a recent fracture lacked fall precautions, and improper use of a mechanical lift was observed.
The facility failed to properly label and store medications for four residents, leading to deficiencies in medication administration. Medications were found unattended in residents' rooms, and an opened medication bottle lacked a date. Staff confirmed that medications should not be left at the bedside without a doctor's order, which was not present. The facility's policies require medications to be labeled with the date opened and not left unattended, but these standards were not followed.
The facility failed to provide adequate incontinent care for three residents, as observed by surveyors. Residents did not receive proper perineal care, including the application of barrier cream and the use of necessary equipment, as per their care plans and facility policy. Staff did not follow hand hygiene protocols, leading to incomplete and improper care.
The facility failed to ensure proper oxygen administration for three residents. One resident had undated oxygen tubing and humidifier bottles, contrary to facility policy. Another resident lacked a humidified water bottle on their oxygen concentrator, despite physician orders. A third resident had an empty, undated humidified water bottle attached to their concentrator. The facility's policy did not address dating oxygen supplies, contributing to these deficiencies.
The facility failed to maintain safe equipment conditions by not adhering to its policy for cleaning lint traps in the laundry area. Observations showed moderate lint accumulation, and staff admitted to not cleaning the traps as required. This poses a potential fire hazard, affecting all 54 residents.
The Facility failed to document the discharge of a resident and did not communicate necessary information to the receiving facility. The resident, who had multiple diagnoses and exhibited behavioral disturbances, was sent to the emergency room but was not accepted back after the bed hold expired. The medical record lacked necessary discharge documentation.
The Facility failed to follow discharge requirements for a resident with severe cognitive impairment and behavioral disturbances. After the resident was sent to the emergency room for physical aggression and sexually inappropriate behaviors, the Facility did not document a discharge plan or notify the resident and her representative, choosing not to readmit her after her bed hold expired.
The Facility failed to readmit a resident after hospitalization, despite having a bed available, due to the resident's expired bed hold and behavioral issues. The resident had severe cognitive impairment and exhibited inappropriate sexual behavior and aggression. The Facility did not comply with its Bed Hold Guarantee Policy or federal regulations.
Failure to Report and Investigate Suspected Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report and investigate an allegation of sexual abuse involving two residents, despite existing policies requiring immediate reporting of suspected abuse. One resident (R3) was an elderly female with unspecified dementia, terminal cerebral atherosclerosis on hospice care, severe cognitive impairment, nonverbal status, and total dependence on staff for ADLs. Another resident (R2) was an elderly male with bipolar disorder, schizoaffective disorder, cerebral infarction, and a documented history of sexually inappropriate behaviors and poor impulse control per psychiatry and progress notes. The facility’s abuse policy required staff, as mandatory reporters, to immediately report suspected physical or sexual abuse, including resident‑to‑resident incidents, to the Administrator and appropriate authorities within specified time frames. On the morning of 03/24/26, CNA V7 assisted R3 with breakfast, then laid her back in bed, applied a new brief, and ensured it was secured tightly, noting that R3 could not loosen or remove the brief herself due to her decline. About 15 minutes later, while walking past R3’s room, V7 looked in and observed R2 up against R3’s bed rail. V7 yelled at R2 that he was not supposed to be in the room. As R2 stepped away, V7 saw his hand inside the front of R3’s brief and then saw him remove his hand; she then entered, removed R2 from the room, and noted that R3’s brief, previously secured tightly, was now loose. V8, the MDS Coordinator, heard the CNA yell, came to the room, and took R2 away. V7 later confirmed that R3 had been positioned on her back and that she saw R2 remove his hand from the front of R3’s brief when she yelled at him. Despite witnessing this event, V7 did not report the incident as abuse or suspected sexual abuse to the Administrator or other supervisory staff. V7 stated she assumed others knew what had happened because V8 removed R2 from the room and the Administrator later moved R2 to a different room, and she acknowledged she did not tell anyone and that no one asked her questions about the incident. V8 reported only that R2 had been found in R3’s room and removed, and the Administrator and other leadership stated that nothing was reported to them that, in their view, justified making a reportable allegation to the state survey agency at that time. The facility’s own abuse prevention policy required prompt investigation and reporting of suspected abuse, including resident‑to‑resident incidents that could cause mental anguish, and specified that anyone suspecting criminal sexual abuse against a resident without decision‑making capacity must immediately report it to the Administrator and DON and that the Administrator must notify state survey, APS, law enforcement, and the Ombudsman within two hours if abuse is suspected. These requirements were not followed in response to the observed incident between R2 and R3. Additional documentation showed that R2 had a known history of sexually inappropriate behavior prior to this event. A psychiatry note from 08/18/25 documented follow‑up for impulsivity and inappropriate sexual behaviors, and a 03/30/26 progress note described ongoing behavioral dysregulation with inappropriate sexual behaviors, poor impulse control, boundary violations, and hypersexual actions including inappropriate touching of staff, requiring increased supervision. However, R2’s care plan did not include any problem, goal, or interventions related to sexually inappropriate behaviors. On 04/02/26, when questioned about the incident with R3, R2 stated he had sexually assaulted her and admitted to touching her inappropriately, though he later denied knowing her during the facility’s internal investigation. Staff interviews indicated that R2 had been wandering and entering rooms, including R3’s, and that he had been moved between units due to behaviors, but staff and administration did not treat the 03/24/26 event as a reportable allegation of sexual abuse at the time it occurred. The surveyors determined that Immediate Jeopardy began on 03/24/26 in the morning when R2, with known sexually inappropriate behavior, was seen with his hand in R3’s brief and staff did not report the incident.
Failure to Protect Residents From Known Sexually Inappropriate and Aggressive Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident‑to‑resident abuse, specifically sexual abuse of one resident and physical aggression toward another, by a resident with known inappropriate sexual behaviors and aggression. One resident (R3) was an elderly female with unspecified dementia, terminal cerebral atherosclerosis, breast cancer, major depressive disorder, and HTN, who was nonverbal, severely cognitively impaired, dependent for all ADLs, and receiving hospice care. Another resident (R2) was a cognitively intact male with bipolar disorder, schizoaffective disorder, cerebral infarction, and a history of impulsive and sexually inappropriate behaviors. Prior to and during his admission, R2 had documented sexually inappropriate comments and behaviors, including asking to play with a resident’s breast and exhibiting impulsive behaviors wanting to touch other residents inappropriately, for which he had been sent to the hospital for evaluation and had psych treatment initiated to target impulsivity and inappropriate sexual behaviors. Despite this history, R2’s care plan at admission did not include any problem, goal, or interventions addressing sexually inappropriate behaviors, although it did address his potential for physical aggression. On the date of the alleged sexual abuse of R3, a CNA (V7) reported that she had assisted R3 with breakfast, then laid her on her back in bed, applied a new brief, and secured it tightly, noting that R3 was not able to remove or loosen the brief herself due to her decline in health. About 15 minutes later, while walking past R3’s room, V7 looked in and saw R2 up against R3’s bed rail. When she yelled at R2 that he was not supposed to be in that room, she observed R2 step away from R3 and saw his hand being removed from the front of R3’s brief; she then noticed that R3’s brief, which she had previously secured tightly, was now loose. V7 removed R2 from the room. She did not report the incident to anyone at that time because she believed others were already aware after another staff member took R2 away and the administrator later moved him, and she stated that no one asked her any questions about the incident. In a later interview, R2 admitted to touching R3 inappropriately and stated, “I f****d her in the a**,” indicating that he had sexually abused her and that this was the reason he was moved to the locked unit. The facility’s own final report to the state agency initially characterized the allegation as hearsay and stated that there were no eyewitnesses, that staff were not aware of any issues between R2 and R3, and that R3 had not appeared in distress when observed, even when R2 was in her room. The report also documented that R2 had ongoing behavioral dysregulation with inappropriate sexual behaviors, poor impulse control, and boundary violations, including hypersexual actions and inappropriate touching of staff, and that he required increased supervision. In a separate incident involving R2 and another resident (R5), who was severely cognitively impaired and dependent for most ADLs, staff reported a resident‑to‑resident physical altercation after R5 was seen coming out of R2’s room and R2 reported that R5 had been in his bed and going through his belongings; R2 stated he fought the other resident and that the other resident was hurt. The facility’s abuse policy states that each resident has the right to be free from abuse, that there is zero tolerance for abuse, and that resident‑to‑resident altercations must be reported if caused by a willful action resulting in physical injury, mental anguish, or pain, and that the presence of a mental disorder does not preclude deliberate non‑accidental behavior. The survey findings concluded the facility failed to ensure residents were protected from resident‑to‑resident abuse, including sexual abuse of R3 by R2, despite R2’s known history of inappropriate sexual behaviors.
Missing alprazolam for two cognitively impaired residents
Penalty
Summary
The facility failed to ensure misappropriation of medication did not occur for two residents who were reviewed for missing controlled substances. The deficiency involved alprazolam for two residents, both of whom had severe cognitive impairment and were unable to answer questions about whether they had missed medications. One resident had diagnoses including POTS, schizoaffective disorder, hypertension, hypothyroidism, atrial fibrillation, anxiety, anemia, insomnia, hyperlipidemia, GERD, polyarthritis, dementia, schizophrenia, cognitive communication deficit, vitamin D deficiency, depression, and allergic rhinitis. The other resident had diagnoses including Parkinson’s disease, asthma, hypotension, dementia with agitation, bipolar disorder, anxiety, insomnia, and dysphagia. The issue began when staff attempted to reorder the residents’ alprazolam and were told by the pharmacy that two cards, totaling 60 doses, had already been sent. Staff then realized there was only one card on file for each resident when there should have been two. Staff reported that narcotics counts were being done, but the sheet showing 60 pills versus 30 was not present, and the discrepancy was not identified until the medication was being reordered. The facility was unable to locate the missing medication, and the medication was replaced by the facility. Record review showed the pharmacy packing slip documented delivery of alprazolam cards for one resident, with an LPN signing for the medication. The residents’ progress notes did not address the missing alprazolam. Initial reports documented alleged misappropriation of property, notification of the MD, POA, and police, and an investigation. Staff interviews reflected uncertainty about who had access to the medications and whether anyone had been drug tested or disciplined. The facility’s abuse policy stated residents have the right to be free from misappropriation of property and that the facility has zero tolerance for such conduct.
Unaccounted-for alprazolam for two residents
Penalty
Summary
The facility was unable to account for alprazolam for 2 of 3 residents reviewed for missing narcotic medication. The report states that one card of 30 alprazolam tablets for one resident and one card of 30 alprazolam tablets for another resident were not accounted for, and that the medications were later replaced at the facility’s expense. The deficiency occurred during the period from 10/8/2025 to 10/29/2025 and involved controlled substance reconciliation for residents on the locked dementia unit. One resident had diagnoses including POTS, schizoaffective disorder, HTN, hypothyroidism, Afib, anxiety, anemia, insomnia, HLD, GERD, polyarthritis, dementia, schizophrenia, cognitive communication deficit, vitamin D deficiency, depression, and allergic rhinitis. Her MDS documented severe cognitive impairment for decision making, and her care plan noted false accusations of mistreatment by staff and peers, along with behaviors such as sitting on the floor, flailing her arms, delusions that cops were coming to take her away, and laying on the floor in the hallway. On survey, she was confused and unable to answer questions about whether she had missed medications. Her pharmacy packing slip showed alprazolam was received on 10/8/2025, but her progress notes did not address missing medication. The other resident had diagnoses including Parkinson’s disease, asthma, hypotension, dementia with agitation, bipolar disorder, anxiety, insomnia, and dysphagia, and his MDS documented severe cognitive impairment. On survey, he was wandering on the locked dementia unit and unable to answer questions about missed medications. The facility’s initial report stated staff reported alleged misappropriation of property after the DON was notified that medications could not be reordered for two residents and a discrepancy was found in the number of alprazolam cards the facility should have had on hand. Staff interviews indicated the narcotic count records were not present and the count was off, and the facility could not determine who took the medications.
Failure to Prevent Elopement from Secured Memory Unit
Penalty
Summary
A deficiency occurred when a resident with a known history of elopement and diagnoses including paranoid schizophrenia, cognitive impairment, and wandering behaviors exited a secured memory care unit without staff intervention. The resident was identified as an elopement risk, with documentation in the elopement binder and care plan noting previous incidents of leaving facilities and attempts to hide or leave unnoticed. On the evening of the incident, the resident exited through a locked door that required a code, which triggered an alarm. However, staff did not immediately recognize the alarm as indicating an exit from the men's unit, partly due to previous issues with a different door alarm and staffing shortages at the time. Only one CNA was present on the hall, as the other was on break, and the nurse was occupied with medication administration on another hall. The alarm was initially misattributed to a sticking door on the women's side, leading to a delay in response. Staff did not immediately check the source of the alarm, and a head count was not initiated until after the alarm had sounded and the resident had already left the building. The resident was unaccounted for during the head count, and a search was initiated. The resident was missing for over two hours, during which time local authorities, canine units, and a helicopter with infrared technology were involved in the search. The resident was eventually found in a residential area, having traversed steep and overgrown terrain in the dark. Interviews with staff revealed that the split staffing and miscommunication about the alarm contributed to the delay in identifying and responding to the elopement. The CNA present on the men's hall had hearing issues and did not immediately investigate the alarm, assuming it was related to the previously malfunctioning door. The nurse and other staff were not immediately aware that the resident had exited, and the search only began after the head count confirmed the resident was missing. The resident was ultimately found unharmed, but the lack of adequate supervision and delayed response allowed the resident to leave the facility unnoticed and unsupervised for an extended period.
Removal Plan
- R2 was moved to a room closer to the nurse's station.
- R2 was placed on 1:1 supervision with re-evaluation.
- R2's elopement risk was re-evaluated.
- A psych medication review was requested for R2.
- Administrator and Director of Nursing were in-serviced by the VP of Clinical Services.
- Administrator in-serviced the Intradisciplinary Team (IDT).
- Current staff were in-serviced on elopement policy and procedure.
- All residents in the facility had an elopement risk assessment completed.
- Elopement Binder was updated based on those risk assessments.
- Review of policy and procedure was completed to reflect current practice.
- All staff were in-serviced on elopement and procedures on steps to take if a resident is at risk.
- All facility staff were in-serviced for elopement and staffing.
- A QA tool was implemented along with audits of the 24-hour report for wandering/elopement risks.
- Audit for elopement risk assessments completed within admission.
- Audits to continue to ensure that elopement risk is documented.
- Root Cause Analysis completed for elopement.
Inadequate Staffing Leads to Resident Elopement and Lapses in Supervision
Penalty
Summary
The facility failed to provide an adequate number of nursing staff to meet the needs of all residents, as evidenced by an incident where a resident eloped from the male locked memory care unit. On the night of the elopement, staffing was insufficient, with only one CNA present on the relevant hall while the other CNA was on break, and the LPN was responsible for multiple areas. Staff interviews confirmed that the nurse was unaware of the staffing shortage at the time, and the CNA present had hearing issues and did not respond to the alarm, mistaking it for a recurring door issue. The facility's staffing policy requires sufficient licensed and unlicensed staff on each shift, but the actual staffing levels did not meet this standard during the incident. Observations also revealed that a nurse was found sleeping during a shift, and staff reported challenges in managing multiple halls and responding to alarms due to inadequate staffing. The administrator stated she had not observed staff sleeping during her visits, but the incident reports and staff interviews indicate lapses in supervision and response. The facility census documented 76 residents at the time, all potentially affected by the staffing deficiencies.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required Registered Nurse (RN) coverage for at least eight consecutive hours per day, seven days a week, as mandated. According to interviews with the Administrator and the Director of Nursing (DON), the DON was the only RN employed and present in the building, and there were no other RNs scheduled or working during the reviewed period. The facility's nursing schedule and facility assessment confirmed that no other RN was present except for the DON, and during the survey period, no RN was observed in the facility, including the DON. The facility census was documented as 75 to 78 residents during this time.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, which is a requirement for maintaining the highest practical physical, mental, and psychosocial well-being of each resident. The Nursing Master Schedule revealed that there were several dates without an RN on duty, specifically on 11/10/24, 11/23/24, 11/24/24, 11/30/24, 12/1/24, 12/7/24, 12/8/24, 12/14/24, and 12/15/24. Interviews with staff, including a Certified Nursing Assistant (CNA) and the Administrator, confirmed the lack of RN coverage, particularly over the weekends. The Administrator acknowledged the shortage and mentioned ongoing efforts to recruit RNs, noting that one RN was unable to work due to health concerns. The facility's Nurse Staffing Policy emphasizes the importance of having sufficient licensed and unlicensed nursing staff on each shift to ensure resident well-being.
Infection Control Deficiencies in Legionella Management and Hand Hygiene
Penalty
Summary
The facility failed to operationalize its Legionella Policy and Procedure, as observed during a survey. The Maintenance Director, V17, stated that he runs water and flushes toilets monthly in empty rooms and checks the temperatures of hot water monthly, contrary to the policy which requires these actions weekly. Additionally, V17 admitted to never taking shower heads apart for cleaning and disinfection, as required every three months. The facility lacked a water flow diagram and had not identified areas with potential waterborne pathogen growth. Furthermore, neither V17 nor any facility staff had been trained on legionella procedures or policies, as confirmed by the Administrator, V1. The facility also failed to ensure proper hand hygiene practices, as observed with R5, a resident with multiple medical conditions including COPD and bilateral above-knee amputations. During incontinent care, a CNA, V9, was seen performing care without changing gloves or performing hand hygiene before, during, or after the procedure. This was contrary to the facility's Hand Hygiene and Perineal Cleansing Policies, which require hand washing after resident contact and glove changes. V9 admitted to only performing hand hygiene at the start of her shift and after resident interactions, which does not align with the facility's expectations. R5's care plan indicated a need for significant assistance with activities of daily living due to his medical conditions, including dependence on supplemental oxygen and frequent incontinence. The facility's failure to adhere to its infection control policies, both in terms of legionella prevention and hand hygiene, posed a risk to all 54 residents, as documented in the survey findings.
Failure to Feed Residents with Dignity
Penalty
Summary
The facility failed to feed residents in a dignified manner, affecting four residents who were reviewed for dignity. Resident R34, who was admitted with diagnoses including dementia with behavioral disturbances, major depressive disorder, and chronic post-traumatic stress disorder, was observed being fed by a CNA who stood over him. R34's Minimum Data Set (MDS) indicated severely impaired cognitive skills and dependence on staff for eating assistance. The care plan for R34, last revised in September 2024, documented that he is dependent on staff for activities of daily living, including eating. Additionally, residents R11, R14, and R17 were seated together in the dining room when CNAs referred to them as "feeders" within their earshot. All three residents were documented as severely cognitively impaired and dependent on staff for eating assistance. The facility's policy on assistance with meals, revised in July 2017, emphasized feeding residents with attention to safety, comfort, and dignity, specifically advising against standing over residents and using labels such as "feeders." However, these guidelines were not followed, leading to the deficiency.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and follow progressive care plan interventions to prevent falls for several residents, leading to multiple incidents of falls. One resident, who was moderately cognitively impaired and at high risk for falls, experienced several falls due to cognitive deficits and improper placement of assistive devices. Despite being on 15-minute checks as an intervention, documentation showed multiple instances where these checks were not completed as required. The administrator acknowledged the issue when presented with the documentation. Another resident, with a history of multiple falls and high fall risk, was observed attempting self-transfers without adequate staff assistance, despite being dependent on staff for mobility. The resident expressed frustration over the lack of assistance, and staff admitted to not always being present during transfers. This lack of supervision and assistance contributed to the resident's repeated falls. Additionally, a resident with a history of osteoporosis and a recent fracture was found without fall precautions in place, and their call light was not within reach. The resident's care plan included interventions to prevent falls, but these were not consistently implemented. The facility's policy on fall prevention and mechanical lift usage was not adhered to, as evidenced by improper use of the lift and lack of staff support during transfers, further compromising resident safety.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication labeling and storage for four residents, leading to deficiencies in medication administration. During observations, medications were found left unattended in residents' rooms, contrary to the facility's policy that requires medications to be administered directly and not left at the bedside. For instance, a resident was observed with a cup of medications on the nightstand, which had been administered earlier by an LPN. Another resident had inhalers left on the nightstand, and the LPN confirmed that inhalers should be kept in the medication cart. Additionally, a medication cart inspection revealed an opened bottle of escitalopram without a date indicating when it was opened, violating the facility's policy that requires dating medication containers upon opening. Interviews with staff, including the Administrator and Director of Nursing, confirmed that medications should not be left at the bedside unless there is a specific doctor's order, which was not present for the residents involved. The facility's policies on medication procurement and administration clearly state that medications must be labeled with the date opened and should not be left unattended. Despite these policies, the facility did not adhere to these standards, resulting in the observed deficiencies.
Inadequate Incontinent Care for Residents
Penalty
Summary
The facility failed to provide proper incontinent care for three residents, R5, R11, and R26, as observed by surveyors. R11, who is severely cognitively impaired and dependent on staff for activities of daily living, did not receive appropriate perineal care. During an observation, CNAs V14 and V15 did not cleanse R11's outer labia, failed to apply barrier cream as per the care plan, and did not use a washcloth, wash basin, and soap as required by facility policy. Similarly, R26, who is also severely cognitively impaired and requires substantial assistance, did not receive proper incontinent care. CNAs V14 and V10 failed to cleanse the outer labia and did not apply barrier cream as documented in R26's care plan. They also did not use the necessary equipment, such as a washcloth, soap, and wash basin, as per the facility's policy. R5, who has multiple diagnoses including COPD and bilateral above-knee amputations, was observed receiving incomplete incontinent care. CNA V9 did not cleanse R5's penis or scrotum and used the same towel for multiple areas without proper hand hygiene. The facility's hand hygiene policy and perineal cleansing policy were not followed, as V9 did not perform hand hygiene before and after resident contact, and the proper sequence of cleansing was not adhered to.
Failure to Ensure Proper Oxygen Administration
Penalty
Summary
The facility failed to ensure proper oxygen administration for three residents, as observed during a survey. For one resident, the oxygen cannula was connected to a humidifier bottle without a date, and the tubing was not dated, contrary to the facility's policy of changing and dating the tubing weekly. The resident's physician orders did not include instructions for changing the oxygen tubing, and despite the facility's policy, the tubing remained undated and in use over several days. Another resident, who was dependent on supplemental oxygen due to multiple health conditions, was observed without a humidified water bottle attached to their oxygen concentrator, despite physician orders and treatment records indicating that the tubing and humidifier should be changed weekly. Similarly, a third resident was found with an empty and undated humidified water bottle attached to their oxygen concentrator, and the nasal cannula was observed lying on the floor. The facility's policy did not address the dating of oxygen supplies, contributing to the oversight.
Failure to Maintain Safe Equipment Conditions in Laundry Area
Penalty
Summary
The facility failed to maintain equipment in a safe condition, specifically regarding the cleaning of lint traps in the laundry area. Observations revealed that the lint traps, each measuring 36 inches by 23 inches, had a moderate accumulation of lint, and the laundry staff member responsible for cleaning them stated she had never cleaned them and was unaware of when they were last cleaned. The Maintenance Director admitted to cleaning the lint traps only monthly, despite the facility's policy requiring daily cleaning. The Regional Maintenance Director confirmed that lint traps should be cleaned after every dryer cycle, highlighting a discrepancy between practice and policy. The facility's policy clearly outlines the necessity for daily cleaning of lint screens and monthly comprehensive cleaning by maintenance staff. However, the actual practice did not align with these guidelines, posing a potential fire hazard due to lint accumulation. The Administrator expected daily cleaning, but this was not being implemented. The report also references an article by a retired fire chief emphasizing the importance of regular lint trap cleaning to prevent fires, further underscoring the facility's failure to adhere to safety protocols. This deficiency has the potential to affect all 54 residents in the facility.
Failure to Document Discharge and Communicate Necessary Information
Penalty
Summary
The Facility failed to document the discharge of a resident (R2) in the medical record and did not communicate necessary information to the receiving facility. R2 was admitted with multiple diagnoses including hypertension, diabetes, chronic liver disease, anxiety, and chronic depression. The Minimum Data Set (MDS) indicated that R2 was severely cognitively impaired and exhibited behavioral disturbances such as verbal aggression and throwing items at staff. On a specific date, R2 was sent to the emergency room after exhibiting physically aggressive and sexually inappropriate behaviors. However, the medical record did not contain any documentation regarding the discharge, basis for discharge, physician documentation, or any other important information necessary for R2's care at the receiving facility. Interviews with the Administrator, Social Services Director, and Director of Nursing revealed that the Facility did not initiate an involuntary discharge for R2. Instead, they stated that R2's bed hold expired, and the resident was not accepted back after that. The Facility's Transfer and Discharge Policy and Procedure require documentation in the resident's clinical record, including the attending physician's documentation that the facility cannot provide for the resident's welfare or that the resident no longer requires the facility's services. This documentation was missing in R2's case.
Failure to Follow Discharge Requirements
Penalty
Summary
The Facility failed to follow discharge requirements for a resident (R2) who was admitted with diagnoses including hypertension, diabetes, chronic liver disease, anxiety, and chronic depression. R2 was documented as severely cognitively impaired with behavioral disturbances such as stripping clothes in public areas, verbal aggression, and throwing things at staff. On a specific date, R2 was sent to the emergency room after exhibiting physical aggression and sexually inappropriate behaviors. Following this incident, there was no documentation in R2's medical record regarding a plan for discharge, the basis for discharge, or advanced notification of discharge to R2 and her representative. The Facility's staff, including the Administrator, Social Services Director, and Director of Nursing, confirmed that R2 was not given an involuntary discharge notice and that her bed hold expired while she was in the hospital. The Facility chose not to readmit her. The Facility's Bed Hold Guarantee Policy and Transfer and Discharge Policy require that if a resident cannot return to the facility, the facility must comply with 42 CFR, Sec 483.15 (c) and notify the resident and their representative of the transfer and the reasons for it. This was not done in R2's case, leading to a deficiency in following proper discharge procedures.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The Facility failed to allow a resident (R2) to return after hospitalization, exceeding the bed-hold policy. R2, who was admitted with diagnoses including hypertension, diabetes, chronic liver disease, anxiety, and chronic depression, was severely cognitively impaired and exhibited behavioral disturbances such as verbal aggression, inappropriate sexual behavior, and physical aggression. Despite having a bed available, the Facility chose not to readmit R2 after the bed-hold period expired, citing R2's inappropriate behavior and aggression as reasons for their decision. The Facility's Bed Hold Guarantee Policy states that a Medicaid resident whose hospitalization exceeds the 10-day bed-hold period may return to their previous room if available or immediately upon the first availability of a bed in a semi-private room. However, the Facility did not comply with this policy or the federal regulation 42 CFR, Sec 483.15 (c), which requires compliance when a resident cannot return to the facility after a transfer with an expectation of return. Interviews with various staff members, including the Business Office Manager, Administrator, Social Services Director, Director of Nursing, and a Licensed Practical Nurse, confirmed that R2 was not readmitted due to her expired bed hold and behavioral issues. The Administrator admitted that there was a bed available for R2 but stated that they chose not to accept her back due to her inappropriate behavior and aggression. The Facility's Bed Census also documented that the room previously occupied by R2 was not occupied at the time of her potential readmission.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 378 citations issued within 25 miles in the last 12 months — including the 22 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lebanon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Ridge Health & Rehab Ctr | 0.6 mi | ★★★★★ | 8 | 0 |
| Nexus At Mascoutah | 8.1 mi | ★★★★★ | 3 | 0 |
| Clinton Manor Living Center | 8.4 mi | ★★★★★ | 0 | 0 |
| La Bella Of Mascoutah | 8.7 mi | ★★★★★ | 15 | 0 |
| Au Well Care Home, Inc | 10.3 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.