Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Waters Of Lebanon, The during CMS and state inspections, most recent first.
Grievance forms and/or posted grievance instructions were not readily accessible for all residents. No forms were observed in the lobby, at the nurses' stations, outside the Social Service Director's office, or in the activity room, and only one grievance note was found on a desk in the main lobby. Residents reported there was no good way to file grievances confidentially, and an LPN, QMA, Activity Assistant, and DON were unable to locate any forms. The facility policy stated grievance information should be posted in prominent locations and residents should be able to express concerns orally, in writing, or anonymously.
Staffing was insufficient to answer call lights promptly, and residents were repeatedly left waiting for toileting, transfers, showers, and other assistance. Observations showed call lights sounding throughout the building while an LPN, QMAs, and only a few CNAs were busy with other tasks, and staff often turned off lights without meeting the resident’s need or said they would return but did not. Residents and staff reported long waits, heavy workloads, and that aides were too short staffed to keep up with care.
Incomplete discharge documentation and medication reconciliation: The facility failed to document all medications sent home with one resident who discharged with multiple chronic conditions, including diabetes and depression, and failed to provide a discharge summary with pertinent health information, code status, and physician orders for another resident sent to the hospital with head swelling. The RNC stated only limited medication disposition documentation could be found for the first resident, and no discharge information was located for the second resident despite an SBAR note in the chart.
MDS medication coding was inaccurate for two residents. One resident’s MDS did not reflect ordered anxiolytic use despite an Ativan order and an anxiety-related care plan, and another resident’s MDS did not reflect ordered anticoagulant use despite an Eliquis order and a bleeding-risk care plan. The RCS stated both MDSs had been corrected, and the facility did not have a policy for assessment accuracy and followed the RAI.
A resident with alcoholic cirrhosis, major depression, difficulty walking, and low BP had a cup of meds left on the bedside table and said he had not taken them because he was nauseous and would take them later. The resident’s record lacked an assessment for self-administration, yet his MAR included multiple scheduled meds such as ciprofloxacin, furosemide, spironolactone, promethazine, rifaximin, and midodrine.
A resident with ESRD and dependence on PD did not receive the prescribed dialysate solutions on multiple treatments, with staff using the wrong bag combinations based on the resident’s weight and BP parameters. The resident also had used effluent left in the room after treatment, with a bag of fluid on the floor and empty solution bags left on the dialysis cart, showing that the drained fluid was not timely measured and disposed of as required.
Medication administration error and incorrect dose given. A QMA was setting up medications for two residents at the same time, could not find one resident's acetaminophen, and an LPN returned with the other resident's 325 mg acetaminophen. The QMA stated the married residents sometimes shared medications and then administered only one 325 mg tablet to a resident whose ordered acetaminophen dose was 500 mg TID, leaving the dose 175 mg short. The RCD later found the 325 mg acetaminophen in the other resident's cart even though that resident's ordered dose was 500 mg.
Medication storage and labeling were deficient when a medication cart contained eye drops mixed with nitroglycerin, ear, and oral meds, and multiple inhalers, nasal sprays, and drops lacked open dates or identifying labels. An expired insulin pen was also found in the cart, and the DON’s policy stated that eye drops, ointments, drops, and inhalers are to be kept separate from other meds and that outdated drugs are to be withdrawn from stock.
Inaccurate medication and wound care documentation was identified for a resident with PTSD, anxiety, respiratory failure, and a stage 4 sacral pressure ulcer. The MAR showed duplicate PRN Lorazepam orders documented as given, and the DON stated an LPN charted both doses in error. The resident’s wound care record also reflected treatment orders that did not match the physician order on file, and the chart lacked documentation of an order for the wound treatment listed in the weekly wound evaluation.
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 safe and supervision was lacking, but does not specify further details or identify the individuals involved.
A facility failed to conduct a self-administration assessment for a resident's Ventolin inhaler stored at bedside. The inhaler was observed unattended on the resident's bedside table, and the resident's record lacked the necessary assessment. The resident had multiple diagnoses, including COPD and dementia, and was prescribed Ventolin for shortness of breath. The DON confirmed the medication should not have been left in the room, contrary to the facility's policy requiring an interdisciplinary assessment for self-administration.
The facility failed to conduct comprehensive quarterly assessments for two residents to evaluate their mobility and range of motion (ROM). One resident, with multiple diagnoses including diabetes and heart failure, lacked assessments to measure joint movement and functional status. Another resident, with COPD and hypertension, also lacked necessary assessments. Interviews revealed inadequate documentation processes, preventing data transfer to the MDS and resulting in missing assessments.
The facility failed to label a vial of tuberculin serum appropriately in one medication room. The serum was found undated in a refrigerator with ice buildup. The DON confirmed it should have been dated upon opening, as per the facility's policy.
The facility failed to ensure proper hand hygiene by staff during lunch tray delivery, affecting two residents. The Social Services Director did not perform hand hygiene before entering and after leaving a room requiring Enhanced Barrier Precautions (EBP) due to a resident's medical condition. Interviews confirmed the lapse, and a review of the facility's policy emphasized the importance of hand hygiene in such situations.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in medical records. A resident with ESRD was not coded for dialysis, another with schizophrenia was not coded for Level II status, and two residents were incorrectly coded for anticoagulant use instead of antiplatelet. Additionally, a resident receiving hospice care was not coded as such. These errors were acknowledged by facility staff.
A resident at risk for pressure ulcers did not receive a pressure-reducing cushion for her wheelchair, as required by her care plan. Despite multiple observations, the cushion was not in place, and the Director of Nursing confirmed its absence. The resident's medical conditions included COPD, congestive heart failure, and lung cancer, necessitating preventative measures for pressure ulcers, which were not effectively implemented.
A resident with COPD, congestive heart failure, and lung cancer did not receive oxygen therapy as ordered. Despite having a physician's order for oxygen every shift, the resident was observed multiple times without the prescribed oxygen, and the care plan lacked revisions to address her noncompliance. The DON acknowledged the issue but did not ensure the care plan reflected the necessary changes.
A facility failed to ensure a resident's medical record was kept private and confidential when the Business Office Manager (BOM) disclosed clinical information to the resident's family without permission. The BOM, not authorized to provide clinical information, shared details about the resident's care and mental capacity, constituting a HIPAA violation.
Grievance Forms Not Readily Accessible
Penalty
Summary
The facility failed to ensure grievance forms and/or a grievance process was readily and easily accessible for all 43 residents who resided in the facility. During daily observations throughout the survey period, no grievance forms and no posted grievance instructions were seen in the front lobby, outside the Social Service Director's office, at either nurses' station, or in the activity room. The only related item observed was one grievance note on a desk in the main front lobby, but there were no blank forms or other grievance materials available. During interviews, the Resident Council President and three other residents stated there was no good way to file grievances confidentially and that they hoped residents would feel comfortable enough to tell staff so a grievance could be filed on their behalf. An LPN, a QMA, and an Activity Assistant each reported they did not know where grievance forms were located or had not seen any available. The DON checked the front lobby, copier room, and front nurses' station and found no grievance forms. The Administrator later provided the facility policy titled Grievance/Complaints/Missing Property, which stated residents and responsible parties should be made aware of the right to express complaints or grievances orally, in writing, or anonymously, and that posted information should be available in prominent locations throughout the facility.
Insufficient Nursing Staff and Delayed Call Light Response
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to answer call lights in a timely and appropriate manner. Survey observations showed multiple call lights illuminated, flashing, and sounding throughout the building while the Manager on Duty/Charge Nurse was busy passing medications and only one LPN, two QMAs, and three CNAs were available on the floor. Staff interviews confirmed the building was short staffed, especially on weekends, and that the aides were trying to care for too many residents at once. During observations, residents were repeatedly left waiting for assistance. One resident’s bathroom call light was turned off by staff more than once, but the resident stated the aide said she would return and did not come back, and the resident reported this happened often when staff said it was not their hall. Another resident asked for help getting up for church services, but the LPN told him his aide was coming later and left the room after turning off the light. A different resident’s call light remained on for an extended period while the resident waited to get up for lunch, and staff acknowledged the aides were busy and that the resident required two people for transfer. Additional observations showed residents waiting for showers, toileting, and other basic needs while staff were occupied with other tasks. One resident was observed waiting for a shower while the LPN said the two CNAs were tied up with another resident requiring care-in-pairs. Another resident was left on a bedpan after the call light had been turned off, and the resident later stated she had fallen asleep while waiting. A resident who reported feeling ill and wanting to go to the hospital was not assessed by the LPN until later, and another resident at the nurses’ station had to ask three times for tissues before the LPN responded. Resident and council interviews also described long waits for assistance, staff turning off call lights without meeting needs, and aides being too short staffed to keep up with care.
Incomplete discharge documentation and medication reconciliation
Penalty
Summary
The facility failed to send adequate documentation with a resident to the hospital and failed to reconcile a resident's medications when another resident discharged home. Resident 46 was discharged home with diagnoses including chronic respiratory failure, diabetes, neuropathy, major depressive disorder, GERD, and anxiety disorder. His record did not contain documentation showing that all of his medications were sent home with him; only hydrocodone and hydroxyzine were documented as disposed of, while the record lacked reconciliation for amitriptyline, amlodipine, aripiprazole, ascorbic acid, atorvastatin, Plavix, docusate sodium, ferrous sulfate, Humalog, insulin glargine, Jardiance, losartan, metformin, metoprolol, oxybutynin, paroxetine, and tamsulosin. The RNC stated the nurse sent the medications home, but documentation could only be found for hydrocodone and hydroxyzine. Resident 44 had diagnoses including cerebral infarction, acute renal failure, cerebral edema, subarachnoid hemorrhage, weakness, and GERD. Her record lacked a discharge summary with pertinent information about her current health, past health concerns, code status, and physician orders when she was sent out with swelling to the right side of her head. The RNC stated that an SBAR was completed in the progress notes, but no discharge information could be found that was sent with the resident to the hospital. The facility policy for discharge/transfer indicated that for a higher level of care transfer, the completed transfer form, face sheet, advanced directives, MAR/TAR, and other required information were to be sent.
MDS Medication Coding Errors
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for medication use for 2 of 5 residents reviewed. For Resident 51, the MDS Section N indicated she did not take an antianxiety medication, but the physician order showed she was prescribed Ativan 0.5 mg twice daily. Her record also included diagnoses of bipolar disorder, allergies, constipation, pain, and anxiety, and the care plan identified her as at risk for increased anxiousness related to diagnoses with need for anxiolytic use. For Resident 41, the MDS Section N indicated he did not take an anticoagulant and instead indicated antiplatelet use, but the physician order showed he was prescribed Eliquis 2.5 mg twice daily. His diagnoses included generalized edema, GERD, weakness, repeated falls, and diabetes. His care plan identified him as at risk for bleeding related to anticoagulant use, with an intervention for staff to administer medications as ordered. The Regional Nurse Consultant stated the MDS for both residents had been corrected, and the facility did not have a policy for accuracy of assessments, following the RAI.
Medications Left at Bedside Without Self-Administration Assessment
Penalty
Summary
The facility failed to prevent the potential for accidents when medications were left at the bedside and the resident was not supervised to take them for 1 of 1 random observation involving Resident 33. Resident 33 had diagnoses including alcoholic cirrhosis of the liver with ascites, major depression, difficulty walking, and low blood pressure. On 9/7/25 at 10:38 a.m., a cup of medications was observed on his bedside table, and Resident 33 stated he had not taken the medications because he was nauseous and would take them later. Resident 33's medical record did not contain an assessment for self-administration of medications. His medication record showed morning medications including ciprofloxacin HCI 500 mg daily, folic acid 1 mg daily, furosemide 40 mg daily, spironolactone 50 mg daily, thiamine 100 mg daily, zinc sulfate 220 mg daily, promethazine 25 mg twice daily, rifaximin 500 mg twice daily, and midodrine 5 mg, 3 tablets. The DON was informed that medications had been left at bedside, and she stated she educated QMA 5 regarding leaving medications at bedside for residents who had not been assessed to keep medications at bedside.
Peritoneal Dialysis Orders Not Followed and Effluent Not Properly Disposed
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident who required peritoneal dialysis. The resident was a short-term rehab resident with diagnoses including end stage renal disease and dependence on peritoneal dialysis. He had detailed physician orders from his dialysis provider specifying which dialysate bags to use based on weight and blood pressure, but the orders were not electronically entered into the medical record until 8/30/25 even though they were present in the room on paper. Review of the resident’s dialysis logs showed that on 9/2/25, with a weight of 231.3 lbs and blood pressure of 132/64, he received two yellow bags instead of one yellow and one green; on 9/5/25, with a weight of 224.2 lbs and blood pressure of 122/60, he received one green and one yellow bag instead of two yellow bags; and on 9/6/25, with a weight of 224 lbs and blood pressure of 158/78, he again received one green and one yellow bag instead of two yellow bags. The facility also failed to follow infection control measures for the used dialysate. On observation, a bag of fluid was left on the resident’s bedroom floor and had leaked onto the floor, and the resident stated he had come off dialysis about 30 minutes earlier and the nurse had not disposed of the effluent fluid. Two empty solution bags were left on top of the dialysis cart. The DON later provided training materials showing skill validation for proper disposal and storage of contaminated or infectious waste and proper completion of dialysis treatment, and stated that drained effluent needed to be measured and disposed of at the completion of treatment and that parameters needed to be followed closely as prescribed.
Medication Administration Error and Incorrect Dose Given
Penalty
Summary
Nursing staff failed to demonstrate the necessary competency to administer a resident's medication and to give the correct ordered dose to another resident. On 9/7/25, QMA 5 was preparing medications for Resident 24 and Resident 23 at the same time and could not locate Resident 24's acetaminophen, so she sent LPN 4 to search the medication room. LPN 4 returned with Resident 23's acetaminophen 325 mg tablet, and QMA 5 stated the two residents sometimes shared medications because they were married. QMA 5 was told that Resident 24's ordered acetaminophen dose was one 500 mg tablet three times daily, not 325 mg, and she stated that giving two tablets would equal 650 mg before administering only one 325 mg tablet, which was 175 mg short of the ordered dose. On 9/11/25, the RCD stated she found the 325 mg acetaminophen in Resident 23's cart even though Resident 23's ordered dose was 500 mg.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles, and medications were not stored as required in the medication cart and medication room. On 9/7/25 at 11:20 a.m., the 100 hall medication cart was observed with eye drops stored in the top drawer together with nitroglycerin, ear medications, and oral medications. QMA 8 stated she would correct the storage and separate the medications. The cart contained multiple medications without dates showing when they were opened, including two bottles of fluticasone nasal spray, an ear drop solution 6.5%, a flutic/vilan 100-25 mcg inhaler, three bottles of fluticasone for another resident, a flutic/salm discus, and a bottle of fluticasone with no name or date. An ellipta inhaler was also found with no name or date. One resident had two bottles of fluticasone with dates, another had a bottle of fluticasone with a date, and a resident had a bottle of latanoprost dated as opened and sent from the pharmacy on 4/3/25. Resident 3 had an expired lantus insulin pen dated 9/4/25. QMA 8 stated she would remove the items from the cart and reorder the medications. The DON provided the facility policy stating eye drops, ointments, drops, and inhalers are to be kept separate from other medications and that outdated, contaminated, or deteriorated drugs are to be immediately withdrawn from stock.
Inaccurate Medication and Wound Care Documentation
Penalty
Summary
The facility failed to ensure accurate documentation for a resident with acute and chronic respiratory failure, PTSD, anxiety, and a stage 4 sacral pressure ulcer. The resident’s record showed duplicate Lorazepam PRN orders, including two different dose instructions for the same medication. The MAR documented both orders as given on multiple occasions, and the DON stated the orders were duplicate and that an LPN had charted both doses in error, saying she did not actually administer both doses. The facility also failed to maintain accurate wound care documentation for the resident’s sacral pressure ulcer. A physician order dated 7/29/25 directed staff to cleanse the wound with normal saline, pat dry, apply Hydrofera blue, skin prep the surrounding tissue, and secure with a bordered foam dressing every 3 days and PRN for soilage. However, a weekly wound evaluation later documented different wound care orders, including calcium alginate with silver, an ABD pad, and tape, and the record lacked documentation of a physician order for that treatment. Additional records showed the wound had changed in appearance and measurements, including documentation of granulation tissue, slough, and undermining in an ER note. The DON stated the wound nurse/ADON was responsible for entering new wound treatment orders after rounds with the NP, but also stated the ADON was not well versed in the process and that the NP had documented something different than what had been communicated. A facility policy on the SWAT program stated that upon receipt of an order there should be immediate transcription onto the MAR/TAR, but no policy on documentation accuracy was provided at exit.
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. No information is provided about the medical history or condition of any residents involved at the time of the deficiency.
Failure to Conduct Self-Administration Assessment for Bedside Medication
Penalty
Summary
The facility failed to ensure that a resident had a self-administration assessment for a medication stored at bedside. An inhaler of Ventolin, used to treat chronic obstructive pulmonary disease (COPD), was observed on the bedside table of a resident who was not present in the room, leaving the medication unattended. The resident had diagnoses including COPD, heart failure, dementia, and anxiety disorder, and had an order for Ventolin to be used as needed for shortness of breath. However, the resident's record lacked a medication self-administration assessment. During an interview, the Director of Nursing acknowledged that the medication should not have been left in the resident's room. The facility's policy required an interdisciplinary team to determine a resident's ability to self-administer medications through a skill assessment.
Failure to Conduct Quarterly Assessments for Mobility and ROM
Penalty
Summary
The facility failed to conduct comprehensive quarterly assessments for two residents to evaluate their mobility and range of motion (ROM). Resident 1, who had diagnoses including type 2 diabetes, difficulty walking, heart failure, and a history of falling, had care plans indicating the need for assistance with activities of daily living (ADLs) and a restorative program for active range of motion. However, his records lacked a comprehensive quarterly assessment to measure joint movement and identify any changes in his functional status. Similarly, Resident 36, with diagnoses such as difficulty swallowing, chronic obstructive pulmonary disease (COPD), and hypertension, had a care plan for a restorative program for dressing and grooming. His records also lacked a comprehensive quarterly assessment to evaluate his joint movement and functional status. Interviews with the Regional MDS Consultant and the Regional Nurse Consultant revealed that the facility's process for documenting and assessing restorative programs was inadequate. The facility failed to refresh and initiate data into the Point of Care (POC) system, preventing the transfer of information to the Minimum Data Set (MDS). This oversight resulted in the absence of necessary quarterly assessments for the residents, as required by the Resident Assessment Instrument (RAI) manual. The facility was reportedly working on addressing these documentation and assessment issues.
Failure to Label Tuberculosis Testing Serum
Penalty
Summary
The facility failed to appropriately label tuberculosis testing serum in one of the two medication rooms reviewed. During an observation on September 9, 2024, a vial of tuberculin serum was found undated in the specimen refrigerator, which had approximately two inches of ice buildup. LPN 21 removed the serum from the refrigerator. In an interview on September 10, 2024, the Director of Nursing (DON) confirmed that the serum should have been dated when opened. The facility's policy, titled 'Tuberculosis Testing (Mantoux Test)' and dated March 2023, specifies that a new vial must be initiated and dated, as it is only valid for 30 days after opening.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure effective hand hygiene practices by staff delivering lunch trays to residents, specifically affecting two residents observed during the lunch service. On the specified date, the Social Services Director (SSD) was seen removing a lunch tray from the mobile kitchen cart and entering Resident 42's room without performing hand hygiene, despite a sign on the door indicating the need for Enhanced Barrier Precautions (EBP). The SSD also failed to perform hand hygiene after leaving Resident 42's room and before serving lunch to Resident 43, who shared the room and required EBP due to having a suprapubic catheter. Interviews conducted with the SSD and the Assistant Director of Nursing (ADON) confirmed the lapse in hand hygiene, with the SSD mistakenly believing she had used hand sanitizer. The Director of Nursing (DON) later confirmed that Resident 43 required EBP due to his medical condition. A review of the facility's policy on Enhanced Barrier Precautions highlighted the critical importance of proper hand hygiene in all aspects of resident care, including when EBP is required.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for five residents, leading to discrepancies in their medical records. Resident 6, diagnosed with End Stage Renal Disease, had a care plan indicating the need for dialysis, yet her MDS assessment did not reflect her dialysis treatments. Similarly, Resident 34, with a diagnosis of schizophrenia, was not accurately coded for her Level II status on the MDS assessment. Resident 13's MDS assessment incorrectly indicated the use of anticoagulant medication, while his records showed he was on an antiplatelet medication. This error was acknowledged by the Regional MDS Consultant during an interview. Resident 43's MDS assessment inaccurately coded aspirin as an anticoagulant, despite physician orders indicating it was used as an antiplatelet. The Director of Nursing confirmed this coding error. Lastly, Resident 29, who was receiving hospice services, had an MDS assessment that failed to reflect her hospice status, despite a physician order and nursing progress note confirming her admission to hospice. The Regional MDS Consultant admitted the oversight, noting the absence of a specific MDS policy but adherence to RAI guidelines.
Failure to Provide Pressure-Reducing Device for At-Risk Resident
Penalty
Summary
The facility failed to provide a pressure-reducing device for a resident at risk for developing pressure ulcers. Observations on multiple occasions revealed that the resident, who was seated in a wheelchair, did not have a pressure-reducing cushion in place. The resident's medical record indicated she was at risk for pressure ulcers and required such a device as part of her care plan. Despite this requirement, the cushion was not observed during several checks, indicating a lapse in the implementation of her care plan. The resident, identified as having chronic obstructive pulmonary disease, congestive heart failure, and lung cancer, was admitted to the facility with a care plan that included preventative measures for pressure ulcers. The Director of Nursing confirmed that the resident should have had a pressure-reducing cushion and acknowledged that it was missing. The facility's policy, which includes monitoring residents at risk for skin breakdown, was not effectively followed in this case, as evidenced by the missing cushion and the inability to determine how long the resident had been without it.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for a resident with chronic obstructive pulmonary disease, congestive heart failure, and lung cancer. The resident was observed multiple times without the prescribed oxygen therapy, despite having a physician's order to apply oxygen via nasal cannula every shift at 3 liters to maintain oxygen saturation levels above 90. The oxygen concentrator was consistently found turned off, and the nasal cannula was not in place, indicating a lack of adherence to the prescribed treatment plan. The resident expressed discomfort and was observed to be in pain, yet the staff did not offer to apply the oxygen therapy. The care plan for the resident lacked revisions to address her noncompliance with oxygen therapy and did not include interventions for her refusals to wear the nasal cannula. The Director of Nursing acknowledged the resident's noncompliance but indicated that the order should have been changed to as needed, which was not reflected in the care plan or physician's orders.
Violation of Resident's Right to Confidentiality
Penalty
Summary
The facility failed to ensure a resident's right to have his medical record kept private and confidential. The Business Office Manager (BOM) disclosed clinical information about Resident H's medical condition, treatment, and services to the resident's family without the resident's permission. This information was shared during a private meeting outside of the facility property. The BOM, who is not authorized to provide clinical information, shared details such as the lack of wound care and physical therapy notes, her opinion on the resident's mental capacity, and overheard conversations between a facility nurse and the resident's dialysis center. The Regional Nurse Consultant (RNC) and the Director of Nursing (DON) confirmed that the BOM's actions were outside her scope of practice and constituted a HIPAA violation, as the resident did not have a Power of Attorney (POA) and was listed as his own responsible party with normal cognitive function. Resident H, a long-term care resident with diagnoses including End Stage Renal Disease, Type 2 Diabetes, and Diabetic Neuropathy, was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The facility's guidelines on resident rights and HIPAA privacy were not followed, as the BOM improperly shared confidential health information without the resident's consent. The facility's policies clearly state that only clinical staff are permitted to provide clinical information to residents or their POA, and any unauthorized sharing of health information is considered a violation of HIPAA regulations.
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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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Nursing homes near Lebanon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Signature Healthcare At Parkwood | 3 mi | ★★★★★ | 2 | 0 |
| Homewood Health Campus | 4.5 mi | ★★★★★ | 1 | 0 |
| Witham Extended Care | 4.7 mi | — | 0 | 0 |
| Restoracy Of Whitestown, The | 5.1 mi | ★★★★★ | 5 | 0 |
| Zionsville Meadows | 9.5 mi | ★★★★★ | 10 | 0 |
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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.