Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Village Of Lebanon during CMS and state inspections, most recent first.
Resident transported in a rear-facing Geri chair. A resident with dementia, anxiety, adult failure to thrive, and depression, who was dependent on staff for transfers and had moderate cognitive impairment, was observed being moved from the dining room in a rear-facing position. CNA staff stated this could be disrespectful and a dignity issue, and the DON and Administrator said residents were expected to be transported forward-facing.
Improper Perineal Care During Incontinence Care: A resident with recurrent UTIs, neurogenic bladder, incomplete bladder emptying, and frequent bladder incontinence was observed during incontinence care with a large amount of stool present. A CNA wiped the resident from back to front instead of front to back, despite the facility policy and staff statements that perineal care should be performed front to back to avoid introducing bacteria into the urinary system.
Medication administration errors exceeded the allowed rate after surveyors observed 3 errors during 27 opportunities. An LPN removed an extra zolpidem tablet when Xanax was intended and gave insulin without priming the pen as required by the manufacturer. An RN also administered a steroid-containing inhaler without instructing a resident to rinse and spit afterward, despite label directions.
Unlocked Medication Carts Left Unsupervised: Surveyors observed medication carts left unlocked and unsupervised on multiple occasions, including one cart outside a resident's room with no staff present and another cart later found unlocked in the same area. RN and LPN staff stated they knew better than to leave the carts unlocked and acknowledged prior training on keeping medications secure. The DON and Administrator stated staff were expected to keep medication carts locked and medications safe at all times.
Resident Transported in Rear-Facing Geri Chair
Penalty
Summary
The facility failed to ensure staff transported 1 resident in a geriatric chair in a forward-facing position to promote dignity. A facility policy titled, Promoting/Maintaining Resident Dignity, stated the facility’s practice was to protect and promote resident rights and treat each resident with respect and dignity while recognizing each resident’s individuality. Resident #31 was admitted on 03/14/2025 with diagnoses including dementia, anxiety disorder, adult failure to thrive, need for assistance with personal care, and major depressive disorder. The admission MDS dated 03/20/2025 showed a BIMS score of 7, indicating moderate cognitive impairment, and the resident was dependent on staff for transfers. The care plan directed staff to use a Geri chair when the resident was out of bed. On 08/11/2025 at 12:40 PM, CNA #1 was observed transporting Resident #31 from the dining room in a rear-facing position in a Geri chair. During interview, CNA #1 stated that transporting a resident in a rear-facing position could be disrespectful and go against the resident’s dignity, and said she transported the resident out of habit even though she knew better than to pull any resident in a rear-facing position. CNA #1 also stated she had been trained to transport all residents in a forward-facing position. CNA #2 stated that residents should always be transported in a forward motion in a wheelchair or Geri chair because otherwise it would be a dignity issue. The DON and Administrator both stated they expected staff to transport residents in a forward-facing position because it could be a dignity issue for the resident.
Improper Perineal Care During Incontinence Care
Penalty
Summary
The facility failed to provide incontinence care in a manner intended to reduce the risk of urinary tract infection for one resident who was dependent on staff for toileting hygiene and was frequently incontinent of bladder and occasionally incontinent of bowel. The resident had a history of recurrent UTIs, stage 4 chronic kidney disease, congestive heart failure, cardiomyopathy, neurogenic bladder, incomplete bladder emptying, and a recent UTI with antibiotic use. The resident’s care plan directed staff to provide incontinence care with each incontinence episode, and the facility policy for perineal care required cleansing from front to back. During an observation of incontinence care, the resident was found with a large amount of bowel movement covering them. A CNA was observed wiping the resident from back to front while removing the stool. When stopped, the CNA stated she had been taught to wipe front to back and acknowledged she had wiped the resident from back to front. The CNA also stated that cleaning the resident from back to front may introduce bacteria into the urinary system and may be the reason for the resident’s many UTIs. The resident stated they had a bowel movement that had oozed out of the brief and were unsure whether staff were providing adequate care after incontinence. Interviews with the SDC/IP, another RN, the DON, and the Administrator confirmed that staff were expected to clean residents front to back during perineal care to avoid introducing bacteria into the urinary system. The resident’s records also showed recurrent urinary issues, including urology follow-up for urinary hesitancy, incontinence, possible incomplete bladder emptying, and recurrent cystitis.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent. During 27 medication error opportunities observed during medication pass, surveyors identified 3 medication errors, resulting in an error rate of 11.11 percent and affecting 2 residents. The facility policy for medication administration required staff to review the MAR, compare the medication source with the MAR to verify the resident, medication, dose, route, and time, and administer medications according to manufacturer specifications. Resident #41 had diagnoses including type 2 diabetes mellitus, generalized anxiety disorder, recurrent major depressive disorder, bipolar disorder, and insomnia, and had a BIMS score of 9 indicating moderate cognitive impairment. The resident had active orders for zolpidem tartrate 5 mg daily for insomnia and Humalog Mix 75/25 insulin 40 units after supper for diabetes. During observation, an LPN removed a zolpidem tablet from the blister pack, then removed a second tablet from the same card when the second tablet was supposed to be Xanax. The same nurse then administered insulin without priming the insulin pen, despite manufacturer instructions stating the pen should be primed before each injection. Resident #47 received Trelegy inhaler medication from an RN. After the inhaler was administered, the RN did not instruct the resident to rinse the mouth and spit out the water, even though the label clearly included that instruction. The RN acknowledged she had forgotten to ask the resident to rinse. The DON stated nurses were expected to follow the rights of medication administration and to rinse the mouth after use of an inhaler containing a steroid, and the CP stated rinsing was important to prevent fungal infections and thrush.
Unlocked Medication Carts Left Unsupervised
Penalty
Summary
The facility failed to ensure that medication carts were locked when unsupervised. A facility policy titled, Controlled Substance Administration & Accountability, revised on 06/01/2025, stated that the facility would have safeguards in place to prevent loss, diversion, or accidental exposure of controlled substances. During an observation on 08/12/2025 from 3:18 PM to 3:26 PM, surveyors observed an unlocked and unsupervised medication cart outside room [ROOM NUMBER] with no staff present. RN #7 was observed leaving a resident's room and walking past the unlocked cart to the nursing station, and she later locked the cart when she returned at 3:26 PM. During an interview on 08/12/2025 at 3:28 PM, RN #7 stated she knew better than to leave the medication cart unlocked and said the cart was not in her line of sight while she was in the resident's room providing a breathing treatment. During a second observation on 08/12/2025 from 4:26 PM to 4:32 PM, the same medication cart was again observed unlocked and unsupervised outside the same room, with no residents or staff nearby. RN #7 later stated she had no excuse for leaving the cart unlocked and described it as a bad habit. On 08/15/2025, another medication cart was observed unlocked and unsupervised outside room [ROOM NUMBER] while LPN #8 was behind a resident's closed door; she returned and locked the cart. LPN #8 stated she knew better than to leave the cart unlocked and had previously been in-serviced on the importance of locking medication carts. The DON and Administrator stated they expected staff to keep medication carts locked and medications safe at all times.
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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) |
|---|---|---|---|---|
| Springfield Nursing And Rehabilitation Center | 9.2 mi | ★★★★★ | 7 | 0 |
| Loretto Living Center At Loretto Motherhouse, Inc | 9.7 mi | ★★★★★ | 0 | 0 |
| Sansbury Care Center | 10.3 mi | ★★★★★ | 0 | 0 |
| The Grandview Nursing And Rehabilitation Facility | 15.7 mi | ★★★★★ | 2 | 0 |
| Campbellsville Nursing And Rehabilitation Center | 16.5 mi | ★★★★★ | 4 | 0 |
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