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 Cedars Of Lebanon Care Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was found with two Tylenol Cold and Flu tablets and one oxycodone-acetaminophen tablet left in a medication cup at the bedside, which had been left by an agency nurse. The facility's policy required staff to remain with residents until all medications were taken, and there was no physician order allowing bedside medication storage. An LPN confirmed the medications included a controlled substance.
The facility failed to maintain sanitary conditions in food storage, preparation, and service, affecting all residents. Observations revealed undated and unlabeled food items, grease and mold buildup, and improper food handling practices by staff. Interviews confirmed these issues, and the facility's policies on food storage, sanitation, and food preparation were not followed.
The facility failed to provide documented mental and behavioral health training for three STNAs, affecting the care of all 44 residents in a 45-bed secured facility specializing in mental health. This deficiency was confirmed through employee file reviews and an HR interview, revealing a gap in compliance with the facility's training requirements.
The facility failed to notify residents or their representatives of room changes, affecting four residents. One resident was moved after a physical altercation, while another was temporarily relocated due to new admissions. The facility did not adhere to its policy requiring advance notice for room changes, resulting in a deficiency.
The facility did not adhere to the Registered Dietitian's plan for pureed diets, affecting four residents. Instead of the prescribed pureed green beans and honey mustard chicken tenders, residents were served pureed coleslaw and chicken with gravy. The staff member admitted to not following the menu spreadsheet or recipe instructions, and the Diet Manager confirmed the absence of accessible puree recipe instructions.
The facility failed to treat residents with dignity and respect, affecting three residents. A resident was found with food stains and soiled fingernails due to lack of a clothing protector. Another resident experienced agitation after a delayed meal service and being given a plastic spoon instead of metal silverware. A third resident reported anxiety from receiving plastic ware. The kitchen staff confirmed a shortage of silverware, leading to the use of plastic ware, violating the facility's dining policy.
A facility failed to report and investigate allegations of resident-to-resident physical abuse and sexual abuse by an unknown person. One resident, with a history of mental health issues, reported being pushed by a roommate, resulting in a bruise, and alleged rape by three men. The facility did not report these incidents to the state agency, citing the resident's delusional behavior. Interviews confirmed the physical altercation, but a thorough investigation was not conducted, violating the facility's abuse and neglect protocol.
The facility failed to investigate allegations of resident-to-resident physical abuse and sexual abuse by an unknown person. A resident with impaired cognition reported being pushed by her roommate, resulting in a bruise, and alleged rape by three men during an outing. The facility did not conduct thorough investigations or report these incidents, contrary to their policy requiring prompt investigation of abuse and injuries of unknown origin.
The facility failed to complete required PASARRs for two residents. One resident was admitted with schizophrenia and other conditions, but the PASARR was for another resident. Another resident had a new diagnosis of paranoid schizophrenia, requiring a new PASARR, which was not completed. These deficiencies were confirmed by the Social Services Designee.
The facility failed to maintain a clean and safe environment, affecting three residents. A resident's room had soiled walls and a broken toilet seat, while another's bathroom had a black stain, gnats, and a strong odor. A third resident's wheelchair was damaged, compromising safety. These deficiencies impacted residents with cognitive impairments and various medical conditions.
A resident with mild cognitive impairment and dependency on staff for daily living was physically abused by an STNA, resulting in skin tears and contusions. The incident occurred during care when the resident became agitated. Despite visible injuries and the resident's allegations, the facility's investigation did not substantiate the abuse claim. The resident called 911 after the facility delayed contacting emergency services. Witness statements revealed inconsistencies, and the facility's policy on abuse was not followed.
The facility failed to ensure a safe and homelike environment, affecting six resident rooms and the main shower room. Observations showed damaged drywall, peeling paint, and black residue in the shower room, along with stained ceiling tiles and holes in the walls of several resident rooms. Staff confirmed these conditions, indicating inadequate maintenance.
Medications Left Unattended at Bedside
Penalty
Summary
Staff failed to ensure that medications were not left at the bedside for a resident with multiple complex medical conditions, including diabetes, chronic pain, and heart disease. The resident was observed to have two yellow tablets and a blue tablet in a medication cup on his bedside table, which he stated had been left by an agency nurse a couple of days prior. The resident indicated he kept the medications to take later if needed. Review of the resident's medical record showed active orders for oxycodone-acetaminophen and Tylenol Cold and Flu, but there was no physician order permitting medications to be left at the bedside. A Licensed Practical Nurse confirmed the presence of the medications in the resident's room, identifying them as two Tylenol Cold and Flu tablets and one oxycodone-acetaminophen tablet, the latter being a controlled substance. Facility policy required staff to remain with residents until all medications had been taken, which was not followed in this instance. The deficiency was identified through resident interview, observation, medical record review, staff interview, and policy review.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage, preparation, and service, affecting all 44 residents. Observations revealed multiple issues, including undated and unlabeled food items in the refrigerator and freezer, a buildup of grease and mold in the kitchen, and improper storage of food scoops. Additionally, the ice machine contained a pink substance consistent with mold, and there was milk spillage on thawing chicken in the refrigerator. Interviews with the Diet Manager and an LPN confirmed these unsanitary conditions and incomplete temperature logs. Further observations highlighted improper food handling practices by a staff member, who failed to change gloves between tasks, leading to potential contamination. The staff member was seen using the same gloves to handle various surfaces and food items, including opening buns and touching the inside of a resident's plate. The facility's policies on food storage, sanitation, and food preparation were not adhered to, as evidenced by the lack of labeling, dating, and cleanliness, as well as the improper use of gloves during food service.
Deficiency in Staff Training on Mental and Behavioral Health
Penalty
Summary
The facility failed to ensure that all staff received the necessary education on mental and behavioral health, as required by their facility assessment. This deficiency was identified through a review of employee files, interviews, and the facility assessment. The facility is a 45-bed secured facility specializing in behaviors and mental health, with a majority of long-term residents. Despite this specialization, the facility did not provide documented evidence of mental and behavioral health training for three State tested Nursing Assistants (STNAs) out of five reviewed. These STNAs, hired between 2015 and 2023, did not have records of receiving the required education, which is crucial for the care and management of the resident population. The lack of documented training for STNAs #505, #504, and #503 was confirmed during an interview with Human Resources. This oversight had the potential to affect all 44 residents residing in the facility, as the entire facility specializes in mental and behavioral health care. The facility's assessment, updated in July 2024, indicated that staff training and competencies are necessary to provide appropriate care and support for the resident population. However, the absence of documented training for these STNAs highlights a significant gap in the facility's compliance with its own training requirements.
Failure to Notify Residents of Room Changes
Penalty
Summary
The facility failed to ensure that residents or their representatives were notified of room changes, affecting four residents. Resident #4, who had schizophrenia and bipolar disorder, was involved in a physical altercation with Resident #146, leading to a room change for safety reasons. However, there was no documentation that Resident #4 or their representative was informed about the reason for the move or given an opportunity to see the new location and ask questions. Similarly, Resident #11, who had intact cognition, was moved for safety reasons without being informed or given an opportunity to ask questions. Resident #146, who also had intact cognition and a court-appointed guardian, was involved in the altercation with Resident #4 and was moved without proper notification to the resident or their guardian. Resident #19, who had multiple diagnoses including COPD and diabetes, was moved temporarily for about twelve hours due to new admissions. There was no documentation that Resident #19, their roommates, or family were notified of this temporary room change. The facility's policy requires a 24-hour advance notice for room changes unless medically necessary for safety, but this was not adhered to in these cases. The lack of documentation and communication regarding room changes for these residents highlights a deficiency in the facility's adherence to its own policies and resident rights.
Failure to Follow Puree Diet Instructions
Penalty
Summary
The facility failed to prepare foods as planned by the Registered Dietitian, affecting four residents who were on a pureed diet. The physician orders for these residents specified a puree consistency diet, which was not followed during a lunch meal observation. Instead of receiving pureed green beans and honey mustard chicken tenders as per the menu spreadsheet, the residents were served pureed coleslaw and chicken with a gravy mix. The staff member responsible for serving the meal admitted to not reading the spreadsheet or following the recipe instructions. Additionally, the Diet Manager confirmed that the staff member did not have access to the necessary recipe instructions for preparing the pureed meals, indicating a lack of available puree recipe instructions for any of the meals served to residents.
Failure to Ensure Dignity and Respect in Meal Service
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, affecting three residents. Resident #38, who was cognitively impaired and dependent on staff for various activities, was observed with dried food and crumbs on his sweatshirt and soiled fingernails. The staff acknowledged that the morning shift did not provide a clothing protector during breakfast, leading to the resident's unkempt appearance. This was in violation of the facility's policy on dignity, which mandates that residents be cared for in a manner that promotes dignity and respect. Resident #8, with intact cognition and requiring supervision during meals, experienced a delay in receiving his breakfast, which led to increased agitation. He waited over 10 minutes for his meal while others were served, and was given a plastic spoon instead of metal silverware, further aggravating his agitation. Similarly, Resident #29, with moderately impaired cognition, reported increased anxiety due to receiving plastic ware instead of silverware during meals. The kitchen staff confirmed the shortage of silverware, which resulted in the use of plastic ware, contrary to the facility's dining policy that requires residents at each table to be served together in a homelike setting.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to report allegations of resident-to-resident physical abuse and an allegation of sexual abuse by an unknown person to the state agency. This deficiency affected two residents, one of whom had a history of cerebral palsy, major depressive disorder, schizoaffective disorder, and other conditions. The resident was noted to have a bruise on her right knee, which she claimed was caused by being pushed by her roommate. Despite this, the facility did not report the incident as an allegation of abuse or investigate it thoroughly. The resident also alleged that she was raped by three men during an outing, but the Director of Nursing (DON) dismissed the claim, citing the resident's history of delusional behavior. The facility's policy required all reports of abuse, neglect, and injuries of unknown origin to be promptly and thoroughly investigated, but this was not adhered to. The DON and the Administrator decided not to investigate or report the sexual abuse allegation, relying on the resident's care plan for delusional behavior as justification. Interviews with staff and residents confirmed the physical altercation between the two residents, but the facility did not conduct a comprehensive investigation or report the incidents. The Assistant Director of Nursing (ADON) confirmed that a head-to-toe assessment was not completed following the sexual abuse allegation, and the only assessment of the knee injury was conducted six days after it was first noted. The facility's failure to report and investigate these incidents violated their own abuse and neglect protocol.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident-to-resident physical abuse and an allegation of sexual abuse by an unknown person, affecting two residents. Resident #06, who has a complex medical history including schizophrenia and impaired cognition, reported being pushed by her roommate, resulting in a bruise on her knee. The facility's interdisciplinary team noted the incident but did not conduct a thorough investigation to determine the cause of the bruise, nor did they report it as an incident of unknown origin or potential abuse. Additionally, Resident #06 alleged that she was raped by three men during an outing, although the Director of Nursing (DON) dismissed the claim due to the resident's history of delusional behavior and stated that no outing had occurred. The facility did not conduct a head-to-toe assessment following this serious allegation, nor did they report it as a self-reported incident. Interviews with staff and residents confirmed the physical altercation between Resident #06 and her roommate, but the facility did not take appropriate steps to investigate or report the incidents. The facility's policy requires prompt and thorough investigation of all reports of abuse, neglect, and injuries of unknown origin, but this was not adhered to in these cases. The Administrator admitted to not investigating or reporting the incidents due to the frequency of such reports, and the DON decided against a full investigation of the sexual abuse allegation based on the facility's abuse form. This lack of action and failure to follow protocol resulted in a deficiency in handling potential abuse cases.
Failure to Complete Required PASARR for Residents
Penalty
Summary
The facility failed to ensure that a Pre-Admission Screening and Resident Review (PASARR) was completed as required for two residents. Resident #15 was admitted with diagnoses including schizophrenia, malignant neoplasm of the base of the tongue, and dementia. The Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and various levels of assistance required for daily activities. However, the PASARR designated for Resident #15 was found to be for another resident, and the facility did not have a PASARR or Level II determination for this resident, as confirmed by the Social Services Designee. Similarly, Resident #1 was admitted with diagnoses including schizophrenia and bladder dysfunction. The PASARR completed at the time of admission did not account for a new diagnosis of paranoid schizophrenia added later. The facility's policy and Ohio Department of Medicaid PASRR instructions require a new PASARR for significant changes in condition, which was not completed for Resident #1. This oversight was verified by the Social Service Designee, who acknowledged the need for a new PASARR due to the new mental health diagnosis.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by the conditions observed in the rooms and bathrooms of three residents. Resident #19's room had a soiled wall with unpainted drywall repairs, a toilet seat that was too small and broken, and a bathroom that was dirty with a dried brown substance and lacked necessary amenities. Resident #35's bathroom had a black stain around the toilet, water at the base, flying gnats, and a strong odor, with the walls and floor being soiled and containing a black substance. Additionally, the wall behind Resident #35's bed was soiled and had a hole, while the wall across from the bed was dirty with splatter. Resident #06's wheelchair was in poor condition, with cracked and torn arms and a tear on the seat where it attaches to the frame. This resident, who was dependent on the wheelchair for safety as advised by her physician, was observed in her bed with the damaged wheelchair beside her. The facility's failure to maintain a clean and safe environment affected the well-being of these residents, who had various medical conditions including cognitive impairments, schizoaffective disorder, diabetes, and hypertension.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a State Tested Nursing Assistant (STNA), resulting in actual harm. Resident #10, who was mildly cognitively impaired and dependent on staff for all activities of daily living, was physically abused by STNA #101. The STNA restrained the resident's arms against his chest, causing numerous skin tears and contusions. The incident occurred when the resident became agitated and attempted to hit and bite the staff members during care. Despite the resident's allegations and visible injuries, the facility's investigation unsubstantiated the abuse claim. The incident was reported to the facility's Director of Nursing (DON) and involved multiple staff members, including STNA #63, who witnessed the event but did not intervene. The resident was taken to the emergency room, where he was treated for multiple skin tears and contusions. The facility's staff, including the DON, did not initially consider the incident as abuse, believing the STNAs were trying to keep the resident and themselves safe. However, the resident insisted on going to the hospital and called 911 himself after the facility delayed contacting emergency services. Interviews with staff and witness statements revealed inconsistencies in the accounts of the incident. STNA #63 admitted to witnessing STNA #101 restraining the resident but did not report it immediately. The facility's policy on abuse and neglect was not followed, as the incident was not reported promptly, and the resident was not protected from harm. The facility's failure to ensure the resident's safety and the inadequate response to the abuse allegations resulted in a deficiency under Complaint Number OH00156392.
Facility Environment Deficiency
Penalty
Summary
The facility failed to maintain a safe, functional, and homelike environment for its residents, affecting six out of eighteen resident rooms and the main shower room used by all residents. Observations revealed damaged drywall and peeling paint on the ceiling of the main shower room, along with black residue on the grout between the ceramic tiles. Additionally, resident rooms 104, 105, 111, 112, 114, and 115 were found to have ceiling tiles with black or brown stains. Further inspection showed holes in the walls behind the main door of one room and behind the middle bed in another room. Staff interviews confirmed these conditions, indicating a lack of maintenance and repair in the facility's environment. This deficiency was investigated under Complaint Number OH00154800, highlighting the facility's non-compliance with maintaining a safe and comfortable environment for its residents.
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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) |
|---|---|---|---|---|
| Cedarview Care Center | 1 mi | ★★★★★ | 9 | 0 |
| Embassy Of Lebanon | 1.2 mi | ★★★★★ | 8 | 0 |
| Otterbein Lebanon Retirement Community | 3.9 mi | ★★★★★ | 8 | 0 |
| Mason Health Care Center | 6.8 mi | ★★★★★ | 0 | 0 |
| Pine Ridge Skilled Nursing And Rehab | 7.1 mi | ★★★★★ | 1 | 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.