Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Cedarview Care Center during CMS and state inspections, most recent first.
A resident with COPD, type 2 DM, and chronic pain received repeated oxycodone dose errors after an order changed from 5 mg to 2.5 mg q6h. The narcotic log showed staff continued giving 5 mg doses instead of the ordered half-tablet dose, and the DON stated the error occurred because staff did not know the order had changed.
The facility failed to properly store and label insulin for two residents and failed to label an ophthalmic medication with an open date for another resident. Two residents with diabetes and severe cognitive impairment had insulin pens on the med cart with open dates beyond the allowed period, and an RN confirmed they should have been discarded. A resident with ALS and an eye medication order had an ophthalmic suspension on the cart with no open date, and the RN and DON verified it should have had one.
A facility failed to administer medications as ordered, resulting in a 10.26% error rate. Three residents were affected: one did not receive eye drops, another missed hepatitis C medication due to a pharmacy issue, and a third did not receive Zyprexa and Biotene mouthwash. The errors were confirmed by an RN, who noted issues with medication availability and documentation.
The facility failed to assist dependent residents with repositioning, leading to prolonged periods without movement for three residents with significant medical conditions. Staff interviews confirmed the lack of repositioning, contrary to the facility's policy aimed at preventing skin breakdown and promoting circulation.
The facility failed to accurately document a skin assessment for a resident with complex medical conditions. An LPN did not report new skin impairments, but later observations revealed excoriation and dry, scaly skin that were not documented.
The facility failed to ensure foods were stored properly, with 10 unlabeled containers and an unsealed, unlabeled sandwich found in a refrigerator without a thermometer or temperature log. An RN confirmed the deficiencies, which violated the facility's food storage policy.
A resident with multiple serious health conditions experienced a 21-pound weight increase in one day. Despite a physician order to report any weight change of three pounds or more, the facility failed to notify the physician, as confirmed by the DON and a review of the resident's medical record.
The facility failed to complete the MDS discharge assessment for a resident with multiple diagnoses within the required 14-day timeframe, as confirmed by medical record review and an interview with the MDS Coordinator.
The facility failed to transmit MDS assessments within the required 14-day timeframe for three residents, despite policy and manual guidelines. The deficiency was confirmed through medical record reviews and staff interviews.
The facility failed to notify the state mental health authority of a significant change in condition for two residents with mental disorders who began receiving hospice services. The required Pre-Admission Screening and Resident Review (PASARR) was not completed within 14 days of the change.
The facility failed to ensure a resident's fluid restriction order was properly implemented and communicated, leading to the resident consuming fluids beyond the prescribed limit. Staff were unaware of the fluid restriction due to lack of documentation and communication in the plan of care.
The facility failed to follow physician orders for assistive devices to prevent further contracture in a resident with limited range of motion. The resident, who had multiple diagnoses and was dependent on staff for all activities of daily living, was observed without the prescribed wash cloths in her hands on multiple occasions. A registered nurse confirmed the non-compliance, admitting to being unaware that the aides had not placed the wash cloths as ordered.
The facility failed to address a significant weight loss in a timely manner for a resident with Huntington's disease and other conditions. Additionally, the facility did not complete weights per physician's orders for two other residents with chronic conditions, leading to multiple undocumented weights. The facility's policies on weight monitoring and documentation were not followed.
The facility failed to ensure that oxygen tubing for two residents was changed and dated as ordered by the physician. Both residents were observed with undated oxygen tubing, and this was confirmed by an LPN and an STNA. The DON verified that the contract company responsible for this task may have forgotten to date the tubing.
The facility failed to provide full visual privacy for two residents, as observed during a survey. One resident had no privacy curtain around their bed, and another had a privacy curtain track that was coming loose from the ceiling, with no curtain in place. This was confirmed by staff and the Housekeeping Director.
The facility failed to post nurse staffing information that included the total number of RNs, LPNs, and STNAs working daily. This deficiency was observed over a period from 03/01/24 to 04/17/24 and confirmed by the Administrator. The issue had the potential to affect all 72 residents in the facility.
Significant Oxycodone Dose Error
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when oxycodone was administered at the wrong dose over multiple administrations. Resident #25 was admitted with diagnoses including COPD, type 2 diabetes, and chronic pain, and the MDS indicated moderate intact cognition and dependence on staff for ADLs. The physician ordered oxycodone 5 mg every six hours initially, then changed the order to oxycodone hydrochloride 2.5 mg every six hours. However, the narcotic documentation/log showed the resident received oxycodone 5 mg every six hours instead of the ordered 2.5 mg dose for multiple doses after the order change. The medication error log identified a medication error involving the resident, and the incident report documented that the Medical Director and DON were notified and assessed the resident because she was her own responsible party. The DON verified that staff administered the wrong dose because they did not know the order had changed, and stated the resident received 29 wrong doses of oxycodone 5 mg instead of the ordered 2.5 mg dose. The resident later verified that the facility managed her medications.
Improper Storage and Labeling of Insulin and Ophthalmic Medication
Penalty
Summary
The facility failed to ensure safe storage of insulin for two residents and failed to ensure ophthalmic medication was labeled with an open date for one resident. Resident #07 had diagnoses including bipolar disorder, diabetes mellitus, and schizophrenia, and the MDS showed severe cognitive impairment with dependence on staff for ADLs. Physician orders included insulin lispro and insulin glargine, and during medication cart observation both insulins had an open date of 02/17/26. RN #96 verified that the open date was the same date as the order and stated the medications should have been discarded. Resident #19 had diagnoses including type two diabetes, seizures, and hyperlipidemia, and the MDS showed severe impaired cognition with dependence on staff for ADLs. The resident had an order for NovoLog flex pen insulin aspart, and observation of the medication cart showed the insulin had an open date of 02/15/26. RN #96 verified the open date and stated the medication should have been discarded. Resident #39 had diagnoses including amyotrophic lateral sclerosis, chronic allergic conjunctivitis, and presence of intraocular lens, and the MDS showed intact cognition with dependence on staff for ADLs. The resident had an order for Simbrinza ophthalmic suspension, and observation showed the medication had no open date. RN #96 verified the medication should have had an open date and should have been discarded due to not having one. The DON later verified the two residents' insulins should have been discarded due to expiration and the ophthalmic medication should have had an open date.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 10.26 percent, which is above the acceptable threshold of 5 percent. This affected three residents who were reviewed for medication administration. Resident #19, who has multiple sclerosis and other conditions, did not receive the prescribed Refresh Liquigel Ophthalmic Gel for dry eyes. Resident #26, with diagnoses including acute kidney failure and heart failure, did not receive the prescribed hepatitis C medication, sofosbuvir and velpatasvir. Resident #27, diagnosed with epilepsy and other conditions, did not receive the prescribed Zyprexa and Biotene mouthwash. The errors were observed during a medication administration session with RN #304, who confirmed the omissions. The nurse acknowledged that Resident #27 did not receive Zyprexa due to a mix-up with the medication dosage in the cart and that Biotene was not administered because it had not been delivered by the pharmacy. Similarly, Resident #19's eye drops were not available in the medication cart, and Resident #26's medication was on back order due to a lack of proper diagnosis documentation. The Director of Nursing admitted to not clarifying the medication order for Resident #26, which contributed to the pharmacy's inability to provide the medication.
Failure to Reposition Dependent Residents
Penalty
Summary
The facility failed to ensure that dependent residents were assisted with repositioning to prevent skin impairment. This deficiency affected three residents who were observed to have remained in the same position for extended periods. Resident #46, who had multiple diagnoses including respiratory failure and was ventilator-dependent, was observed lying on his back in bed without repositioning at various times throughout the day. Similarly, Resident #53, who had diagnoses including hypoxic ischemic encephalopathy and was also ventilator-dependent, was observed sitting upright in a geriatric chair without repositioning. Resident #72, with diagnoses including respiratory failure and diabetes, was observed lying on her back in bed without repositioning during the same observation periods. Interviews with staff revealed that the State tested Nurse Aide (STNA) #75 acknowledged not having had the chance to turn and reposition the three residents on the day of observation. The facility's policy on repositioning, which aims to prevent skin breakdown and promote circulation, was not followed. The policy mandates frequent repositioning for bed- or chair-bound residents to provide pressure relief and promote skin integrity. This deficiency was investigated under Complaint Number OH00153613.
Failure to Accurately Document Skin Assessment
Penalty
Summary
The facility failed to complete an accurate skin assessment for Resident #72, who had multiple complex medical conditions including respiratory failure, obstructive uropathy, pneumonia, diabetes, and seizure disorder. The resident was dependent on toileting, bed mobility, and had an indwelling catheter, tracheostomy, and ventilator. A skin assessment documented by an LPN on the morning of the incident did not report any new areas of skin impairment. However, later observations revealed bright red excoriation under the resident's left armpit and dry, scaly skin on the resident's feet, which were not documented in the skin assessment or progress notes. During an interview, the LPN acknowledged knowing about the excoriation under the resident's left armpit but admitted to not documenting it. The LPN also stated she was unaware of the condition of the resident's feet. This discrepancy between the documented skin assessment and the actual condition of the resident's skin indicates a failure to accurately assess and document the resident's skin condition, leading to a deficiency in the care provided.
Failure to Properly Store and Label Food in Refrigerator
Penalty
Summary
The facility failed to ensure foods were stored in a manner to protect against the potential spread of food-borne illness. During an observation, it was found that the refrigerator on the facility's C-hall contained 10 unlabeled containers with unidentified substances. Additionally, there was a sandwich loosely wrapped in a plastic sandwich bag that was unsealed, unlabeled, and undated. The refrigerator also lacked a thermometer and any type of temperature log. Registered Nurse (RN) #375 confirmed that the containers were unlabeled and undated, and that the sandwich was not sealed, labeled, or dated. RN #375 also verified that the refrigerator did not have a thermometer and that refrigerator temperatures should be checked and recorded on each shift. The facility's policy titled 'Food Receiving and Storage,' dated October 2017, was reviewed and it revealed that all foods stored in the refrigerator should be covered, labeled, and dated with a use-by date. The policy also stated that refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines. This deficiency had the potential to affect all 59 residents who received food from the kitchen, although 13 residents were identified as NPO and did not receive food from the kitchen. The facility census was 72.
Failure to Notify Physician of Significant Weight Change
Penalty
Summary
The facility failed to ensure the physician was notified of a significant change in a resident's condition. Resident #22, who had multiple serious diagnoses including end-stage renal disease and chronic heart failure, experienced a 21-pound weight increase over a single day. Despite an existing physician order to report any weight change of three pounds or more, there was no documentation in the resident's medical record indicating that the physician was notified of this significant weight change. The Director of Nursing confirmed the lack of documentation regarding the weight change or physician notification. The resident's medical record showed that they were admitted and readmitted to the facility with several critical health conditions. The comprehensive Minimum Data Set (MDS) assessment indicated that the resident had moderately impaired cognition and required varying levels of assistance for daily activities. Despite these vulnerabilities, the facility did not follow its own policy, which mandates notifying the attending physician of any changes in the resident's condition. This oversight was confirmed through staff interviews and a review of the facility's policy on changes in a resident's condition or status.
Failure to Complete MDS Discharge Assessment Within Required Timeframe
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) discharge assessment for a resident was completed within the required 14-day timeframe. The resident, who had diagnoses including schizoaffective disorder, anxiety disorder, polysubstance abuse, and nicotine addiction, was discharged on a specified date. However, the MDS discharge assessment was not completed until 04/17/24, which exceeded the 14-day requirement. This deficiency was confirmed through medical record review, the Resident Assessment Instrument (RAI) User Manual, the facility's policy and procedure on MDS completion and submission timeframes, and an interview with the MDS Coordinator.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days of completion, affecting three residents. Resident #25, diagnosed with Alzheimer's disease, bipolar disorder, schizoaffective disorder, anxiety disorder, and alcohol abuse, had an MDS quarterly assessment completed on 03/28/24 but transmitted on 04/14/24. Resident #50, with diagnoses including cerebrovascular accident with right-sided hemiplegia, alcohol abuse, chronic pain syndrome, seizure disorder, coronary artery disease, chronic obstructive pulmonary disease, and diabetes mellitus type II with neuropathy, had an MDS quarterly assessment completed on 03/26/24 but transmitted on 04/14/24. Resident #59, diagnosed with Wernicke's encephalopathy, depression, PTSD, anxiety disorder, and alcohol abuse, had an MDS quarterly assessment completed on 01/26/24 but transmitted on 02/12/24. The facility's policy, as well as the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, requires that MDS quarterly assessments be transmitted within 14 days after completion. Interviews with the Administrator and MDS Coordinator confirmed the late transmissions for all three residents, acknowledging that the transmission dates exceeded the 14-day timeline. This deficiency was identified through a review of medical records, the RAI User Manual, the facility's MDS Completion and Submission Timeframe policy, and staff interviews.
Failure to Notify State Mental Health Authority of Significant Change in Condition
Penalty
Summary
The facility failed to notify the state mental health authority of a significant change in condition for residents with mental disorders. This deficiency affected two residents who were reviewed for the Pre-Admission Screening and Resident Review (PASARR) admission process. Resident #49, who had diagnoses including dementia, encephalopathy, major depressive disorder, and anxiety disorder, was admitted to the facility and later had orders for hospice services. However, there was no PASARR completed within 14 days of this significant change in condition. Similarly, Resident #9, with diagnoses including dementia, major depressive disorder, bipolar disorder, and schizoaffective disorder, also had orders for hospice services on two separate occasions, but no PASARR was completed within 14 days of these changes in condition. Interviews with the Business Office Manager and Social Service Designee confirmed that both residents had significant changes in condition when they began receiving hospice services. The staff acknowledged that the facility should have completed a revised PASARR and reported the significant change to the state mental health board within the required 14-day period. This oversight indicates a failure in the facility's process for managing and reporting significant changes in the condition of residents with mental disorders.
Failure to Implement and Communicate Fluid Restriction Order
Penalty
Summary
The facility failed to ensure that the plan of care for a resident with a fluid restriction order was properly implemented and communicated to all relevant staff. The resident, who had diagnoses including acute respiratory failure with hypoxia, dementia, chronic gastric ulcer, malnutrition, dependence on oxygen, and heart failure, was ordered a fluid restriction of 2000 cc per day by the physician. However, the plan of care did not initially reflect this fluid restriction, and the division of fluids between departments was not documented. Observations revealed that the resident's meal tickets did not indicate any fluid restriction, and large containers of fluid were present at the resident's bedside, exceeding the prescribed limits. Interviews with staff members, including State Tested Nurse Assistants (STNAs) and the Dietary Manager, confirmed that they were unaware of the fluid restriction order due to the lack of communication and documentation in the plan of care. The MDS Coordinator acknowledged that the fluid restriction and its division should have been included in the plan of care and communicated to the dietary department. The deficiency was further highlighted when the night shift STNA verified that the fluid restriction intervention was only added to the plan of care after the issue was identified. The facility's policy on encouraging and restricting fluids, which required removing fluids from the room and reviewing the care plan for special needs, was not followed. This oversight led to the resident consuming fluids beyond the prescribed limit, as staff were not informed of the fluid restriction order.
Failure to Follow Physician Orders for Assistive Devices
Penalty
Summary
The facility failed to ensure physician orders were followed for assistive devices to prevent further contracture in a resident with limited range of motion. Resident #52, who had diagnoses including encephalopathy, anxiety, hypothyroidism, depression, chronic obstructive pulmonary disease, and muscle weakness, was observed without the prescribed wash cloths in her hands on multiple occasions. The resident, who had moderately impaired cognition and was dependent on staff for all activities of daily living, confirmed that staff were not consistently placing the wash cloths in her hands as ordered by the physician. The physician's order dated 04/02/24 specified that bilateral towel rolls should be applied in the resident's palms for seven hours daily, from 11:00 A.M. to 6:00 P.M. However, observations on 04/16/24 at 1:20 P.M. and 3:50 P.M. revealed that the resident did not have the wash cloths in her hands. A registered nurse verified that the wash cloths were not in place and admitted to being unaware of the non-compliance, assuming that the aides had put them in. This failure to follow physician orders was confirmed through both staff interviews and direct observations.
Failure to Address Significant Weight Loss and Complete Weights Per Physician's Orders
Penalty
Summary
The facility failed to address a significant weight loss in a timely and accurate manner for Resident #42, who had diagnoses including Huntington's disease, mood disorder, and schizophrenia. Despite the resident's weight dropping from 160.2 pounds to 144.2 pounds over six months, the weight loss was not addressed promptly. The Diet Technician Registered (DTR) acknowledged that the weight loss trend warranted attention but had not reviewed the weights obtained 18 days prior to the interview. The facility's policy required weights to be reviewed and addressed within seven days, which was not adhered to in this case. Additionally, the resident's care plan inaccurately described the weight as stable despite the ongoing weight loss, and no new dietary recommendations were made after the significant weight loss was noted. The DTR confirmed that the resident had been on the same diet and supplement order since November 2023, with no adjustments made despite the weight loss. The Director of Nursing (DON) also confirmed that the expectation was for weights to be reviewed within seven days, which did not occur in this instance. The facility's policy on nutrition and unplanned weight loss required close monitoring and reporting of significant weight loss, which was not followed in this case. The facility also failed to complete weights per the physician's order for Resident #22, who had diagnoses including end-stage renal disease, chronic heart failure, and diabetes. The resident had orders for daily and weekly weights, but multiple weights were not documented, and there was no record of refusals or attempts to weigh the resident on several dates. The Registered Dietitian (RD) verified that the weights were not documented as required. Similarly, Resident #9, who had diagnoses including dementia, edema, and heart failure, had a physician order for daily weights, but multiple weights were missing from the record. The RD confirmed that the daily weights were not documented and that she had not been informed of any refusals to be weighed. The facility's policy required weights to be obtained and recorded at established intervals, which was not followed in this case.
Failure to Change and Date Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure that oxygen tubing for two residents was changed and dated as ordered by the physician. Resident #19, who has diagnoses including dementia, Down syndrome, chronic respiratory failure, and pseudobulbar affect, was observed on 04/15/24 with undated oxygen tubing. The resident's medical record indicated a physician's order to change and date the oxygen tubing every Wednesday. This was confirmed by an LPN and an STNA during an interview on the same day. Similarly, Resident #61, who has diagnoses including acute respiratory failure with hypoxia, dementia, chronic gastric ulcer, malnutrition, dependence on oxygen, and heart failure, was also observed on 04/15/24 with undated oxygen tubing. The resident's medical record indicated a physician's order to change the oxygen tubing every Tuesday. This was also confirmed by the same LPN and STNA. The Director of Nursing verified that the contract company responsible for changing and dating the oxygen tubing may have forgotten to date the tubing for both residents.
Failure to Provide Full Visual Privacy for Residents
Penalty
Summary
The facility failed to provide full visual privacy for two residents, which was observed during a survey. Resident #48, who has diagnoses including acute respiratory failure, schizoaffective disorder, bipolar disorder, anxiety disorder, and depressive disorder, was found to have no privacy curtain around their bed, preventing full privacy. This was confirmed by an LPN and an STNA during an observation. Resident #48 had a roommate, further necessitating the need for a privacy curtain. Similarly, Resident #61, who has diagnoses including acute respiratory failure with hypoxia, dementia, chronic gastric ulcer, malnutrition, dependence on oxygen, and heart failure, was also found to lack full visual privacy. The privacy curtain track in Resident #61's room was coming loose from the ceiling, and there was no privacy curtain in place. This deficiency was also confirmed by an LPN and an STNA. The Housekeeping Director later verified that both double-occupied rooms lacked privacy curtains, which compromised the residents' privacy during care.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to post nurse staffing information that included the total number of Registered Nurses (RN), Licensed Practical Nurses (LPN), and State tested Nurse Aides (STNA) working daily. This deficiency was observed on 04/17/24, when the nursing staffing posting did not include the required information. A review of the daily staffing postings from 03/01/24 to 04/17/24 revealed that all postings were missing the number of RNs, LPNs, and STNAs that worked. The Administrator confirmed on 04/18/24 that the staffing postings did not show the number of working RNs, LPNs, or STNAs. This issue had the potential to affect all 72 residents in the facility, which had a census of 72 at the time of the survey.
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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) |
|---|---|---|---|---|
| Cedars Of Lebanon Care Center | 1 mi | ★★★★★ | 1 | 0 |
| Embassy Of Lebanon | 1.1 mi | ★★★★★ | 8 | 0 |
| Otterbein Lebanon Retirement Community | 5 mi | ★★★★★ | 8 | 0 |
| Pine Ridge Skilled Nursing And Rehab | 6.3 mi | ★★★★★ | 1 | 0 |
| Mason Health Care Center | 7.3 mi | ★★★★★ | 0 | 0 |
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