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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Embassy Of Lebanon during CMS and state inspections, most recent first.
The facility failed to maintain the required continuous 8-hour daily RN coverage when the DON left the building to accompany a resident to outpatient surgical procedures, leaving only LPNs on duty for resident care. Staffing records showed no RN worked in the facility on one of the days in question, despite schedules indicating the DON was present, and the DON later confirmed she was away from the facility for much of the day and not present for eight consecutive hours. Interviews with the resident, the transportation coordinator, the DON, the administrator, and a regional RN corroborated that the DON twice accompanied the resident to a surgical center in another city, that her time in the facility that day was brief, and that the staffing documentation inaccurately reflected her hours, resulting in a day without the required RN coverage for all residents.
A facility failed to timely report an allegation of verbal abuse to the state survey agency after a severely cognitively impaired hospice resident with dementia and behavioral disturbances was subjected to raised voice and hand-clapping in the face by a CNA during care, which another CNA viewed as verbal abuse and reported to the DON by text. The accused CNA later wrote a statement describing the hand-clapping as an attempt to calm the resident, and an LPN stated she did not witness aggression, but the facility’s file contained only limited documentation and no complete investigation or body assessment. Staff interviews revealed that multiple residents had requested not to receive care from this CNA, and that the CNA had previously been escorted out and suspended for unacceptable behavior toward staff, with residents describing the CNA as loud and confrontational. The DON acknowledged not obtaining the requested witness statement and determining the incident was not abuse, and the Administrator acknowledged that an SRI was not initiated as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident with severe cognitive impairment, multiple psychiatric and medical diagnoses, and total dependence for ADLs was the subject of an alleged verbal abuse incident when a CNA reportedly raised her voice and clapped her hands in front of the resident’s face during care, which another CNA reported to the DON by text. The facility’s investigation file contained only the alleged CNA’s written account, an LPN’s statement that no aggression was witnessed, and evidence of a group text titled “Abuse and Neglect,” but lacked further investigation documentation such as additional witness statements, resident assessments, or interviews, despite facility policy requiring immediate and comprehensive investigation of suspected abuse.
Two dependent residents who required staff assistance with eating did not receive timely meal assistance; their trays were delivered and left covered and untouched in their rooms without staff present, despite one resident having quadriplegia and the other having ALS with dysphagia and high aspiration risk. Another dependent resident with impaired cognition and multiple comorbidities, who relied on staff for personal hygiene and bathing, was observed with long facial hair on the chin, jawline, and upper lip, with records showing a missed scheduled shower and no documentation that shaving was performed during multiple showers.
A resident with end stage renal disease, recent sepsis from pneumonia, and multiple chronic conditions was prescribed numerous medications, including antibiotics for pneumonia. During a med pass, an LPN, interrupted by another resident’s behaviors and faced with two residents sharing the same last name and adjacent rooms, failed to follow the five rights of medication administration and gave this resident another resident’s full medication regimen, which included metformin despite a documented metformin allergy. After receiving the wrong medications, the resident developed abnormal VS, increased confusion, altered level of consciousness, and abnormal speech, and was later hospitalized with altered mental status, acute hypoxic and hypercapnic respiratory failure requiring mechanical ventilation, and septic shock secondary to pneumonia.
Surveyors found multiple instances where medications and biologicals were left unsecured and unsupervised in resident rooms, contrary to facility policy requiring safe, locked storage. One resident with significant neurologic and mobility impairments had diclofenac gel and an antiseptic solution left in the room, both labeled to contact poison control if ingested. Another resident with respiratory failure, a Foley catheter, and a G-tube had a prescription nystatin powder bottle sitting on the dresser, labeled for external use only and to contact poison control if ingested. A third resident with Parkinson’s disease and dementia had an Inbrija inhalation device left on the dresser without an order for bedside self-administration, which an LPN acknowledged should not have been in the room.
Surveyors found that the facility’s water management plan for Legionella control was incomplete and lacked key CDC-recommended elements, including specific water temperature monitoring locations, defined validation measurements, and detailed processes to ensure effectiveness. The plan did not include clear procedures for frequent monitoring of temperature, disinfectant residuals, and pH, nor did it ensure a detectable disinfectant residual throughout the potable water system. During interviews, the Administrator could not produce chlorine monitoring logs and confirmed that no chlorine testing logs existed, acknowledging that the current water management plan was not comprehensive. This deficiency had the potential to affect all 59 residents in the facility.
Two medication errors occurred when an LPN administered and crushed enteric coated Aspirin and extended release Guaifenesin for a resident with multiple diagnoses, despite facility policy and physician orders prohibiting this practice. This resulted in a medication error rate of eight percent, exceeding the allowable threshold.
A resident did not receive his morning medications on a day he was on a leave of absence from the facility. The medications were left in the cart and not sent with him, leading to the resident experiencing vomiting and diarrhea. The incident was confirmed by an LPN after the resident reported the issue.
A facility failed to maintain a resident's privacy during catheter care, as a CNA did not pull the curtain or close the door, potentially exposing the resident to others. The resident, who required substantial assistance and had a suprapubic catheter, was left without privacy during the procedure, contrary to the facility's dignity policy.
A facility failed to document catheter care for a resident with a suprapubic catheter, despite a physician's order for care every shift. The resident had multiple health issues, including neuromuscular dysfunction of the bladder and quadriplegia, and was dependent on staff for care. The Treatment Administration Record showed several instances of undocumented catheter care, which was confirmed by the DON.
The facility failed to follow physician orders for medication administration, affecting two residents. One resident received conflicting doses of melatonin due to duplicate orders, while another was given midodrine without proper blood pressure checks, contrary to physician instructions. The DON confirmed these errors, which violated the facility's medication administration policy.
A resident with type one diabetes mellitus received insulin injections without the required safety test being performed by an LPN, resulting in a significant medication error. The LPN did not prime the insulin pen-injectors as per manufacturer instructions and facility policy, leading to non-compliance identified during a complaint investigation.
A facility failed to accurately document the dietary intake of a resident dependent on staff for meals, resulting in incomplete records over a two-week period. Despite the resident's stable weight and no reported issues with meal support, the facility did not adhere to its policy on supporting activities of daily living, leading to a deficiency.
Two residents experienced medication administration errors, resulting in an 8% error rate. An LPN failed to withhold blood pressure medication for a resident with low systolic pressure and administered the wrong laxative to another resident. These actions were contrary to the facility's medication administration policy.
The facility failed to follow infection control procedures for two residents requiring Enhanced Barrier Precautions (EBP). A nurse administered medication to a resident with a g-tube without wearing a gown, and a respiratory therapist performed tracheostomy suctioning on another resident without a gown. Both residents had EBP signs and isolation carts with PPE outside their rooms, and the facility's policy mandates gown use during high-contact care activities.
Failure to Maintain Required RN Coverage Due to DON Escorting Resident to Surgery
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a registered nurse (RN) was present in the facility for eight consecutive hours a day as required, affecting all 59 residents. Review of staffing schedules for 04/01/26 to 04/07/26 showed that the RN/Director of Nursing (DON) was scheduled for eight hours daily Monday through Friday. However, review of employment time punches for 04/06/26 revealed that no RN worked in the facility that day and that three LPNs each worked 12-hour shifts to care for residents. The facility’s policy on Sufficient Staffing, dated 01/2026, stated that a RN would serve as the DON and provide administrative oversight of nursing services consistent with regulatory requirements. Resident and staff interviews further clarified the circumstances leading to the deficiency. One resident reported that the DON had to accompany him to an outpatient surgical appointment on a Monday because there was a mix-up with times and the respiratory therapist could not go, and that the same situation occurred for another appointment on 04/02/26. The transportation coordinator stated that on 04/06/26 the DON left the facility with this resident at 10:00 A.M. for outpatient surgery in a bordering city about 40 minutes away, returned briefly to the facility for about 20 minutes after the surgical center confirmed a respiratory therapist did not need to stay, and then had to return to pick up the resident, with another staff member ultimately going to the surgical center after the coordinator’s shift ended. The DON confirmed she accompanied the resident to the surgical center on 04/02/26 and 04/06/26, verified that the staffing tool reflected incorrect hours for her on 04/06/26, and acknowledged she was not in the facility continuously for eight hours and that there was no RN in the facility that day. The administrator and a regional RN also verified that the employment punches for 04/06/26 did not show the required eight RN hours for facility coverage.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse to the state survey agency as required by its abuse, neglect, and exploitation policy. A resident with severe cognitive impairment, dementia with behavioral disturbances, intermittent explosive disorder, psychosis, anxiety, and multiple psychoactive and other medications was dependent for all ADLs and receiving hospice services. The resident’s care plan noted cognitive loss with memory problems, impaired decision-making, and altered mental status, with interventions focused on monitoring understanding and honoring preferences. Progress notes around the time of the incident documented increased anxiety and an increase in Ativan dosage, but subsequent notes were silent regarding behaviors. During care, a CNA was observed by another CNA to raise her voice and clap her hands in front of the resident’s face while providing care, which the witnessing CNA considered verbal abuse. This witnessing CNA reported the incident to the DON via text and stated she was never contacted for additional information. A written statement later obtained from the accused CNA described clapping her hands and calling the resident’s name in an attempt to calm the resident, who was reportedly screaming uncontrollably, and asserted she was not aggressive. Another LPN provided a statement indicating she did not witness the CNA being aggressive toward the resident. The file contained a text message titled “Abuse and Neglect” sent to current employees, but lacked further documentation such as a complete investigation, additional witness statements, or body assessments related to the incident. Interviews with staff revealed broader concerns about the CNA’s behavior and the facility’s response. An LPN reported that several residents had requested that this CNA not provide their care and that the CNA had been previously suspended for alleged verbally abusive behavior toward staff, then returned to work and reportedly boasted about having a paid vacation. Another CNA reported knowledge of the CNA being escorted out of the facility for unacceptable behavior toward staff, and that residents had described the CNA as loud and confrontational. The DON acknowledged speaking with the reporting staff member the morning after the incident and requesting a witness statement that was never received, and stated she concluded the incident was not abuse based on the resident’s behavioral history and staff statements. The Administrator confirmed that the facility did not initiate a self-reported incident (SRI) for this event and acknowledged that one should have been initiated, despite facility policy requiring reporting of all alleged violations to the administrator, state agency, adult protective services, and other required agencies within specified time frames.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and document an allegation of abuse involving Resident #53. Resident #53 had multiple diagnoses including COPD, intermittent explosive disorder, psychosis, dementia with behavioral disturbances, and anxiety, with severely impaired cognition and dependence for all ADLs, and was receiving hospice services and several psychotropic and other medications. The care plan noted cognitive loss with memory problems, impaired decision-making, and altered mental status, with interventions to monitor understanding, repeat information as needed, and honor resident choices. During care, CNA #32 reported witnessing CNA #31 raise her voice and clap her hands in front of Resident #53’s face while providing care, which CNA #32 considered verbal abuse. CNA #32 stated she reported the incident to the DON via text and was never contacted for additional information. The facility’s investigation file for this incident contained a witness statement from CNA #31, who documented that Resident #53 was screaming uncontrollably after being gotten up into a chair, and that she gently clapped her hands and called the resident’s name to get her attention and calm her, after which the resident calmed but later began screaming again related to a shower. The file also contained a statement from an LPN who reported not witnessing CNA #31 being aggressive, and a document showing that a text message titled “Abuse and Neglect” was sent to current employees. The file did not include any further documentation such as additional investigation notes, other witness statements, body assessments, or resident interviews. The Administrator confirmed that a self-reported incident and thorough investigation should have been completed but were not, contrary to the facility’s Abuse, Neglect and Exploitation policy requiring immediate investigation and identification and interviewing of all involved persons when abuse is suspected.
Failure to Provide Timely Meal Assistance and Grooming for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living (ADLs), specifically meal assistance, for two dependent residents and grooming care for one dependent resident. One resident with chronic respiratory failure, cervical vertebra fracture, and quadriplegia was care planned as totally dependent for all ADLs, including eating, and had an active order for a regular pureed diet with thin liquids. Surveyors observed that this resident’s meal tray was delivered to the room and left covered on the bedside table, with the resident lying in bed with eyes closed and no staff present to assist with eating. Another resident with ALS, intact cognition, and high aspiration risk due to dysphagia and respirator dependence was also care planned to receive assistance with feeding in an upright position. This resident’s meal tray was delivered and left covered and untouched on a table to the resident’s right, with no staff present to assist, and the resident reported that staff had not come to feed him and that he was unable to feed himself and had not seen the tray delivered due to limited vision. The deficiency also includes failure to provide grooming care related to facial hair for a dependent resident. This resident had COPD, moderate persistent asthma, and schizoaffective disorder bipolar type, with impaired cognition and documented dependence on staff for toileting, personal hygiene, and bathing, and a care plan indicating total dependence and the need for two staff for showering and bathing. Review of the shower schedule and CNA documentation showed a missed scheduled shower and lack of documentation that shaving occurred during multiple showers. During observation, the resident was noted to have long white facial hair on the chin, jawline, and upper lip, and shower sheets provided for several dates were silent regarding shaving, with some shower documentation unavailable. The Regional Director of Operations confirmed the presence of long facial hair on this resident.
Significant Medication Error Due to Wrong-Resident Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered to the correct resident, resulting in significant medication errors. A resident with end stage renal disease, recent hospitalization for sepsis secondary to pneumonia and hypothermia, and multiple chronic conditions was admitted with numerous prescribed medications, including antibiotics for pneumonia and other routine therapies. The resident’s care plan included administering medications as ordered, monitoring for adverse reactions to antibiotics, and reporting pertinent lab results to the physician. On the evening in question, the resident was mistakenly given another resident’s full set of medications, which included aspirin, Entresto, Lasix, Lexapro, metformin, metoprolol tartrate, quetiapine fumarate, Rexulti, Seroquel, and Xanax. The resident had a documented allergy to metformin. The error occurred during a medication pass when the LPN was interrupted by the potentially dangerous behaviors of another resident. The LPN later stated that the two residents involved had the same last name, lived on the same unit in adjacent rooms, and that she failed to follow the five rights of medication administration, leading to the wrong medications being given. Following administration of the incorrect medications, the resident exhibited changes in condition, including abnormal vital signs and a mental status change characterized by increased confusion, altered level of consciousness, and abnormal speech. Initial vital signs documented after the error included low blood pressure and decreased respiratory rate, and an e-interact change in condition evaluation noted the resident was tired, weak, confused or drowsy, with low blood pressure and reduced oxygen saturation on room air. The resident was subsequently sent to the hospital, where records documented admission for altered mental status and diagnoses including acute hypoxic and hypercapnic respiratory failure requiring mechanical ventilation and septic shock secondary to pneumonia. The facility’s own policy defined a medication error as preparation or administration of drugs not in accordance with physician orders or accepted professional standards and stated that significant errors are those resulting in cognitive deterioration or impairment.
Unsecured Medications and Biologicals Left in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were securely stored and not left unsecured in resident rooms. For one resident with cerebrovascular disease, right-sided hemiplegia, contractures, diabetes mellitus, decreased mobility, and a chronic skin condition, surveyors found two tubes of diclofenac sodium 1% gel and a bottle of Dyna-Hex 4 antiseptic solution left in the room, unsecured and unsupervised, despite orders for diclofenac gel to be applied topically for pain. Both products were labeled with instructions to contact poison control if ingested. The DON confirmed these items should not have been left in the room and should have been stored locked in the treatment cart. Another resident with acute on chronic respiratory failure with hypoxia, non-traumatic subarachnoid hemorrhage, hypothyroidism, decreased mobility, a Foley catheter, and a gastrostomy tube had a prescription bottle of nystatin powder 100,000 units/gram found sitting unsecured on the dresser, with a pharmacy label stating it was for external use only and to contact poison control if ingested; the resident’s physician orders were silent for any topical medications. A third resident with neurocognitive disorder with Lewy bodies, dementia with psychotic disturbances, delusions, and Parkinson’s disease had an Inbrija (Parkinson treatment) inhalation device found on the dresser, unsecured and unsupervised, despite an order for PRN inhalation and no order for bedside self-administration. An LPN confirmed the inhaler should not have been left in the room, and the facility’s “Storage of Medication” policy required all drugs and biologicals to be stored in a safe, secure, and orderly manner.
Non-comprehensive Water Management Plan and Lack of Chlorine Monitoring Logs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive water management plan (WMP) for infection prevention and control, specifically related to Legionella control, as outlined by CDC guidance. The existing undated WMP included a team list, building water system descriptions, diagrams of water flow and potential Legionella growth areas, control measures and monitoring, general interventions when control limits were not met, and a broad validation statement. However, the plan did not specify the exact areas or sources from which water temperatures would be obtained. The validation section lacked defined measurements or processes and only stated that control measures should be followed and records of findings and testing should be kept, without detailing how effectiveness would be evaluated. Further review against the CDC Legionella Control Toolkit showed that the facility’s WMP did not meet key elements recommended for a comprehensive program, such as frequent monitoring of temperatures, disinfectant residuals, and pH, and ensuring a detectable disinfectant residual throughout the potable water system. During interviews, the Administrator was unable to locate WMP chlorine logs and confirmed there were no logs of chlorine testing. The Administrator also acknowledged that the facility’s WMP was not a comprehensive plan that included the key elements according to CDC guidelines. This deficiency had the potential to affect all 59 residents in the facility, as the census at the time was 59.
Medication Error Rate Exceeds Five Percent Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as two medication errors were identified out of 25 opportunities, resulting in an eight percent error rate. The errors involved a resident with a history of kidney disease, metabolic encephalopathy, and seizures, who had mild cognitive impairment. The resident had active physician orders for Aspirin 81 mg chewable daily for DVT prevention and Mucinex (Guaifenesin) 12-hour 600 mg extended release twice daily for pneumonia. During medication administration, an LPN prepared and administered Aspirin 81 mg enteric coated and Guaifenesin 400 mg extended release, instead of the prescribed forms. The medications were also crushed, despite facility policy and documentation stating that enteric coated and extended release medications should not be crushed. There was no physician order to crush these medications. Interviews with the LPN and the DON confirmed that the medications were crushed and that this was not in accordance with the physician's orders or facility policy.
Medication Error During Resident's Leave of Absence
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting one resident. Resident #27, who was cognitively intact and independent with activities of daily living, was admitted with diagnoses including coronary artery disease, heart failure, hypertension, and diabetes. On the morning of December 25, 2024, the resident did not receive his prescribed morning medications, which included Norvasc, Plavix, Pepcid, and several other medications, as they were left in the medication cart and not sent with him during his leave of absence. The resident confirmed that he had left the facility on a leave of absence after receiving his evening medications on December 24, 2024, but did not receive his morning medications for the following day. Upon realizing the omission, the resident contacted the facility, and it was confirmed by LPN #159 that the medications were still in the cart. The resident experienced vomiting and diarrhea on the morning of December 25, 2024, and was uncertain if these symptoms were related to the missed medications. This incident was investigated under Complaint Number OH00160745.
Failure to Ensure Privacy During Catheter Care
Penalty
Summary
The facility failed to provide urinary catheter care in a dignified manner for Resident #19, who was cognitively intact and required substantial maximal assistance for toileting and bathing. The resident had a suprapubic catheter due to neuromuscular dysfunction of the bladder and other related diagnoses. The care plan included specific interventions for catheter care, such as changing the Foley collection bag per facility policy and ensuring the catheter tubing was positioned correctly. However, during an observation, a CNA provided catheter care without ensuring the resident's privacy, as the curtain was not pulled, and the door was not closed, potentially exposing the resident to others in the hallway. The CNA acknowledged the oversight during an interview, and the Director of Nursing confirmed that privacy should have been maintained by pulling the curtain or closing the door. The facility's policy on Quality of Life-Dignity emphasized the importance of promoting and protecting resident privacy during personal care and procedures. This deficiency was identified during an investigation under Complaint Number OH00159216, highlighting a lapse in maintaining the resident's right to a dignified existence and privacy.
Failure to Document Catheter Care
Penalty
Summary
The facility failed to ensure that urinary catheter care was completed and documented as ordered for a resident with a suprapubic catheter. The resident, who had diagnoses including infection and inflammatory reaction due to a urinary catheter, neuromuscular dysfunction of the bladder, quadriplegia, and a history of sepsis, was dependent on staff for various activities and had an intact cognition with delusions. The plan of care included assisting with catheter care, educating the resident to report signs of infection, and monitoring for urinary tract infections. Despite a physician's order for catheter care every shift, the Treatment Administration Record (TAR) for June and July 2024 showed multiple instances where catheter care was neither documented as completed nor refused on the day shift. The Director of Nursing confirmed that the documentation was incomplete, which should have been recorded for the resident. This deficiency was investigated under a specific complaint number.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to adhere to physician orders for medication administration, affecting two residents. For Resident #30, there was a discrepancy in the administration of melatonin. The medical record showed two conflicting orders: one for a single 3 mg tablet and another for three 3 mg tablets at bedtime. The Medication Administration Record (MAR) for October 2024 indicated that both orders were followed, leading to an error in medication administration. The Director of Nursing (DON) confirmed that Resident #30 received melatonin incorrectly due to the presence of two orders for the same medication. For Resident #64, the facility did not consistently follow the physician's order to hold midodrine if the systolic blood pressure (SBP) was over 110 or if the blood pressure was not documented. The MAR showed multiple instances in May, June, July, and August 2024 where midodrine was administered without obtaining or documenting the required blood pressure readings, or when the SBP was elevated. The DON verified these discrepancies, acknowledging that the medication was not administered as ordered. The facility's policy on medication administration, dated November 2017, mandates adherence to physician orders and manufacturer recommendations, which was not followed in these cases.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a staff member performed a safety test when using an insulin pen-injector, resulting in a significant medication error. This incident involved a resident with type one diabetes mellitus who was cognitively intact and received insulin injections. The physician's orders for the resident included specific dosages of Lantus SoloStar and Humalog Kwik Pen insulin to be administered subcutaneously. During an observation, an LPN was seen administering insulin to the resident without priming the insulin pen-injectors, which is a necessary step to ensure accurate dosing. The manufacturer's instructions for both the Lantus SoloStar and Humalog Kwik Pen require a safety test to be performed before each injection. This involves dialing a test dose, tapping the insulin reservoir, and ensuring insulin comes out of the needle. The facility's policy on medication administration also mandates adherence to manufacturer recommendations. However, the LPN confirmed during an interview that she did not perform the safety test before administering the insulin, leading to the medication error. This deficiency was identified during a complaint investigation.
Failure to Document Dietary Intake
Penalty
Summary
The facility failed to ensure accurate documentation of dietary intake for a resident who required staff assistance with meals. The resident, who had diagnoses including quadriplegia and a history of sepsis, was dependent on staff for eating and other activities of daily living. Despite being on a regular diet with thin liquids, the facility's records showed significant gaps in documenting the resident's meal consumption over a two-week period. Specifically, there were no recorded dietary intakes for several days and incomplete documentation for others. Interviews with the Registered Dietician and the Director of Nursing confirmed the lack of complete documentation. The Registered Dietician noted that the resident did not report any issues with meal support or missing meal trays, and the resident's weight stabilized after admission. However, the facility's policy on supporting activities of daily living, including dining, was not implemented as written, leading to this deficiency. This issue was investigated under a specific complaint number.
Medication Administration Errors Lead to 8% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during the observed period. This deficiency was identified through the incorrect administration of medications to two residents. Resident #38, who has a history of hypertension and severe cognitive impairment, was supposed to have their blood pressure medication, Norvasc, withheld due to a low systolic reading of 107 mmHg. However, the LPN responsible for administering the medication placed the Norvasc in the medication cup and intended to administer it, despite having charted that it should be held. Resident #39, who is cognitively intact and has a history of acute respiratory failure, hypertension, and diabetes, was prescribed Senna for constipation. During medication administration, the LPN mistakenly gave Senna Plus, which includes an additional stool softener, instead of the prescribed Senna. The LPN confirmed the error upon review. These incidents highlight the facility's failure to adhere to its medication administration policy, which requires verification of medication details and adherence to physician orders, including holding medications when necessary.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control procedures for two residents, both of whom required Enhanced Barrier Precautions (EBP) due to their medical conditions. Resident #10, who had anoxic brain damage, anxiety, dependence on a ventilator, a tracheostomy, and seizures, was observed receiving medication via a gastrointestinal tube without the administering nurse wearing a gown, despite the presence of an EBP sign and an isolation cart with personal protective equipment (PPE) outside the room. The nurse confirmed the omission of the gown, acknowledging the EBP sign and isolation cart. Similarly, Resident #13, with acute and chronic respiratory failure, dependence on a ventilator, a spinal cord injury, and atrial fibrillation, was observed undergoing tracheostomy suctioning by a respiratory therapist who also failed to wear a gown. An EBP sign and an isolation cart with PPE were present outside the room. The respiratory therapist confirmed the lack of gown use during the procedure. The facility's policy on EBP, revised in June 2024, mandates gown and glove use during high-contact care activities, including device care such as tracheostomy and ventilator tubes.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 736 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lebanon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedarview Care Center | 1.1 mi | ★★★★★ | 9 | 0 |
| Cedars Of Lebanon Care Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Otterbein Lebanon Retirement Community | 4.7 mi | ★★★★★ | 8 | 0 |
| Pine Ridge Skilled Nursing And Rehab | 7.3 mi | ★★★★★ | 1 | 0 |
| Otterbein Middletown | 7.4 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Embassy Of Lebanon.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.