Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Otterbein Lebanon Retirement Community during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple respiratory diagnoses, including COPD, did not have a care plan developed to address their COPD or supplemental oxygen use. Despite ongoing respiratory symptoms, oxygen therapy, and medication adjustments, the care plan lacked problem statements or interventions for COPD, which staff confirmed was an oversight.
Two resident rooms were found not cleaned and maintained in a sanitary condition. CNA checklists showed missed cleaning tasks, and surveyors observed cobwebs, debris on an AC unit, drywall peelings, and dust on the floor. CNAs stated the rooms should have been cleaned, and the DON and ADON confirmed the issues should have been addressed by staff.
A resident with moderate cognitive impairment and Stage 2 and Stage 4 pressure ulcers was ordered to have EBP with gloves and gown during care. During toileting assistance, a COTA wore gloves but did not don a gown, stating she was unaware the resident was on EBP, despite EBP signage on the door and staff education that high-contact care required the listed PPE.
A resident with multiple chronic conditions was inappropriately administered both Warfarin and Eliquis after a hospital stay, due to the facility's failure to discontinue INR testing and properly review medication orders. The error occurred when INR results were reported to the Coumadin Clinic, which, unaware of the change to Eliquis, ordered Warfarin to be restarted. This led to the resident receiving two anticoagulants simultaneously, with drug interaction warnings triggered but not acted upon by staff.
A resident with multiple chronic conditions was administered both Warfarin and Eliquis concurrently after a medication order error, following a transition from Warfarin to Eliquis post-surgery. Despite drug interaction warnings and pharmacy awareness, both anticoagulants were dispensed and administered due to a lack of order clarification and continued INR monitoring. The error was only discovered after a high INR result prompted further review, with no adverse outcome reported for the resident.
Failure to Develop Care Plan for COPD Diagnosis
Penalty
Summary
The facility failed to develop and implement a care plan addressing the needs of a resident diagnosed with chronic obstructive pulmonary disease (COPD), despite the resident's complex medical history and ongoing respiratory needs. The resident, who had severe cognitive impairment and required substantial to maximum assistance with activities of daily living, was admitted with diagnoses including COPD with acute exacerbation, Alzheimer's disease, and acute respiratory failure with hypoxia. The resident was observed receiving supplemental oxygen and nebulizer treatments, and medical records documented ongoing respiratory symptoms and interventions, including oxygen therapy and medication adjustments. However, a review of the care plan report and the resident's hard chart revealed no problem statement or interventions related to COPD or supplemental oxygen use. Interviews with facility staff, including the MDS Coordinator and Director of Nursing, confirmed that a care plan for COPD should have been developed but was overlooked. The facility's policy required the interdisciplinary team to create a comprehensive, person-centered care plan with measurable objectives and timeframes for all identified needs, but this was not followed for the resident's primary respiratory diagnosis. Documentation showed that care planning discussions and changes were communicated with the resident's family, but these were not reflected in the formal care plan documentation.
Resident rooms were not cleaned and maintained as scheduled
Penalty
Summary
The facility failed to ensure occupied resident rooms were cleaned and maintained in a sanitary condition in two rooms in Magnolia Way. In one room, the Resident Room Clean Checklist dated 09/06/25 and signed by CNA #5 showed that dusting furniture, the windowsill, and removing cobwebs were not completed. An observation on 09/09/25 found cobwebs on the windowsill, and a later observation on 09/10/25 found brown debris on top of the air conditioning unit and cobwebs in the corners of the windowsill. CNA #5 stated housekeeping did not come to Magnolia and that the CNAs completed the cleaning, and she confirmed the room should have been cleaned. In the second room, the Resident Room Clean Checklist dated 09/07/25 and signed by CNA #4 showed that sweeping under furniture and in the closet and mopping the floors were not completed. Observations on 09/09/25 and 09/10/25 found the resident's bed near a wall with peeling drywall, approximately two feet of drywall peelings and dust on the floor, and the same debris remained on the floor during the later observation. CNA #5 stated the drywall dust should have been cleaned and the wall issue should have been reported to maintenance. ADON #2 observed the debris and stated it should have been addressed by staff. Facility interviews and records showed Magnolia Way used CNA cleaning checklists and that CNAs were responsible for cleaning resident rooms. The DON stated Magnolia Way was considered a small house and there were no excuses for staff not to clean the rooms. The Housekeeping Manager stated the CNAs were responsible for cleaning resident rooms and that housekeeping had not trained them to do so. Facility documents also showed no work orders for the wall damage or the debris on the air conditioning unit until the issues were brought to the facility's attention.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were followed for one resident reviewed for infection control. Resident #27 was admitted with diagnoses including an unspecified displaced fracture of the second cervical vertebra and sequela, and an unspecified stage pressure ulcer of the sacral region. The resident’s MDS assessment showed moderate cognitive impairment, a Stage Two pressure ulcer, and a Stage Four pressure ulcer, and the care plan included an intervention for EBP. The active orders also directed EBP with gloves and gown during treatment and/or care every shift. During an observation, COTA #6 entered the resident’s room and later exited carrying soiled linen after assisting the resident with toileting and lunch. COTA #6 stated she wore gloves but did not don a gown because she was unaware the resident was on EBP, even though she acknowledged she had been educated to wear gloves, gown, and a mask for toileting a resident on EBP. The resident’s door had EBP signage with pictures of handwashing, gloves, and a gown. ADON #7 stated residents with wounds, indwelling catheters, and IV lines should be on EBP and that staff were educated to follow the orders and signage. The DON and Administrator also stated staff were required to wear the appropriate PPE, including a gown and gloves, for high-contact care such as toileting when residents were on EBP.
Concurrent Administration of Warfarin and Eliquis Due to Failure to Discontinue INR Testing and Medication Review
Penalty
Summary
A deficiency occurred when a resident with a history of atrial fibrillation, congestive heart failure, type II diabetes mellitus, and chronic kidney disease was prescribed and administered two anticoagulant medications, Warfarin and Eliquis, concurrently. The resident was originally on Warfarin, which was discontinued following a hospital procedure, and Eliquis was started per hospital orders. However, the facility continued to perform INR testing, which is only indicated for Warfarin therapy, not Eliquis. On receiving a low INR result, the facility communicated this to the Coumadin Clinic, which, unaware that the resident was now on Eliquis, ordered Warfarin to be restarted. As a result, the resident received both Warfarin and Eliquis for several days. Medication administration records showed that drug interaction warnings were triggered each time both anticoagulants were administered, but the orders were not reviewed or questioned by facility staff during this period. The error was discovered when a nurse noticed the concurrent administration of both anticoagulants after an elevated INR result was obtained. The facility's daily clinical review process failed to identify the inappropriate orders due to the absence of the Director of Nursing during that week. Interviews confirmed that the facility should have discontinued INR testing after Warfarin was stopped and that the Coumadin Clinic had access to the updated medication list but did not verify it before issuing new orders.
Concurrent Administration of Warfarin and Eliquis Resulting in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident with a history of atrial fibrillation, congestive heart failure, type II diabetes mellitus, and stage III chronic kidney disease received two anticoagulant medications, Warfarin and Eliquis, concurrently. The resident had been on Warfarin since admission, with regular INR monitoring and dosage adjustments. Following an elective surgical procedure, hospital discharge instructions discontinued Warfarin and initiated Eliquis, and the facility updated orders accordingly. However, INR testing continued despite the switch to Eliquis, which does not require such monitoring. Subsequently, when a low INR result was reported to the Coumadin Clinic, new orders were given to restart Warfarin without discontinuing Eliquis, resulting in both anticoagulants being administered simultaneously. The medication administration records confirmed that the resident received both Warfarin and Eliquis over several days. Drug interaction warnings were triggered in the medication administration system, but the orders were still processed and administered. The pharmacy was aware of the duplicate anticoagulant therapy but did not clarify the order with the facility before dispensing the medications. Multiple staff interviews revealed that the error was not identified until a nurse noticed the concurrent administration of both anticoagulants after a high INR result. The facility's daily clinical review process failed to catch the error due to the absence of the Director of Nursing. The Coumadin Clinic and hospital staff also did not verify the current medication list before issuing new orders. The resident did not recall receiving both medications and did not experience any adverse outcomes during the incident.
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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 | 3.9 mi | ★★★★★ | 1 | 0 |
| Otterbein Middletown | 4.1 mi | ★★★★★ | 13 | 0 |
| Arlington Pointe Care Center | 4.2 mi | ★★★★★ | 5 | 0 |
| Ohio Living Mount Pleasant | 4.6 mi | ★★★★★ | 3 | 0 |
| Embassy Of Lebanon | 4.7 mi | ★★★★★ | 8 | 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.