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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lebanon Veterans Home during CMS and state inspections, most recent first.
Expired medications were found in resident med storage areas, including open Prednisolone eye drops with an unreadable open date, expired acetaminophen, two open insulin pens without open dates, Ondansetron tablets, and triple antibiotic ointment. Staff stated eye drops and insulin pens were to be labeled when opened and discarded after 30 days, and that expired meds were to be removed from storage and not kept in use.
Food temperatures were not maintained during meal service, and residents reported meals were cold, tasteless, and unpalatable. During observation, tuna, rice pilaf, and broccoli were served below the required holding temperature, with items repeatedly reheated in a microwave or oven before serving. A surveyor test tray was described as rubbery, dry, crunchy, mushy, and unpalatable, and the DON stated the temperature drop was a known issue.
Infection control standards were not followed in the [NAME] House 100 unit during a COVID outbreak. The frosted glass door lacked signage, PPE, trash cans, and hand sanitization supplies, even though the IC RN stated these items were expected at all doors to the unit. Two visitors were observed exiting through that door, removing their masks after leaving, and opening multiple doors with their hands, and a staff member was also observed exiting, removing a mask, crossing the lobby to discard it, and then sanitizing hands. The DNS acknowledged the missing COVID precautions at the door.
Failure to obtain a resident’s advance directive. A resident admitted with anxiety and HF repeatedly stated in care conferences that they were looking for a copy of the document and wanted help completing it, but the record showed no indication staff assisted with the advance directive, and the SSD acknowledged no one followed up on the request.
Dirty Carpeting in Common Areas: The facility failed to keep carpeting clean in Delta 3. A CNA stated the carpets had been cleaned about two weeks earlier but the brown spots returned a few days later, and the Housekeeping Manager stated the stains around the dining room had been present for at least two years and could not be removed despite cleaning at least every two weeks.
Failure to protect a resident from physical abuse by another resident. A resident with dementia and a history of wandering entered another resident’s room, and the other resident, who also had dementia and a history of verbal and physical aggression, pushed the resident hard, causing a fall. Staff reported the aggressive resident could be unpredictable, and one CNA initially observed the interaction without intervening.
A resident with dementia and a stroke history was started on Seroquel for agitation related to wanting to visit a spouse, even though the resident was often calm after visits and labs were not obtained before the antipsychotic was started. The resident's care plan was not updated for the psychotropic, and the record did not show monitoring for side effects; staff later stated the medication was not appropriate and did not improve behaviors.
Care plans were not updated for two residents with changing ROM and infection control needs. One resident with dementia and a left-hand contracture was using a soft hand wrap, but the care plan did not include it. Another resident was placed on EBP for chronic wounds, yet staff observations showed EBP was not being implemented and the care plan was not updated after the wounds and catheter issues had resolved.
Incomplete neurological monitoring after an unwitnessed fall: A resident with dementia was found on the floor in the activity room and was slow to arouse, unable to follow simple commands, and initially had a nonresponsive pupil. The ordered neuro checks were to continue at set intervals for 48 hours, but the flow sheet was incomplete, had missing assessment areas, and stopped after three hours. An RNCM acknowledged the checks were incomplete, and an LPN stated the resident took about an hour to return to baseline.
Failure to follow transfer and fall safety care plans led to accidents for two residents. One resident with dementia fell from a wheelchair after a mechanical lift transfer when the armrest was not properly latched, causing a forehead laceration. Another resident with stroke, cognitive communication deficit, and repeated falls was care planned for 2-person assist with a sit-to-stand lift, but a CNA performed the transfer without another staff member present, despite the care plan requiring two staff.
The facility failed to complete trauma screens for two residents with PTSD. One resident had a care plan noting a history of trauma related to childhood deprivation and abuse, but no completed trauma screen or documented triggers were found. A second resident was described by staff as becoming aggravated at times, yet the record showed no trauma screen or PTSD care plan. Staff stated trauma screen information was supposed to identify trauma types and triggers and be placed on the care plan.
Failure to monitor medications for two residents. One resident with arterial fibrillation had an order for warfarin, but there was no blood thinner care plan or monitoring for adverse side effects. Another resident with heart failure had an order for furosemide, showed weight gain and edema, but had no diuretic care plan and was not being monitored for weight gain.
Incomplete Daily Staffing Postings: The facility failed to post complete DCSDR staffing information each day. Observations showed the posted reports were dated for the prior day and did not include evening or night shift staff numbers or hours on multiple occasions. The DNS stated the timing of documenting evening and night shift information on the DCSDR needed improvement.
The facility failed to inform a resident about changes in their standing frame therapy, leading to missed sessions, and did not obtain consent from another resident's responsible party before increasing the dosage of an antipsychotic medication.
A resident with dementia and urinary retention experienced red-tinged urine and severe abdominal pain, but the physician was not notified. The resident was later diagnosed with a UTI, hematuria, and sepsis, leading to hospitalization. Staff acknowledged the need to notify the physician, but no documentation was found.
The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) for a resident admitted with heart attack and dehydration. The NOMNC was signed a day before the last covered day, and it was confirmed that the notice was not provided within the required timeframe.
A resident's grievance about activity rule changes and alleged prejudice was not addressed promptly due to an insufficient grievance policy and delayed response by the facility. The grievance policy lacked clear timeframes and did not acknowledge oral or anonymous grievances, leading to a 15-day delay in communication with the resident.
A facility failed to document and conduct a Significant Change MDS assessment for a resident whose condition had significantly deteriorated, including cognitive decline, increased pain, and worsening pressure ulcers. Despite these changes, no significant change assessment was considered or ruled out, placing the resident at risk for unassessed needs.
The facility failed to revise care plan interventions for three residents, leading to unmet needs. One resident's care plan did not reflect a significant decline in mobility, another's care plan lacked necessary fall prevention measures, and a third's care plan was not updated to reflect changes in preferences.
A resident with multiple sclerosis and spinal degeneration did not receive the required assistance with bathing due to staffing shortages. Despite filing a grievance, the resident continued to miss expected showers, and staff confirmed the difficulty in completing the task due to being short-handed.
The facility failed to monitor a resident for a change of condition, make a urology appointment, and follow physician orders for two residents. One resident exhibited UTI symptoms and was hospitalized with sepsis, while another resident did not receive prescribed Kefir due to unavailability, and staff failed to notify the physician.
The facility failed to accurately assess and document pressure ulcers for two residents, leading to a risk of worsening wounds. One resident's sacral wound progressed to a Stage 4 pressure ulcer without proper documentation or inclusion in the care plan, while another resident's wound assessments lacked comprehensive details and were often incomplete.
The facility failed to assess a resident's ability to transfer from a reclining chair and did not timely investigate falls for two residents. One resident with dementia was observed attempting to transfer from a recliner with elevated leg rests, increasing fall risk. Another resident experienced two falls, with investigations delayed by several days.
The facility failed to obtain orders for oxygen for a resident with COPD. The resident used oxygen as needed, but no orders were found in their medical record. Staff confirmed the resident's use of oxygen without proper orders.
A resident with a diagnosis of partial intestinal obstruction was administered both Loperamide and Senna simultaneously due to an incorrect entry in clinical records. This led to the resident not having a bowel movement for five days, requiring additional interventions. The error was identified when staff noted the medications should not have been given together.
The facility failed to ensure complete and accurate records for a resident with diabetes. Despite physician orders to administer insulin three times a day, records showed missed doses on multiple occasions. Staff later claimed these records were marked in error and that the medication was administered as ordered.
The facility failed to practice proper infection control procedures for a resident with a Stage 4 pressure ulcer and did not sanitize resident care equipment between uses. An LPN did not perform hand hygiene after removing gloves during wound care, and a CNA did not sanitize equipment between residents.
The facility failed to protect two residents from abuse. One resident with dementia and PTSD was sexually abused by another resident with Alzheimer's Disease during a video call. In a separate incident, a resident with moderate cognitive impairment was struck by an object thrown by another resident with dementia and PTSD. Both incidents were witnessed by staff, but only the sexual abuse was substantiated.
The facility failed to timely investigate an abuse allegation involving a resident with panic disorder, dementia, and PTSD, and another resident with Alzheimer's Disease. The incident occurred during a video call when one resident rubbed the other's chest area. The investigation, which confirmed sexual abuse, was not completed in a timely manner.
Expired Medications Found in Resident Storage Areas
Penalty
Summary
The facility failed to ensure medications were not expired in resident medication storage areas and in medication storage in two sampled houses. In one medication storage room, an open bottle of Prednisolone 1% eye drops was observed with an unreadable open date and had been dispensed on 6/13/25. In the same area, an open bottle of acetaminophen was found with an expiration date of 2/2025, and two open insulin pens were observed without open dates and had been dispensed on 7/1/25. Staff stated that eye drops were to be discarded 30 days after opening, medications were to be destroyed when expired, and insulin pens were to be labeled when opened and discarded after 30 days. In the resident medication storage cabinets in the [NAME] House 100 unit, one box of Ondansetron 4 mg tablets was found with an expiration date of 8/2025. In the resident medication storage cabinets in the [NAME] House 200 unit, one tube of triple antibiotic ointment was found with an expiration date of 7/2025. Staff acknowledged the expired medications and stated that resident medications were expected to be removed and replaced before they expired and were not to be expired while in use.
Food Temperatures Not Maintained During Meal Service
Penalty
Summary
The facility failed to ensure proper food temperatures were maintained for meals served from 2 of 12 facility kitchens reviewed for food service. During interviews, multiple residents stated the food was unpleasant, tasteless, cold, not palatable, and difficult to eat. On 9/5/25, during observation of the lunch meal service in the [NAME] 200 house, lemon pepper tuna, rice pilaf, and broccoli were delivered from the kitchen at temperatures of 160 degrees F, 149 degrees F, and 135 degrees F, respectively. The broccoli was reheated in the microwave multiple times until it reached 165 degrees F, and the mechanical soft texture tuna was placed in an oven set to 200 degrees F after being delivered at 125 degrees F. Throughout the meal service, the food was kept in separate foil-covered metal containers on the kitchen counter and opened repeatedly while being served, and all plates were reheated in the microwave before being served to residents. A surveyor test meal served immediately after the resident meal was described as rubbery, dry, crunchy, mushy, and unpalatable, with temperatures of 121 degrees F for lemon pepper tuna, 136 degrees F for mechanical soft texture tuna, 123 degrees F for rice pilaf, and 87 degrees F for broccoli. The Dietary Manager stated the drop in resident meal temperatures was a known issue, and the Administrator acknowledged the drop in temperatures and the unpleasantness of the surveyor test tray. During a separate observation, tuna on the Alpha 200 house meal cart was placed in the oven and later observed at 131 degrees F, and the Dietary Manager stated the required holding temperature was 140 degrees F.
Infection Control Precautions Missing at Unit Door During COVID Outbreak
Penalty
Summary
The facility failed to ensure infection control standards were followed in 1 of 4 houses reviewed for infection control. During observation of COVID precautions in the [NAME] House 100 unit, the frosted glass door did not have signage, PPE, trash cans, or hand sanitization supplies on either side of the door. Staff 5, the Infection Control RN, stated that units with active COVID outbreaks were to have signage, PPE, trash cans, and hand sanitization supplies for staff and visitors on all doors to the unit. Two visitors were later observed exiting the unit through the frosted glass door, removing their masks after exiting, placing the masks in their pockets, and opening multiple doors with their hands while leaving the building. A staff member was also observed exiting through the frosted glass door, removing their mask, walking across the lobby to discard it, and then sanitizing their hands. Staff 5 later stated staff and visitors were not supposed to use the frosted glass door and said he did not place signage, PPE, trash cans, or hand sanitization supplies by that door because it was not supposed to be used by anyone. The DNS acknowledged the lack of COVID precautions for the frosted glass door and stated the expectation during a COVID outbreak was for signage, PPE, trashcans, and hand sanitization supplies to be at every door for that unit.
Failure to Obtain Resident Advance Directive
Penalty
Summary
The facility failed to obtain a copy of Resident 13’s advance directive. Resident 13 was admitted in 2023 with diagnoses including anxiety and heart failure. Interdisciplinary care conference notes from 7/23/23 through 7/9/25 showed that Resident 13 would look for a copy of the advance directive, and the 10/15/24 care conference documented that Resident 13 would look for the document and wanted assistance with completing it. Review of the medical record showed no indication that staff assisted Resident 13 with completing an advance directive, and on 9/8/25 at 11:33 AM, the Social Service Designee acknowledged that no one followed up on Resident 13’s request to complete one.
Dirty Carpeting in Common Areas
Penalty
Summary
The facility failed to ensure carpeting was clean in 1 of 3 houses, Delta 3. On observation, the carpet between the fireplace and dining room had three large brown stains about one foot in diameter, the carpet in front of the recliners by the television had dark brown stains about four feet long by one foot wide, and the carpet between the dining room and room [ROOM NUMBER] had a dark brown stain about one and one-half feet in diameter. A CNA stated the carpets had been cleaned about two weeks earlier but the brown spots resurfaced a few days later. The Housekeeping Manager stated the stains around the dining room had been present for at least two years and that the carpet was cleaned at least every two weeks, but the stains were not able to be removed.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident’s right to be free from physical abuse by another resident. Resident 68 was admitted with dementia and had a care plan noting a history of wandering into other residents’ rooms, with staff directed to attempt redirection before entry and offer food. Resident 135 was admitted with dementia and had a care plan noting verbal and physical aggression, with interventions to avoid invading the resident’s space and to monitor the resident when in close proximity to other residents. According to the Resident to Resident/Staff Assessment form, CNAs witnessed Resident 68 walk into Resident 135’s room while Resident 135 was in the dining room eating. Resident 135 then went into the room, spoke with Resident 68, looked toward the dining room at staff, and pushed Resident 68 hard, causing Resident 68 to fall. Staff interviews stated Resident 68 wandered into other residents’ rooms and was usually redirected, and that Resident 135 could be unpredictable and sometimes became aggressive suddenly. One CNA stated she did not intervene and initially observed the interaction, and another staff member acknowledged the care plan directed staff to be in close proximity when Resident 135 was with other residents.
Unnecessary psychotropic use and lack of monitoring
Penalty
Summary
The facility failed to ensure a resident with dementia and a history of stroke was not started on a psychotropic medication without indication for use. The resident was admitted in 2/2024 and had behaviors related to wanting to visit a spouse on campus. Records showed the resident was generally calm and content after visits with the spouse, but also had episodes of agitation, including kicking or hitting staff when unable to leave the facility or visit the spouse. On 3/10/25, an external visit note documented worsening behaviors and stated the resident was on daily oxycodone for pain; the use of Seroquel was discussed with the family and agreed to, and an order was written for bedtime administration. The MAR showed Seroquel was given starting 3/11/25 for agitation/behaviors, but laboratory tests were not obtained before the medication was started, and staff later stated the medication was not appropriate and did not improve the resident's behaviors. The facility also failed to monitor the resident for side effects of Seroquel and did not update the care plan to include the antipsychotic. The resident's care plan, initiated on 2/29/24, was not revised to address Seroquel use or monitoring for side effects, and the clinical record did not show monitoring for side effects of the medication. A psychotropic pharmacy review form dated 6/24/25 identified the resident as receiving Seroquel, and staff later acknowledged that a care plan for Seroquel had not been developed and that there was no monitoring for side effects of the antipsychotic.
Care plans not updated for ROM and infection control needs
Penalty
Summary
The facility failed to update care plans for 2 of 3 sampled residents reviewed for ROM and infection control. Resident 9 was admitted in 10/2020 with dementia, and the 4/11/25 annual MDS showed decreased ROM and a left-hand contracture. On 9/8/25, Resident 9 was observed in the dining area with a soft lamb wool Velcro wrap on the left hand, but the care plan initiated in 10/2020 did not include the Velcro wrap. Staff 28 stated on 9/4/25 that Resident 9 had a contracture and fingers that were hard to bend at times and had the wrap for quite a while. Staff 12 stated on 9/8/25 that staff had previously placed a towel in the resident’s hand to prevent a tight grip due to the contracture, but the resident pulled it out, and that a new soft splint had been ordered about one month earlier without updating the care plan. Resident 74 was admitted in 1/2025 with diagnoses including UTI and cancer. Physician orders showed Resident 74 was placed on EBP on 4/23/25 due to chronic ulcers on the right ankle and heel, with no end date documented. On 9/2/25, Resident 74 stated the shoulder wound was basically healed but wounds remained on the leg. On 9/3/25, a nurses note stated there was no wound on the right lateral foot, no wound care was provided, and the wound was resolved. Observations from 9/2/25 through 9/5/25 showed staff were not implementing EBP for Resident 74. On 9/8/25, the care plan listed EBP, and Staff 5 and Staff 2 confirmed the resident’s catheter had been removed and wounds had resolved, but the care plan had not been updated after the pressure ulcer resolved on 8/19/25.
Incomplete Neurological Monitoring After Unwitnessed Fall
Penalty
Summary
The facility failed to ensure neurological assessments were completed for a resident who was found on the floor in the activity room after an unwitnessed fall. The resident had diagnoses including dementia. The incident report stated the resident took 10 minutes to fully arouse, was unable to follow simple commands, and the right pupil was not responding to light at first. The on-call doctor and the resident's POA were notified, and the decision was made to keep the resident in the facility and monitor neurological status closely. The neurological flow sheet for the resident directed checks every 15 minutes for an hour, every 30 minutes for two hours, every hour for four hours, every four hours for 16 hours, and every eight hours for 48 hours. The flow sheet was incomplete, with missing assessment areas, and stopped after three hours. An RNCM acknowledged the neurological checks were incomplete and stated they were to continue until completed. An LPN stated the resident took approximately an hour to return to baseline neurologically after the fall.
Failure to Follow Transfer and Fall Safety Care Plans
Penalty
Summary
The facility failed to ensure residents received services to prevent accidents for 2 of 5 sampled residents reviewed for falls and rehabilitation. One resident with dementia was involved in a witnessed fall in the dining room after being transferred into a wheelchair with a mechanical lift. The post-fall assessment stated the wheelchair armrest was not properly latched, and the resident leaned to the left, fell to the floor, and sustained a forehead laceration. Staff later verified that the armrest had not been latched correctly and that the resident's movement and lack of trunk control contributed to the fall out of the wheelchair. A second resident, admitted with diagnoses including stroke, cognitive communication deficit, and a history of repeated falls, had a fall risk assessment identifying confusion, multiple diagnoses and medications, and prior falls. The revised care plan required two-person assistance with a mechanical sit-to-stand lift for transfers. During an observed transfer, one CNA entered the room with the sit-to-stand lift and later exited without another staff member being present in the room. The CNA stated she did not have another staff member present during the transfer and was confused about whether all sit-to-stand transfers required two staff. The DNS stated staff were expected to follow residents' care plans and confirmed all sit-to-stand lift transfers required two staff.
Failure to Complete Trauma Screens for Residents with PTSD
Penalty
Summary
The facility failed to complete trauma assessments for two residents with PTSD, including one resident admitted with diagnoses that included PTSD and a care plan noting a history of trauma related to childhood deprivation and abuse. That resident’s care plan included a goal to identify individual strengths and an intervention for assistance, supervision, and support to identify precipitating factors and stressors, but the medical record showed no completed trauma screen. Staff stated that trauma screens were usually completed on admission to identify specific types of trauma and triggers and that this information was placed in the care plan, but the resident’s triggers were not documented there. A second resident was also admitted with PTSD, and staff described the resident as becoming aggravated at times and sometimes wanting to be left alone. One CNA stated the resident was aggravated at times, and an LPN stated she was unsure what caused the agitation. A social service designee was unable to locate a completed trauma screen for this resident, and the medical record showed no indication of a completed trauma screen or a PTSD care plan. The DNS stated every resident was to have a trauma screen completed to identify types of trauma and triggers, and that the information was to be placed on the care plan so staff would be aware of what to watch for.
Failure to Monitor Blood Thinners and Diuretics
Penalty
Summary
The facility failed to monitor medications for 2 of 10 sampled residents reviewed for nutrition and unnecessary medications. One resident was admitted with diagnoses including arterial fibrillation and had an order for warfarin. The resident’s care plan contained no evidence of a blood thinning medication care plan or monitoring for adverse side effects of blood thinning medications. Staff stated that adverse side effects for warfarin should be listed in a warfarin care plan, and both the RCM and DNS acknowledged that the resident had no care plan for blood thinners and no monitors in place for adverse side effects. Another resident was admitted with diagnoses including heart failure and had an order for furosemide. The resident’s weights showed an increase from 218 lbs. to 229.2 lbs. over the documented period. The resident’s care plan contained no evidence of a diuretic medication care plan. Staff reported the resident had some edema in the feet or both legs, used compression socks, and had weight gain that was not identified until the interview. The RNCM acknowledged the resident was not being monitored for weight gain, and the DNS stated the resident should have been monitored for weight gain and assessed for whether the increase was related to heart failure and fluid retention.
Incomplete Daily Staffing Postings
Penalty
Summary
The facility failed to post complete nurse staffing information every day. Observation of the Direct Care Staff Daily Reports from 9/2/25 through 9/8/25 showed that on 9/3/25 at 7:00 AM the posted report was dated 9/2/25 and did not include evening or night shift staff numbers or hours. On 9/4/25 at 7:11 AM the posted report was dated 9/3/25 and also did not include evening or night shift staff numbers or hours. On 9/5/25 at 6:07 AM the posted report was dated 9/4/25 and did not include evening or night shift staff numbers or hours. On 9/8/25 at 6:45 AM the posted report was dated 9/7/25 and did not include evening or night shift staff numbers or hours. On 9/9/25 at 8:16 AM, 10:34 AM, and 11:04 AM, Staff 2, the DNS, stated they needed to improve the timing of documenting evening shift and night shift information on the DCSDR.
Failure to Inform Residents and Obtain Consent for Medication and Therapy Changes
Penalty
Summary
The facility failed to provide adequate information and communication regarding the use of an antipsychotic medication and changes in therapy services for two residents. Resident 80, diagnosed with multiple sclerosis and spinal degeneration, was initially scheduled to use a standing frame three times a week. However, the therapy was changed to a PRN basis without informing the resident. As a result, the resident was unaware that they needed to request the standing frame service, leading to a lack of therapy sessions. Staff confirmed that the resident was not notified of the changes, and the resident expressed confusion and frustration over the lack of communication. Resident 118, diagnosed with bipolar disorder and dementia, was prescribed Seroquel, an antipsychotic medication. The dosage was increased without obtaining consent from the resident's responsible party. There was no documentation in the clinical records indicating that the risks and benefits of the medication were communicated to the responsible party. Staff confirmed that consent was not received for the use of Seroquel, indicating a failure to provide necessary information and obtain proper authorization before administering the medication.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician of a change in condition for a resident diagnosed with dementia, urinary retention, and an irregular heartbeat. The resident was observed to have red-tinged urine on two separate occasions, but the physician was not notified. On the first occasion, the resident denied pain, and there was no indication that the physician was informed. On the second occasion, the resident reported a stomach ache and was found to have blood on their incontinent brief and genitalia, yet again, the physician was not notified. The resident's urinary status was not assessed for several days following these observations. The situation escalated when the resident experienced severe abdominal pain, shaking, and crying, leading to their transport to the hospital. The resident was diagnosed with urinary retention, a UTI with hematuria, and sepsis with sudden onset of kidney failure. Interviews with staff revealed that there were difficulties in obtaining orders from the physician for urinalysis, and it was acknowledged that the physician should have been notified of the symptoms. The Director of Nursing Services confirmed that there was no documentation indicating the physician was notified of the resident's condition changes.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) for a resident reviewed for notices. The resident was admitted in 2024 with diagnoses including heart attack and dehydration. The NOMNC documented the last covered day as 4/3/24 and was signed by the resident on 4/2/24. On 5/2/24, a Social Services Designee confirmed that the notice was not provided within the required timeframe to the resident.
Insufficient Grievance Policy and Delayed Response
Penalty
Summary
The facility failed to develop a sufficient grievance policy and provide a timely response to a grievance filed by a resident. The facility's grievance policy, revised in December 2023, did not specify a reasonable expected timeframe for reviewing grievances and neglected to include that residents had the right to file grievances orally or anonymously and obtain a written decision. A resident expressed dissatisfaction with rule changes to a game activity and alleged prejudice from activity staff in a hand-written letter to the Recreation Director. Despite the letter being observed by the Social Service Designee on the same day it was written, the Grievance Officer did not read it until 16 days later, resulting in a delayed response to the resident's concerns. The resident stated that they had not received any communication about their concerns for 15 days after filing the complaint. The Assistant Administrator confirmed the delay, attributing it to a team effort to determine the best way to handle the information in the letter. The Social Service Designee did not consider the letter a grievance because it was not on the official grievance form. A late conversation with the resident regarding their concerns was conducted 19 days after the letter was written, highlighting the insufficiency of the facility's grievance policy when it was updated in December 2023.
Failure to Conduct Significant Change MDS Assessment
Penalty
Summary
The facility failed to document and conduct a Significant Change MDS assessment within the required timeframe for a resident reviewed for nutrition. The resident was admitted to the facility in 2023 with diagnoses including diabetes, pressure ulcer, and dementia. Initially, the resident was cognitively intact with no mood or behavioral concerns. However, by the next quarterly MDS assessment, the resident's cognitive status had declined to moderate impairment, and they exhibited depressive symptoms, behavioral issues, and increased pain levels. Additionally, the resident's pressure ulcer had worsened from Stage 3 to Stage 4, and they were administered a broader range of medications, including antipsychotics, antianxiety, anticoagulants, and opioids. Despite these significant changes in the resident's condition, there was no documentation in the clinical records to indicate that a significant change assessment was considered or ruled out. When questioned, a staff member stated they did not know why the assessment was not completed. This oversight placed the resident at risk for unassessed needs and potentially inadequate care adjustments.
Failure to Revise Care Plan Interventions
Penalty
Summary
The facility failed to revise care plan interventions for three residents, leading to unmet needs. Resident 38, diagnosed with Parkinson's disease, had a care plan indicating the need for walks despite a significant decline in mobility. The resident could no longer walk and required maximum assistance for balance, but the care plan was not updated to reflect these changes. Staff confirmed the resident's decline and the outdated care plan. Resident 121, with a history of falls and moderate cognitive impairment, had a care plan that did not include the use of room and bed sensors despite their effectiveness in preventing falls. The resident experienced a fall, and the care plan lacked documentation of these necessary interventions. Staff confirmed the omission of the room and bed sensors in the care plan. Resident 101, diagnosed with dementia, had a care plan indicating enjoyment of bird watching, but after moving to a new room, the resident no longer liked to watch birds and preferred the window blinds to be shut. Staff confirmed the resident's change in preference, but the care plan was not updated to reflect this. The recreational director acknowledged that the care plan might not have been updated to reflect the resident's current preferences. These failures in updating care plans placed the residents at risk for unmet needs and inadequate care.
Failure to Provide Required Assistance with ADLs
Penalty
Summary
The facility failed to ensure that a dependent resident received the required assistance with activities of daily living (ADLs), specifically bathing. Resident 80, who has multiple sclerosis and spinal degeneration, was admitted in 2020 and required one staff member to assist with bathing. Despite this, the resident's shower calendar for March and April 2024 indicated that the resident received only one shower per week on specific dates, with no showers provided on Sundays as expected. The resident confirmed that they had not received the expected Sunday showers and had filed a grievance, but the issue persisted due to staffing shortages. Staff members corroborated the resident's claims, noting that it was difficult to complete the resident's shower task at night due to being short-handed. Staff 12 and Staff 27 both indicated that the resident's shower required significant staff assistance, which was challenging to provide due to staffing issues. The Assistant Administrator confirmed that the resident had raised concerns about missed showers in January 2024 and expected follow-up showers to be provided if weekend showers were missed. The Director of Nursing Services (DNS) and Assistant DNS acknowledged that the staffing coordinator had been directed to ensure that the same resident unit was not always short-handed, but teamwork was necessary to meet the resident's needs, which did not occur.
Failure to Monitor Condition and Follow Physician Orders
Penalty
Summary
The facility failed to monitor a resident for a change of condition, make a urology appointment, and follow physician orders for two residents reviewed for UTIs and medications. Resident 36, who was admitted with a diagnosis of dementia, exhibited symptoms of a UTI, including red-tinged urine and abdominal pain, but staff did not consistently monitor these symptoms or notify the physician. The resident was eventually hospitalized with urinary retention, UTI with hematuria, and sepsis. Additionally, there was no documentation that a referral to urology was completed as ordered upon discharge from the hospital. Resident 118, admitted with diagnoses including a pressure ulcer and diabetes, was prescribed Kefir to be administered twice daily. However, the medication administration record indicated that Kefir was not available on multiple occasions, and staff failed to notify the physician about its unavailability. This lack of communication and failure to follow physician orders placed the resident at risk for unmet medical needs.
Inadequate Pressure Ulcer Assessment and Documentation
Penalty
Summary
The facility failed to accurately assess and document pressure ulcers for two residents, leading to a risk of worsening wounds. Resident 59, who was admitted with paraplegia, had a sacral wound initially identified as moisture-associated damage. Over time, the wound was inconsistently documented and eventually identified as a Stage 4 pressure ulcer. Despite the wound's progression, it was not correctly assessed or included in the care plan, and the resident required hospitalization for wound debridement. Staff acknowledged the misclassification and lack of proper documentation for the wound's severity and progression. Resident 118, admitted with a sacral pressure ulcer, also experienced inadequate wound assessments. The evaluations from January to April lacked comprehensive details such as wound bed description, drainage, surrounding tissue condition, pain level, and treatment. On several occasions, the evaluations were incomplete or not performed at all. The Director of Nursing Services confirmed that the evaluations should have been fully comprehensive, indicating a failure in the facility's wound care documentation and assessment processes.
Failure to Assess Transfer Ability and Timely Investigate Falls
Penalty
Summary
The facility failed to assess and care plan a resident's ability to transfer from a reclining chair and timely investigate a fall for two residents. Resident 142, who was admitted with a diagnosis of dementia, was observed in a recliner with elevated leg rests and was not assessed for her/his ability to use the remote control to lower the leg rests. Staff acknowledged that many residents in the memory care unit, including Resident 142, were not able to use the remote control. On multiple occasions, Resident 142 was observed attempting to transfer out of the recliner with elevated leg rests, increasing the risk of falls. The care plan did not direct staff to ensure leg rests were down if staff were not in the common area and the resident was asleep. Staff confirmed that there were times when all staff were assisting other residents and may not be available to help Resident 142, who was unsteady when standing without assistance. Resident 121, admitted with diagnoses including anxiety and cramp and spasm disorder, experienced two falls that were not investigated in a timely manner. A post-fall assessment revealed that Resident 121 was found on the floor, but the investigation was completed seven days later. Another post-fall assessment indicated that Resident 121 reported a fall in the bathroom, but the investigation was completed eight days later. Staff confirmed that the fall investigations were not completed in a timely manner, which could have delayed identifying and addressing the causes of the falls.
Failure to Obtain Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to obtain orders for oxygen for a resident with chronic obstructive pulmonary disease (COPD). The resident, admitted in December 2022, had a care plan dated March 3, 2023, for as-needed oxygen. On April 8, 2024, a progress note indicated the resident received oxygen due to respiratory difficulties and shortness of breath. An oxygen concentrator was observed by the resident's bed on April 29, 2024, and the resident stated they used oxygen a couple of times a week, usually in the evenings. A review of the resident's medical record on May 1, 2024, revealed no evidence of oxygen orders. Staff interviews on May 2, 2024, confirmed the resident used oxygen as needed but had no orders for it.
Significant Medication Error Involving Loperamide and Senna
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, specifically for one resident who was administered both Loperamide and Senna simultaneously. The resident, who was admitted with a diagnosis of partial intestinal obstruction, had physician orders for Loperamide to treat diarrhea and Senna to treat constipation. These medications were administered daily from February through April, despite the conflicting purposes of the medications. This error was due to an incorrect entry in the clinical records, which led to the resident receiving both medications concurrently instead of Loperamide being administered on a PRN basis. As a result of this medication error, the resident did not have a bowel movement for five days in April, prompting the administration of a suppository and Miralax for bowel care. The error was identified when a staff member noted that the resident should not have been given both medications at the same time. The incorrect order in the clinical records was acknowledged as a significant medication error, placing the resident's health status at risk.
Incomplete and Inaccurate Resident Records for Medication Administration
Penalty
Summary
The facility failed to ensure resident records were complete and accurate for one resident reviewed for medications. Resident 118, who was admitted in 2023 with a diagnosis of diabetes, had a physician order dated 3/11/24 to administer insulin injections three times a day starting from 10/22/23. However, the Diabetic Orders report for April 2024 documented that the resident was not administered insulin on multiple occasions because the resident was sleeping. Specifically, the missed administrations were recorded on 4/1/24 at 5:00 PM, 4/13/24 at 7:00 AM, 4/14/24 at 7:00 AM, 4/16/24 at 12:00 PM, 4/21/24 at 12:00 PM, and 4/23/24 at 12:00 PM. On 5/3/24, Staff 21 (RCM) stated that these dates were marked in error and that the resident was actually administered the medication as ordered by the physician.
Infection Control Deficiencies
Penalty
Summary
The facility failed to practice proper infection control procedures for a resident with a Stage 4 pressure ulcer and did not sanitize resident care equipment between uses. Resident 59, admitted in March 2017 with paraplegia, had a Stage 4 pressure ulcer on the sacrum as of April 29, 2024. On May 1, 2024, an LPN was observed performing wound care for Resident 59 without performing hand hygiene after removing gloves and before applying new ones. The LPN and a CNA both stated they were unaware of the need to perform hand hygiene in this situation. Additionally, on April 29, 2024, a CNA was observed completing blood pressure and oxygenation checks for multiple residents without sanitizing the equipment between uses. The CNA acknowledged not sanitizing the equipment after each resident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from sexual and physical abuse, affecting two residents. Resident 38, who has diagnoses including panic disorder, dementia, and PTSD, was sexually abused by Resident 141, who has Alzheimer's Disease. During a video call with a family member, Resident 141 reached over and rubbed Resident 38's chest area. This incident was witnessed by the family member and a CNA, and the facility substantiated the sexual abuse. The incident was reported, and staff intervened by moving Resident 38 to a different location and escorting Resident 141 back to their unit. In another incident, Resident 108, who has a history of trauma and moderate cognitive impairment, was physically abused by Resident 139, who has dementia, psychotic disturbance, mood disturbance, anxiety, and PTSD. Resident 139's behaviors escalated, leading them to throw a handheld game into Resident 108's room, striking Resident 108 on the side of the face. This incident was witnessed by two CNAs, and although no injuries were identified, the facility did not substantiate the abuse, attributing Resident 139's actions to a PTSD trigger and agitation. Staff continued to monitor Resident 108 for any abnormalities following the incident.
Failure to Timely Investigate Abuse Allegation
Penalty
Summary
The facility failed to timely investigate an abuse allegation involving Resident 38, who has diagnoses including panic disorder, dementia, and PTSD, and Resident 141, who has Alzheimer's Disease. On 4/4/24, while Resident 38 was on a video call with a family member, Resident 141 reached over and rubbed Resident 38's chest area. The family member intervened by telling Resident 141 to keep their hands to themselves. The facility's investigation, which took place from 4/4/24 to 4/10/24, substantiated the sexual abuse. However, Staff 21 confirmed on 5/3/24 that the investigation was not completed in a timely manner.
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What surveyors actually found near you
We read the 80 citations issued within 25 miles in the last 12 months — 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.
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A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Avamere Rehabilitation Of Lebanon | 0.8 mi | ★★★★★ | 28 | 0 |
| Mennonite Home | 8.8 mi | ★★★★★ | 8 | 0 |
| Regency Albany | 11 mi | ★★★★★ | 14 | 0 |
| Timberline Post Acute | 11.7 mi | ★★★★★ | 8 | 0 |
| Corvallis Manor Nursing & Rehabilitation Center | 17 mi | — | 20 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.