Village of Lebanon

Based on observation, interview, and facility policy review, the facility failed to ensure staff transported 1 (Resident #31) of 4 residents in their geriatric chair in a forward-facing position to promote dignity. Findings included: A facility policy titled, Promoting/Maintaining Resident Dignity, revised 10/01/2024, indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. An admission Record indicated the facility admitted Resident #31 on 03/14/2025. According to the admission Record, the resident had medical history that included diagnoses of dementia, anxiety disorder, adult failure to thrive, need for assistance with personal care, and major depressive disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2025, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 7,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, review of facility records, and policy review, the facility failed to provide incontinence care in such a manner as to reduce the risk of a urinary tract infection for 1 (Resident #47) of 2 residents whose incontinence care was observed.Findings included: A facility policy titled, Perineal Care, revised 10/01/2024, indicated, If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. A. Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes. An admission Record revealed the facility admitted Resident #47 on 01/01/2023. According to the admission Record, the resident had a medical history that included urinary tract infection, Stage 4 (severe) chronic kidney disease, chronic systolic (congestive) heart failure, and unspecified cardiomyopathy. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/05/2025, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, review of manufacturer's instructions for medication administration, and review of the facility policy, the facility failed to maintain a medication error rate of less than 5 percent (%). Three medication errors were observed during 27 medication error opportunities, for a medication error rate of 11.11%, which affected 2 (Resident #41 and Resident #47) of 3 residents observed during medication pass.Findings included: A facility policy titled, Medication Administration, revised 08/01/2025, indicated, 11. Review the MAR [Medication Administration Record] to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. 17. Administer medication as ordered in accordance with manufacturer specifications. 1. An admission Record indicated the facility admitted Resident #41 on 01/14/2015 and most recently readmitted the resident on 02/05/2024. According to the admission Record, the resident had a medical history that included…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, the facility failed to ensure 1 of 2 medication carts were locked when unsupervised. Findings included: A facility policy titled, Controlled Substance Administration & Accountability, revised on 06/01/2025, indicated, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure. An observation on 08/12/2025 from 3:18 PM to 3:26 PM revealed an unlocked/unsupervised medication cart outside room [ROOM NUMBER] with no staff present. During the observation, the nurse came out of a resident's room (the door was closed) and walked past the unlocked cart and went on to the nursing station. Registered Nurse (RN) #7 locked the cart when she returned at 3:26 PM. During an interview on 08/12/2025 at 3:28 PM, RN #7 stated she knew better than to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and a review of facility policies, it was determined the facility failed to provide privacy/dignity during medication administration for one (1) of twenty (20) sampled residents (Resident #9). Staff was observed to administer eye drops medication to Resident #9 while the resident was seated in the day room area with six (6) other residents. The findings include: Review of the facility policy titled, Resident's Rights-Federal Law, dated October 2007, revealed the residents had the right to personal privacy and confidentiality to include medical treatment. Review of the facility policy titled, Medication Administration General Guidelines for the Administration of Medications number 6.2, undated. revealed medications were supposed to be administered at the resident's bedside and if administration would expose the resident's skin, the curtain would be drawn for privacy. Review of Resident #9's medical record revealed the facility admitted the resident on 05/17/2021 with diagnoses including Alzheimer's Disease, and Glaucoma. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, facility policy review, and review of the facility investigation, it was determined the facility failed to ensure residents were free from abuse for one (1) of twenty (20) sampled residents (Resident #7). On 04/11/2021, Licensed Practical Nurse (LPN) #6 was overheard by State Registered Nurse Aide (SRNA) #1 and SRNA #3, state she would smack Resident #7 in the face if he/she didn't calm down. Based on validation of the Quality Assurance (QA) Plan, the State Survey Agency determined the deficient practice represented past non-compliance, as it was identified and corrected regarding protecting residents from abuse, prior to initiation of the investigation by the State Survey Agency. The findings include: Review of facility policy, titled, Abuse, last revised 02/13/2019, revealed the facility would prohibit abuse, mistreatment, neglect, misappropriation of resident property and exploitation for all residents. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure all drugs and biologicals were stored in locked compartments for one (1) of three (3) facility medication carts. Observation on 04/19/2022, revealed the South hall medication cart was observed to be unlocked and unattended. The findings include: Review of the facility Medication Administration General Guidelines for the Administration of Medications policy number 6.2, undated, revealed the Nurse or Certified Medication Aide would ensure the medication cart was locked any time the cart was out of direct line of vision. Observation of the South hall medication cart, on 04/19/2022 at 5:10 PM, revealed the cart was fifteen(15) feet from the nurse's station and was unlocked with no staff present. Further observation revealed Registered Nurse (RN) #1 came to the cart at 5:20 PM and then walked away from the cart, leaving the cart unlocked. Further observation revealed at 5:23 PM, RN #1 returned to the cart and locked the cart. No wondering residents were identified, and no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to have an effective infection control program to prevent the spread of infection for two (2) of twenty (20) sampled residents (Resident #9 and #37). Nursing staff was observed to touch Resident #9 and #37's medications with bare hands prior to administration on 04/21/2022. The findings include: Review of the facility policy, titled, Medication Administration Infection Control Standards of Practice, undated, revealed the facility staff would provide safe medication administration to residents. However, the policy did not address the touching of resident's medications with bare hands. Observation of medication administration for Resident #9, on 04/20/2022 at 8:28 AM, revealed Registered Nurse (RN) #1 prepared Aspirin 81 milligram (mg) tablet (pain reliever, fever reducer), Losartan 50 mg tablet (medication used to treat hypertension), Metoprolol 25 mg tablet (medication to treat hypertension), and Vitamin B 12 500 microgram (mcg) tablet by removing the medications from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure one (1) staff member who was unvaccinated for COVID-19 due to a religious exemption, wore the required mask when providing care to residents. Observation on 04/21/2022, revealed LPN #2, who was unvaccinated for COVID-19, and had a religious exemption was wearing a blue medical mask. The findings include: Review of the facility policy titled, Employee COVID-19 Vaccinations, reviewed/revised 04/2022, revealed the facility would implement additional precautions to mitigate the transmission and spread of COVID-19 for all staff who were not fully vaccinated (i,e., had not completed primary series yet, had a pending or granted religious/medical exemption, or vaccine was delayed for a certain reason, etc.) (CMS term) or up to date (CDC term) for COVID-19. (Facility precautions/mitigation actions to be taken, may include, but not limited to i.e., masking, social distancing, reassignment, weekly testing, use of N95 or higher-level respirator, etc.) Review of the listing of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of the facility policy, it was determined the facility failed to ensure food was palatable related to seasoning of the food. Six (6) residents in the Resident Council Meeting conducted at 9:30 AM on 02/20/19 complained that the food tasted like the facility had opened the can, heated, and served the food. The findings include: Review of the facility policy titled Food Preparation Guidelines, revised 10/01/18, revealed the facility would provide palatable food to include using spices or herbs to season food in accordance with recipes. In addition, the facility would honor resident preferences, as possible, regarding food and drinks. Observation at 11:48 AM on 02/20/19 of a test tray revealed there was no seasoning in the regular and pureed green beans. The Administrator accompanied the surveyor with the palatability test. The Administrator agreed that the green beans (regular and pureed) tasted like the can had been opened, heated, and served. Interview with the Dietary Manager (DM) at 11:53 AM on 02/20/19 revealed the facility did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a person-centered plan of care related to respiratory therapy was implemented for one (1) of twenty-six (26) sampled residents (Resident #35). Review of the care plan revealed an intervention for Resident #35 to get oxygen as ordered by the physician. Review of the physician orders revealed an order for oxygen at three (3) liters per minute (LPM). Observations of Resident #35 on 02/19/19, 02/20/19, and 02/21/19 revealed Resident #35 did not receive the physician-ordered oxygen flow rate. The findings include: Review of the facility's policy, Care Plan Interdisciplinary, dated 10/01/07 and reviewed on 10/01/18, revealed an individualized care plan would be developed for all residents admitted to the facility. The policy stated an updated and current individualized care plan was necessary to ensure each resident received the nursing care needed to treat identified problems that were specific…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, medical record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of twenty-six (26) sampled residents (Resident #35) received respiratory care (oxygen therapy) according to the physician's orders and the comprehensive care plan. Resident #35 had physician's orders for oxygen at three (3) liters per minute (LPM) via nasal cannula; however, on 02/19/19, 02/20/19, and 02/21/19 the facility failed to provide Resident #35's oxygen as ordered. The findings include: Review of the facility's oxygen policy titled Oxygen and General Nursing, dated 10/01/07 (with a reviewed date of 10/01/18), revealed only licensed nurses and respiratory therapists were authorized to make changes in residents' oxygen administration and should instruct other staff not to change the oxygen flow rate. Review of Resident #35's medical record revealed he/she was admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation, Acute and Chronic combined…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.