Cedars of Lebanon Care Center

In the surveyor’s words

From the most serious findings on record at Cedars of Lebanon Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 29, 2024

  Based on medical record review, staff interview, resident interview, review of Emergency Medical Services (EMS) report, review of hospital records, review of witness statements, review of a facility Self-Reported Incident (SRI), and review of a facility policy, the facility failed to ensure a resident was free from staff-to-resident physical abuse. This resulted in Actual Harm when Resident #10 was physically abused by Stated tested Nursing Assistant (STNA) #101 who restrained the resident's arms against his chest causing numerous skin tears and contusions to the resident's arms and hands. Subsequently, Resident #10 was transferred to a local hospital where he was assessed and treated for injuries including, multiple skin tears, and contusions of the elbow and forearm. […]

• No harm, potential for more than minimal, widespreadF812Jul 16, 2026

  Based on observation, staff interviews and policy review, the facility failed to ensure food items and kitchen equipment were maintained in a manner to prevent foodborne illness. This had the potential to affect all 45 residents who receive food from the kitchen.Findings include:1. Observation of the facility's kitchen on 07/13/26 at 10:10 A.M. revealed there was a dirty pair of gloves that were turned inside out sitting on the ledge underneath the steam table, and there was gray debris resembling dust on a fan which was located over the knives and pointed towards the steam table, on the hood above the stove, and on the plate cover rack.Interview with Dietary Manager #64 on 07/13/26 at 10:10 A.M. […]

• No harm, potential for more than minimal, widespreadF812Oct 17, 2024

  Based on observations, staff interviews, temperature log review, and policy review, the facility failed to store, prepare and serve food under sanitary conditions. This affected all 44 residents receiving food from the facility. The facility total census was 44. Finding include: 1. Observations on 10/15/24 at 8:50 A.M., revealed the following: In the reach in refrigerator there were packages of grated cheese and sliced cheese with no date. The stove had an a black substance built up of the appearance of grease on the stove surface ad in the heating elements. There as a built up of wet substance with the appearance of grease on the hood louvers above the stove cooking surface. There was one large food storage bin label sugar with the food scoop stored on top of the sugar. […]

• No harm, potential for more than minimal, widespreadF949Oct 17, 2024

  Based on employee file review, interview, and review of the facility assessment, the facility failed to ensure all staff received education on mental and behavioral health. This affected three State tested Nursing Assistants (STNAs)(#505, #504 and #503) of five STNAs reviewed for mental and behavioral health training. This had the potential to affect all 44 residents residing in the facility. The faciliy census was 44. Findings include: Review of the facility Assessment updated 07/29/24 revealed the facility is a 45-bed secured facility specializing in behaviors and mental health. The facility has a majority of long-term residents with the entire facility specializing in mental and behavioral health. […]

• No harm, potential for more than minimal, widespreadF921Jul 10, 2024

  Based on observations and staff interviews, the facility failed to ensure a safe, functional, and homelike environment for the residents. This affected six resident rooms of 18 resident rooms and one shower room utilized by all residents. The census was 42. Findings include: Observation on 07/10/24, of the main shower room, utilized by all facility residents, revealed damaged drywall and peeling paint on the shower stall ceiling and grout between the ceramic tile that had a black residue. Observation on 07/10/24, revealed resident Rooms 104, 105, 111, 112, 114 and 115 to have ceiling tile with black or brown stains. Observation on 07/10/24 of room [ROOM NUMBER] revealed a hole in the wall behind the main door and room [ROOM NUMBER] revealed a hole in the wall behind the middle bed. […]