Lebanon Veterans Home

In the surveyor’s words

From the most serious findings on record at Lebanon Veterans Home, in the surveyor’s own words.

• Actual harm, isolatedF686Oct 18, 2022

  Based on interview and record review it was determined the facility failed to ensure treatments and services related to wound care were provided for 2 of 3 sampled residents (#s 1 and 3) who had pressure injury wounds. Resident 1 developed an unstageable pressure injury with resultant [CONDITION(S)] (occurs when the body's response to an infection damages its own tissues) and [CONDITION(S)] (bone infection) and required hospitalization . Findings include: 1. Resident 1 was admitted to the facility in ,d+[DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's wound Care Plan, last updated on [DATE] revealed the resident was at risk for actual skin impairment/pressure ulcer related to immobility, atrophy (wasting away) of muscles and polyneuropathy (nerve damage). […]

• Actual harm, isolatedF600Jul 21, 2021

  Based on interview and record review it was determined the facility failed to ensure residents were free from abuse for 1 of 4 sampled residents (#4) reviewed for abuse and resident rights. Resident 4 experienced psychosocial harm as a result of the abuse. Findings include: Resident 4 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/22/21 Admissions MDS revealed Resident 4's cognition was moderately impaired with a BIMS score of eight out of 15. The 4/2/21 updated care plan revealed Resident 4 was on hospice, incontinent of bowel and bladder and conversations were to be intitiated before ADL care was provided. […]

• Actual harm, isolatedF684Jul 21, 2021

  Based on interview and record review it was determined the facility failed to follow physician's orders for 2 of 3 sampled residents (#s 1 and 2) reviewed for following physician's orders. Resident 1's wound became infected and required acute care intervention. Findings include: 1. Resident 1 admitted to the facility in 2/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/24/21 admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/24/21 Nursing Admission Assessment indicated Resident 1 had a dressing to her/his left foot on admission from a left great toe amputation. The resident's 3/1/21 care plan indicated the resident had a wound and wound care was to be done per physician's orders. […]

• No harm, potential for more than minimal, patternF761Sep 9, 2025

  Based on observation and interview it was determined the facility failed to ensure medications were not expired for 2 of 4 sampled houses reviewed for medication storage. This placed residents at risk for altered medication effectiveness. Findings include: 1. On 9/5/25 at 3:03 PM, an open bottle of Prednisolone 1% eye drops was observed with Staff 19 (LPN) in the medication storage in room [ROOM NUMBER]. The bottle of Prednisolone had an open date which was unreadable and was dispensed on 6/13/25. Staff 19 stated eye drops were expired after being open for 30 days. On 9/5/25 at 3:05 PM, an open bottle of acetaminophen was observed with Staff 19 in the medication storage in room [ROOM NUMBER] which expired in 2/2025. […]

• No harm, potential for more than minimal, patternF804Sep 9, 2025

  Based on observation and interview it was determined the facility failed to ensure proper food temperatures were maintained for meals served from 2 of 12 facility kitchens reviewed for food service. This placed residents at risk for unpalatable and unpleasant meals. Findings include:1. On 9/2/25 at 11:55 AM, Resident 130 stated the ground up food was completely unpleasant. On 9/3/25 at 8:12 AM, Resident 15 stated the food was tasteless, and always cold. On 9/3/25 at 10:09 AM, Resident 2 stated the food was not palatable and she/he did not like to eat it. During an observation of the lunch meal service on 9/5/25 at 12:24 PM, a meal of lemon pepper tuna, rice pilaf, and broccoli was served to residents of the [NAME] 200 house. […]