Otterbein Lebanon Retirement Community

In the surveyor’s words

From the most serious findings on record at Otterbein Lebanon Retirement Community, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 25, 2022

  Based on record review, observation, resident and staff interview, and review of the facility policy, the facility failed to ensure fall prevention interventions were in place per the resident's plan of care and failed to conduct thorough investigations to determine root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls and falls with injury. This resulted in Actual Harm when Resident #399 experienced repeated falls resulting in a laceration which required surgical repair. […]

• No harm, potential for more than minimal, patternF574Aug 19, 2026

  Based on observation, staff interview, and policy review the facility failed to ensure that the advocates and Ombudsman information and number was posted on a secured unit for residents, families, and visitors. This had the potential to affect all 53 residents residing in the secured unit. The facility census was 141 residents. Findings include: Observation on 08/17/26 at 10:30 A.M. with the Director of Nursing (DON) revealed there was no Ombudsman information posted in the [NAME] building. An observation on 08/18/26 at 8:58 A.M. of the [NAME] Building revealed there was no Ombudsman information posted in the [NAME] building. Interview on 08/18/26 at 10:11 A.M. […]

• No harm, potential for more than minimal, patternF803Oct 25, 2022

  Based on review of the facility menus, observations, staff interview and policy review, the facility failed to provide puree food portions as planned by a Registered Dietitian. This had the potential to eight (#27, #14, #24, #73, #65, #35, #71,and #48) residents who received food from the [NAME] Hall kitchettes. The total facility census was 143. Findings include: Review of Registered Dietitian approved puree meal tickets dated 10/20/22 revealed a puree menu and portions of hotdog and bun eight ounces, (#8 scoop, doubled), corn of four ounces, mashed potatoes four ounces, (#8 scoop) and pudding four ounces. Observation on 10/20/22 at 12:15 P.M. […]

• No harm, potential for more than minimal, patternF689May 3, 2022

  Based on observation, record review, review of the safety data sheet and interviews, the facility failed to provide a safe environment for cognitively impaired mobile residents residing on the secured unit. This had the potential to affect 34 Residents (#01, #02, #03, #04, #05, #07, #08, #09, #10, #77, #79, #80, #81, #82, #83, #84, #85, #86, #87, #90, #91, #92, #93, #94, #95, #96, #97, #98, #100, #103, #105, #106, #107, and #109) of 43 residents residing in the secured unit. The facility census was 136. Findings Include: Record review for Resident #04 revealed an admitted [DATE]. His diagnosis included, Alzheimer's disease, [CONDITION(S)], dysphagia, chronic kidney disease stage two, [CONDITION(S)], and [CONDITION(S)]. […]

• No harm, potential for more than minimal, patternF761May 3, 2022

  Based on observation, record review, review of the product informational sheet, and interviews, the facility failed to ensure medications were safely stored. This had the potential to affect 34 mobile cognitively impaired residents (#01, #02, #03, #04, #05, #07, #08, #09, #10, #77, #79, #80, #81, #82, #83, #84, #85, #86, #87, #90, #91, #92, #93, #94, #95, #96, #97, #98, #100, #103, #105, #106, #107, and #109) of 43 residents residing in the secured unit. The facility census was 136. Findings Include: Record review for Resident #08 revealed an admitted [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #08 did not have a MDS assessment completed due to her length of stay at the facility. […]