Village of Lebanon

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF550Aug 15, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF690Aug 15, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF759Aug 15, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF761Aug 15, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF550Apr 21, 2022

  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. […]