Waters of Lebanon, The

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF585Sep 11, 2025

  Based on observations, interview, and record review, the facility failed to ensure grievance forms and/or a grievance process was readily and easily accessible for residents for 43 of 43 residents who resided in the facility. Findings include: No grievance forms and/or posted grievance instructions were observed throughout the survey period during daily observations of the front lobby, outside of the Social Service Director's office, either nurses' station, or the activity room.There was one grievance note on a desk in the main front lobby, but no blank forms or other grievance material was found. On 9/10/25 at 10:26 a.m., a meeting was conducted with the Resident Council President and 3 other residents who regularly attended the Resident Council Meetings. […]

• No harm, potential for more than minimal, widespreadF725Sep 11, 2025

  Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff were available to answer call lights in a timely and appropriate manner as evidenced by delayed call light response times, residents left waiting for toileting assistance, residents left on bedpans, staff and resident interviews reporting inadequate staffing levels. This deficient practice had the potential to effect 43 of 43 residents who resided in the facility and received nursing care. Findings include:Upon the survey entrance on 9/7/25 from 9:40 a.m. until 10:30 a.m., the following was observed: No administrative staff were present, and the Manager on Duty/Charge Nurse was busy working on the floor as a nurse passing medication. […]

• No harm, potential for more than minimal, widespreadF921Jul 14, 2023

  Based on interview and record review, the facility failed to ensure compliance with Indiana Department of Environmental Management's (IDEM) requirement to submit documentation of a fully certified Water Distribution Manager to comply with the Safe Drinking Water Act. Further, the facility failed to ensure a Plan of Correction was submitted after an onsite inspected which resulted in deficient practice on [DATE]. These deficient practices had the potential to effect 43 of 43 residents who resided in the facility. Findings include: During an interview on [DATE] at 12:14 p.m., the Section Chief for the IDEM Drinking Water Field Inspection, (SC), indicated, IDEM did not have documentation to satisfy the requirement of a designated water safety operator. […]

• No harm, potential for more than minimal, patternF761Jul 14, 2023

  Based on observation, and interview, the facility failed to ensure medications were stored properly in 2 of 2 medication carts, and 2 of 2 treatment carts reviewed for medication storage (100 hallway, and 200 hallway). Findings include: During a random observation of the 100 hallway medication cart with Registered Nurse (RN) 9, on 7/10/23 at 10:09 a.m., the following was observed to be unbagged, not stored separately, or treatments in the medication cart among oral medications, a. […]

• No harm, potential for more than minimal, patternF812Jul 14, 2023

  Based on observation, interview, and record review, the facility failed to ensure all kitchen foods were covered, hand washing was correctly completed in the kitchen and dining room (Resident 7 and 10), and failed to clean to fryer in a timely manner for 2 of 2 days of observations. These deficient practices had the potential to effect 43 of 43 residents who received food from the kitchen. Findings include: 1. On 7/10/23 at 10:45 a.m., 2 large, pre-cooked turkey breasts were observed, uncovered, sitting on the stainless steel counter top. The Dietary Manager (DM) indicated the internal temperature of the turkey breasts were 83.4 degrees F. She indicated the danger zone for food sitting-out was 70 degrees F. The DM indicated she took them out of the refrigerator at 8:30 a.m. […]