Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waters Of Lebanon, The during CMS and state inspections, most recent first.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that the environment was not safe and supervision was lacking, but does not specify further details or identify the individuals involved.
A facility failed to conduct a self-administration assessment for a resident's Ventolin inhaler stored at bedside. The inhaler was observed unattended on the resident's bedside table, and the resident's record lacked the necessary assessment. The resident had multiple diagnoses, including COPD and dementia, and was prescribed Ventolin for shortness of breath. The DON confirmed the medication should not have been left in the room, contrary to the facility's policy requiring an interdisciplinary assessment for self-administration.
The facility failed to conduct comprehensive quarterly assessments for two residents to evaluate their mobility and range of motion (ROM). One resident, with multiple diagnoses including diabetes and heart failure, lacked assessments to measure joint movement and functional status. Another resident, with COPD and hypertension, also lacked necessary assessments. Interviews revealed inadequate documentation processes, preventing data transfer to the MDS and resulting in missing assessments.
The facility failed to label a vial of tuberculin serum appropriately in one medication room. The serum was found undated in a refrigerator with ice buildup. The DON confirmed it should have been dated upon opening, as per the facility's policy.
The facility failed to ensure proper hand hygiene by staff during lunch tray delivery, affecting two residents. The Social Services Director did not perform hand hygiene before entering and after leaving a room requiring Enhanced Barrier Precautions (EBP) due to a resident's medical condition. Interviews confirmed the lapse, and a review of the facility's policy emphasized the importance of hand hygiene in such situations.
The facility failed to accurately code MDS assessments for several residents, leading to discrepancies in medical records. A resident with ESRD was not coded for dialysis, another with schizophrenia was not coded for Level II status, and two residents were incorrectly coded for anticoagulant use instead of antiplatelet. Additionally, a resident receiving hospice care was not coded as such. These errors were acknowledged by facility staff.
A resident at risk for pressure ulcers did not receive a pressure-reducing cushion for her wheelchair, as required by her care plan. Despite multiple observations, the cushion was not in place, and the Director of Nursing confirmed its absence. The resident's medical conditions included COPD, congestive heart failure, and lung cancer, necessitating preventative measures for pressure ulcers, which were not effectively implemented.
A resident with COPD, congestive heart failure, and lung cancer did not receive oxygen therapy as ordered. Despite having a physician's order for oxygen every shift, the resident was observed multiple times without the prescribed oxygen, and the care plan lacked revisions to address her noncompliance. The DON acknowledged the issue but did not ensure the care plan reflected the necessary changes.
A facility failed to ensure a resident's medical record was kept private and confidential when the Business Office Manager (BOM) disclosed clinical information to the resident's family without permission. The BOM, not authorized to provide clinical information, shared details about the resident's care and mental capacity, constituting a HIPAA violation.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report. No information is provided about the medical history or condition of any residents involved at the time of the deficiency.
Failure to Conduct Self-Administration Assessment for Bedside Medication
Penalty
Summary
The facility failed to ensure that a resident had a self-administration assessment for a medication stored at bedside. An inhaler of Ventolin, used to treat chronic obstructive pulmonary disease (COPD), was observed on the bedside table of a resident who was not present in the room, leaving the medication unattended. The resident had diagnoses including COPD, heart failure, dementia, and anxiety disorder, and had an order for Ventolin to be used as needed for shortness of breath. However, the resident's record lacked a medication self-administration assessment. During an interview, the Director of Nursing acknowledged that the medication should not have been left in the resident's room. The facility's policy required an interdisciplinary team to determine a resident's ability to self-administer medications through a skill assessment.
Failure to Conduct Quarterly Assessments for Mobility and ROM
Penalty
Summary
The facility failed to conduct comprehensive quarterly assessments for two residents to evaluate their mobility and range of motion (ROM). Resident 1, who had diagnoses including type 2 diabetes, difficulty walking, heart failure, and a history of falling, had care plans indicating the need for assistance with activities of daily living (ADLs) and a restorative program for active range of motion. However, his records lacked a comprehensive quarterly assessment to measure joint movement and identify any changes in his functional status. Similarly, Resident 36, with diagnoses such as difficulty swallowing, chronic obstructive pulmonary disease (COPD), and hypertension, had a care plan for a restorative program for dressing and grooming. His records also lacked a comprehensive quarterly assessment to evaluate his joint movement and functional status. Interviews with the Regional MDS Consultant and the Regional Nurse Consultant revealed that the facility's process for documenting and assessing restorative programs was inadequate. The facility failed to refresh and initiate data into the Point of Care (POC) system, preventing the transfer of information to the Minimum Data Set (MDS). This oversight resulted in the absence of necessary quarterly assessments for the residents, as required by the Resident Assessment Instrument (RAI) manual. The facility was reportedly working on addressing these documentation and assessment issues.
Failure to Label Tuberculosis Testing Serum
Penalty
Summary
The facility failed to appropriately label tuberculosis testing serum in one of the two medication rooms reviewed. During an observation on September 9, 2024, a vial of tuberculin serum was found undated in the specimen refrigerator, which had approximately two inches of ice buildup. LPN 21 removed the serum from the refrigerator. In an interview on September 10, 2024, the Director of Nursing (DON) confirmed that the serum should have been dated when opened. The facility's policy, titled 'Tuberculosis Testing (Mantoux Test)' and dated March 2023, specifies that a new vial must be initiated and dated, as it is only valid for 30 days after opening.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure effective hand hygiene practices by staff delivering lunch trays to residents, specifically affecting two residents observed during the lunch service. On the specified date, the Social Services Director (SSD) was seen removing a lunch tray from the mobile kitchen cart and entering Resident 42's room without performing hand hygiene, despite a sign on the door indicating the need for Enhanced Barrier Precautions (EBP). The SSD also failed to perform hand hygiene after leaving Resident 42's room and before serving lunch to Resident 43, who shared the room and required EBP due to having a suprapubic catheter. Interviews conducted with the SSD and the Assistant Director of Nursing (ADON) confirmed the lapse in hand hygiene, with the SSD mistakenly believing she had used hand sanitizer. The Director of Nursing (DON) later confirmed that Resident 43 required EBP due to his medical condition. A review of the facility's policy on Enhanced Barrier Precautions highlighted the critical importance of proper hand hygiene in all aspects of resident care, including when EBP is required.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of Minimum Data Set (MDS) assessments for five residents, leading to discrepancies in their medical records. Resident 6, diagnosed with End Stage Renal Disease, had a care plan indicating the need for dialysis, yet her MDS assessment did not reflect her dialysis treatments. Similarly, Resident 34, with a diagnosis of schizophrenia, was not accurately coded for her Level II status on the MDS assessment. Resident 13's MDS assessment incorrectly indicated the use of anticoagulant medication, while his records showed he was on an antiplatelet medication. This error was acknowledged by the Regional MDS Consultant during an interview. Resident 43's MDS assessment inaccurately coded aspirin as an anticoagulant, despite physician orders indicating it was used as an antiplatelet. The Director of Nursing confirmed this coding error. Lastly, Resident 29, who was receiving hospice services, had an MDS assessment that failed to reflect her hospice status, despite a physician order and nursing progress note confirming her admission to hospice. The Regional MDS Consultant admitted the oversight, noting the absence of a specific MDS policy but adherence to RAI guidelines.
Failure to Provide Pressure-Reducing Device for At-Risk Resident
Penalty
Summary
The facility failed to provide a pressure-reducing device for a resident at risk for developing pressure ulcers. Observations on multiple occasions revealed that the resident, who was seated in a wheelchair, did not have a pressure-reducing cushion in place. The resident's medical record indicated she was at risk for pressure ulcers and required such a device as part of her care plan. Despite this requirement, the cushion was not observed during several checks, indicating a lapse in the implementation of her care plan. The resident, identified as having chronic obstructive pulmonary disease, congestive heart failure, and lung cancer, was admitted to the facility with a care plan that included preventative measures for pressure ulcers. The Director of Nursing confirmed that the resident should have had a pressure-reducing cushion and acknowledged that it was missing. The facility's policy, which includes monitoring residents at risk for skin breakdown, was not effectively followed in this case, as evidenced by the missing cushion and the inability to determine how long the resident had been without it.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide oxygen therapy as ordered for a resident with chronic obstructive pulmonary disease, congestive heart failure, and lung cancer. The resident was observed multiple times without the prescribed oxygen therapy, despite having a physician's order to apply oxygen via nasal cannula every shift at 3 liters to maintain oxygen saturation levels above 90. The oxygen concentrator was consistently found turned off, and the nasal cannula was not in place, indicating a lack of adherence to the prescribed treatment plan. The resident expressed discomfort and was observed to be in pain, yet the staff did not offer to apply the oxygen therapy. The care plan for the resident lacked revisions to address her noncompliance with oxygen therapy and did not include interventions for her refusals to wear the nasal cannula. The Director of Nursing acknowledged the resident's noncompliance but indicated that the order should have been changed to as needed, which was not reflected in the care plan or physician's orders.
Violation of Resident's Right to Confidentiality
Penalty
Summary
The facility failed to ensure a resident's right to have his medical record kept private and confidential. The Business Office Manager (BOM) disclosed clinical information about Resident H's medical condition, treatment, and services to the resident's family without the resident's permission. This information was shared during a private meeting outside of the facility property. The BOM, who is not authorized to provide clinical information, shared details such as the lack of wound care and physical therapy notes, her opinion on the resident's mental capacity, and overheard conversations between a facility nurse and the resident's dialysis center. The Regional Nurse Consultant (RNC) and the Director of Nursing (DON) confirmed that the BOM's actions were outside her scope of practice and constituted a HIPAA violation, as the resident did not have a Power of Attorney (POA) and was listed as his own responsible party with normal cognitive function. Resident H, a long-term care resident with diagnoses including End Stage Renal Disease, Type 2 Diabetes, and Diabetic Neuropathy, was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The facility's guidelines on resident rights and HIPAA privacy were not followed, as the BOM improperly shared confidential health information without the resident's consent. The facility's policies clearly state that only clinical staff are permitted to provide clinical information to residents or their POA, and any unauthorized sharing of health information is considered a violation of HIPAA regulations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lebanon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Signature Healthcare At Parkwood | 3 mi | — | 2 | 0 |
| Homewood Health Campus | 4.5 mi | — | 1 | 0 |
| Witham Extended Care | 4.7 mi | — | 0 | 0 |
| Restoracy Of Whitestown, The | 5.1 mi | — | 5 | 0 |
| Zionsville Meadows | 9.5 mi | — | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.