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 Lebanon Veterans Home during CMS and state inspections, most recent first.
The facility failed to inform a resident about changes in their standing frame therapy, leading to missed sessions, and did not obtain consent from another resident's responsible party before increasing the dosage of an antipsychotic medication.
A resident with dementia and urinary retention experienced red-tinged urine and severe abdominal pain, but the physician was not notified. The resident was later diagnosed with a UTI, hematuria, and sepsis, leading to hospitalization. Staff acknowledged the need to notify the physician, but no documentation was found.
The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) for a resident admitted with heart attack and dehydration. The NOMNC was signed a day before the last covered day, and it was confirmed that the notice was not provided within the required timeframe.
A resident's grievance about activity rule changes and alleged prejudice was not addressed promptly due to an insufficient grievance policy and delayed response by the facility. The grievance policy lacked clear timeframes and did not acknowledge oral or anonymous grievances, leading to a 15-day delay in communication with the resident.
A facility failed to document and conduct a Significant Change MDS assessment for a resident whose condition had significantly deteriorated, including cognitive decline, increased pain, and worsening pressure ulcers. Despite these changes, no significant change assessment was considered or ruled out, placing the resident at risk for unassessed needs.
The facility failed to revise care plan interventions for three residents, leading to unmet needs. One resident's care plan did not reflect a significant decline in mobility, another's care plan lacked necessary fall prevention measures, and a third's care plan was not updated to reflect changes in preferences.
A resident with multiple sclerosis and spinal degeneration did not receive the required assistance with bathing due to staffing shortages. Despite filing a grievance, the resident continued to miss expected showers, and staff confirmed the difficulty in completing the task due to being short-handed.
The facility failed to monitor a resident for a change of condition, make a urology appointment, and follow physician orders for two residents. One resident exhibited UTI symptoms and was hospitalized with sepsis, while another resident did not receive prescribed Kefir due to unavailability, and staff failed to notify the physician.
The facility failed to accurately assess and document pressure ulcers for two residents, leading to a risk of worsening wounds. One resident's sacral wound progressed to a Stage 4 pressure ulcer without proper documentation or inclusion in the care plan, while another resident's wound assessments lacked comprehensive details and were often incomplete.
The facility failed to assess a resident's ability to transfer from a reclining chair and did not timely investigate falls for two residents. One resident with dementia was observed attempting to transfer from a recliner with elevated leg rests, increasing fall risk. Another resident experienced two falls, with investigations delayed by several days.
The facility failed to obtain orders for oxygen for a resident with COPD. The resident used oxygen as needed, but no orders were found in their medical record. Staff confirmed the resident's use of oxygen without proper orders.
A resident with a diagnosis of partial intestinal obstruction was administered both Loperamide and Senna simultaneously due to an incorrect entry in clinical records. This led to the resident not having a bowel movement for five days, requiring additional interventions. The error was identified when staff noted the medications should not have been given together.
The facility failed to ensure complete and accurate records for a resident with diabetes. Despite physician orders to administer insulin three times a day, records showed missed doses on multiple occasions. Staff later claimed these records were marked in error and that the medication was administered as ordered.
The facility failed to practice proper infection control procedures for a resident with a Stage 4 pressure ulcer and did not sanitize resident care equipment between uses. An LPN did not perform hand hygiene after removing gloves during wound care, and a CNA did not sanitize equipment between residents.
The facility failed to protect two residents from abuse. One resident with dementia and PTSD was sexually abused by another resident with Alzheimer's Disease during a video call. In a separate incident, a resident with moderate cognitive impairment was struck by an object thrown by another resident with dementia and PTSD. Both incidents were witnessed by staff, but only the sexual abuse was substantiated.
The facility failed to timely investigate an abuse allegation involving a resident with panic disorder, dementia, and PTSD, and another resident with Alzheimer's Disease. The incident occurred during a video call when one resident rubbed the other's chest area. The investigation, which confirmed sexual abuse, was not completed in a timely manner.
Failure to Inform Residents and Obtain Consent for Medication and Therapy Changes
Penalty
Summary
The facility failed to provide adequate information and communication regarding the use of an antipsychotic medication and changes in therapy services for two residents. Resident 80, diagnosed with multiple sclerosis and spinal degeneration, was initially scheduled to use a standing frame three times a week. However, the therapy was changed to a PRN basis without informing the resident. As a result, the resident was unaware that they needed to request the standing frame service, leading to a lack of therapy sessions. Staff confirmed that the resident was not notified of the changes, and the resident expressed confusion and frustration over the lack of communication. Resident 118, diagnosed with bipolar disorder and dementia, was prescribed Seroquel, an antipsychotic medication. The dosage was increased without obtaining consent from the resident's responsible party. There was no documentation in the clinical records indicating that the risks and benefits of the medication were communicated to the responsible party. Staff confirmed that consent was not received for the use of Seroquel, indicating a failure to provide necessary information and obtain proper authorization before administering the medication.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician of a change in condition for a resident diagnosed with dementia, urinary retention, and an irregular heartbeat. The resident was observed to have red-tinged urine on two separate occasions, but the physician was not notified. On the first occasion, the resident denied pain, and there was no indication that the physician was informed. On the second occasion, the resident reported a stomach ache and was found to have blood on their incontinent brief and genitalia, yet again, the physician was not notified. The resident's urinary status was not assessed for several days following these observations. The situation escalated when the resident experienced severe abdominal pain, shaking, and crying, leading to their transport to the hospital. The resident was diagnosed with urinary retention, a UTI with hematuria, and sepsis with sudden onset of kidney failure. Interviews with staff revealed that there were difficulties in obtaining orders from the physician for urinalysis, and it was acknowledged that the physician should have been notified of the symptoms. The Director of Nursing Services confirmed that there was no documentation indicating the physician was notified of the resident's condition changes.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) for a resident reviewed for notices. The resident was admitted in 2024 with diagnoses including heart attack and dehydration. The NOMNC documented the last covered day as 4/3/24 and was signed by the resident on 4/2/24. On 5/2/24, a Social Services Designee confirmed that the notice was not provided within the required timeframe to the resident.
Insufficient Grievance Policy and Delayed Response
Penalty
Summary
The facility failed to develop a sufficient grievance policy and provide a timely response to a grievance filed by a resident. The facility's grievance policy, revised in December 2023, did not specify a reasonable expected timeframe for reviewing grievances and neglected to include that residents had the right to file grievances orally or anonymously and obtain a written decision. A resident expressed dissatisfaction with rule changes to a game activity and alleged prejudice from activity staff in a hand-written letter to the Recreation Director. Despite the letter being observed by the Social Service Designee on the same day it was written, the Grievance Officer did not read it until 16 days later, resulting in a delayed response to the resident's concerns. The resident stated that they had not received any communication about their concerns for 15 days after filing the complaint. The Assistant Administrator confirmed the delay, attributing it to a team effort to determine the best way to handle the information in the letter. The Social Service Designee did not consider the letter a grievance because it was not on the official grievance form. A late conversation with the resident regarding their concerns was conducted 19 days after the letter was written, highlighting the insufficiency of the facility's grievance policy when it was updated in December 2023.
Failure to Conduct Significant Change MDS Assessment
Penalty
Summary
The facility failed to document and conduct a Significant Change MDS assessment within the required timeframe for a resident reviewed for nutrition. The resident was admitted to the facility in 2023 with diagnoses including diabetes, pressure ulcer, and dementia. Initially, the resident was cognitively intact with no mood or behavioral concerns. However, by the next quarterly MDS assessment, the resident's cognitive status had declined to moderate impairment, and they exhibited depressive symptoms, behavioral issues, and increased pain levels. Additionally, the resident's pressure ulcer had worsened from Stage 3 to Stage 4, and they were administered a broader range of medications, including antipsychotics, antianxiety, anticoagulants, and opioids. Despite these significant changes in the resident's condition, there was no documentation in the clinical records to indicate that a significant change assessment was considered or ruled out. When questioned, a staff member stated they did not know why the assessment was not completed. This oversight placed the resident at risk for unassessed needs and potentially inadequate care adjustments.
Failure to Revise Care Plan Interventions
Penalty
Summary
The facility failed to revise care plan interventions for three residents, leading to unmet needs. Resident 38, diagnosed with Parkinson's disease, had a care plan indicating the need for walks despite a significant decline in mobility. The resident could no longer walk and required maximum assistance for balance, but the care plan was not updated to reflect these changes. Staff confirmed the resident's decline and the outdated care plan. Resident 121, with a history of falls and moderate cognitive impairment, had a care plan that did not include the use of room and bed sensors despite their effectiveness in preventing falls. The resident experienced a fall, and the care plan lacked documentation of these necessary interventions. Staff confirmed the omission of the room and bed sensors in the care plan. Resident 101, diagnosed with dementia, had a care plan indicating enjoyment of bird watching, but after moving to a new room, the resident no longer liked to watch birds and preferred the window blinds to be shut. Staff confirmed the resident's change in preference, but the care plan was not updated to reflect this. The recreational director acknowledged that the care plan might not have been updated to reflect the resident's current preferences. These failures in updating care plans placed the residents at risk for unmet needs and inadequate care.
Failure to Provide Required Assistance with ADLs
Penalty
Summary
The facility failed to ensure that a dependent resident received the required assistance with activities of daily living (ADLs), specifically bathing. Resident 80, who has multiple sclerosis and spinal degeneration, was admitted in 2020 and required one staff member to assist with bathing. Despite this, the resident's shower calendar for March and April 2024 indicated that the resident received only one shower per week on specific dates, with no showers provided on Sundays as expected. The resident confirmed that they had not received the expected Sunday showers and had filed a grievance, but the issue persisted due to staffing shortages. Staff members corroborated the resident's claims, noting that it was difficult to complete the resident's shower task at night due to being short-handed. Staff 12 and Staff 27 both indicated that the resident's shower required significant staff assistance, which was challenging to provide due to staffing issues. The Assistant Administrator confirmed that the resident had raised concerns about missed showers in January 2024 and expected follow-up showers to be provided if weekend showers were missed. The Director of Nursing Services (DNS) and Assistant DNS acknowledged that the staffing coordinator had been directed to ensure that the same resident unit was not always short-handed, but teamwork was necessary to meet the resident's needs, which did not occur.
Failure to Monitor Condition and Follow Physician Orders
Penalty
Summary
The facility failed to monitor a resident for a change of condition, make a urology appointment, and follow physician orders for two residents reviewed for UTIs and medications. Resident 36, who was admitted with a diagnosis of dementia, exhibited symptoms of a UTI, including red-tinged urine and abdominal pain, but staff did not consistently monitor these symptoms or notify the physician. The resident was eventually hospitalized with urinary retention, UTI with hematuria, and sepsis. Additionally, there was no documentation that a referral to urology was completed as ordered upon discharge from the hospital. Resident 118, admitted with diagnoses including a pressure ulcer and diabetes, was prescribed Kefir to be administered twice daily. However, the medication administration record indicated that Kefir was not available on multiple occasions, and staff failed to notify the physician about its unavailability. This lack of communication and failure to follow physician orders placed the resident at risk for unmet medical needs.
Inadequate Pressure Ulcer Assessment and Documentation
Penalty
Summary
The facility failed to accurately assess and document pressure ulcers for two residents, leading to a risk of worsening wounds. Resident 59, who was admitted with paraplegia, had a sacral wound initially identified as moisture-associated damage. Over time, the wound was inconsistently documented and eventually identified as a Stage 4 pressure ulcer. Despite the wound's progression, it was not correctly assessed or included in the care plan, and the resident required hospitalization for wound debridement. Staff acknowledged the misclassification and lack of proper documentation for the wound's severity and progression. Resident 118, admitted with a sacral pressure ulcer, also experienced inadequate wound assessments. The evaluations from January to April lacked comprehensive details such as wound bed description, drainage, surrounding tissue condition, pain level, and treatment. On several occasions, the evaluations were incomplete or not performed at all. The Director of Nursing Services confirmed that the evaluations should have been fully comprehensive, indicating a failure in the facility's wound care documentation and assessment processes.
Failure to Assess Transfer Ability and Timely Investigate Falls
Penalty
Summary
The facility failed to assess and care plan a resident's ability to transfer from a reclining chair and timely investigate a fall for two residents. Resident 142, who was admitted with a diagnosis of dementia, was observed in a recliner with elevated leg rests and was not assessed for her/his ability to use the remote control to lower the leg rests. Staff acknowledged that many residents in the memory care unit, including Resident 142, were not able to use the remote control. On multiple occasions, Resident 142 was observed attempting to transfer out of the recliner with elevated leg rests, increasing the risk of falls. The care plan did not direct staff to ensure leg rests were down if staff were not in the common area and the resident was asleep. Staff confirmed that there were times when all staff were assisting other residents and may not be available to help Resident 142, who was unsteady when standing without assistance. Resident 121, admitted with diagnoses including anxiety and cramp and spasm disorder, experienced two falls that were not investigated in a timely manner. A post-fall assessment revealed that Resident 121 was found on the floor, but the investigation was completed seven days later. Another post-fall assessment indicated that Resident 121 reported a fall in the bathroom, but the investigation was completed eight days later. Staff confirmed that the fall investigations were not completed in a timely manner, which could have delayed identifying and addressing the causes of the falls.
Failure to Obtain Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to obtain orders for oxygen for a resident with chronic obstructive pulmonary disease (COPD). The resident, admitted in December 2022, had a care plan dated March 3, 2023, for as-needed oxygen. On April 8, 2024, a progress note indicated the resident received oxygen due to respiratory difficulties and shortness of breath. An oxygen concentrator was observed by the resident's bed on April 29, 2024, and the resident stated they used oxygen a couple of times a week, usually in the evenings. A review of the resident's medical record on May 1, 2024, revealed no evidence of oxygen orders. Staff interviews on May 2, 2024, confirmed the resident used oxygen as needed but had no orders for it.
Significant Medication Error Involving Loperamide and Senna
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, specifically for one resident who was administered both Loperamide and Senna simultaneously. The resident, who was admitted with a diagnosis of partial intestinal obstruction, had physician orders for Loperamide to treat diarrhea and Senna to treat constipation. These medications were administered daily from February through April, despite the conflicting purposes of the medications. This error was due to an incorrect entry in the clinical records, which led to the resident receiving both medications concurrently instead of Loperamide being administered on a PRN basis. As a result of this medication error, the resident did not have a bowel movement for five days in April, prompting the administration of a suppository and Miralax for bowel care. The error was identified when a staff member noted that the resident should not have been given both medications at the same time. The incorrect order in the clinical records was acknowledged as a significant medication error, placing the resident's health status at risk.
Incomplete and Inaccurate Resident Records for Medication Administration
Penalty
Summary
The facility failed to ensure resident records were complete and accurate for one resident reviewed for medications. Resident 118, who was admitted in 2023 with a diagnosis of diabetes, had a physician order dated 3/11/24 to administer insulin injections three times a day starting from 10/22/23. However, the Diabetic Orders report for April 2024 documented that the resident was not administered insulin on multiple occasions because the resident was sleeping. Specifically, the missed administrations were recorded on 4/1/24 at 5:00 PM, 4/13/24 at 7:00 AM, 4/14/24 at 7:00 AM, 4/16/24 at 12:00 PM, 4/21/24 at 12:00 PM, and 4/23/24 at 12:00 PM. On 5/3/24, Staff 21 (RCM) stated that these dates were marked in error and that the resident was actually administered the medication as ordered by the physician.
Infection Control Deficiencies
Penalty
Summary
The facility failed to practice proper infection control procedures for a resident with a Stage 4 pressure ulcer and did not sanitize resident care equipment between uses. Resident 59, admitted in March 2017 with paraplegia, had a Stage 4 pressure ulcer on the sacrum as of April 29, 2024. On May 1, 2024, an LPN was observed performing wound care for Resident 59 without performing hand hygiene after removing gloves and before applying new ones. The LPN and a CNA both stated they were unaware of the need to perform hand hygiene in this situation. Additionally, on April 29, 2024, a CNA was observed completing blood pressure and oxygenation checks for multiple residents without sanitizing the equipment between uses. The CNA acknowledged not sanitizing the equipment after each resident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents were free from sexual and physical abuse, affecting two residents. Resident 38, who has diagnoses including panic disorder, dementia, and PTSD, was sexually abused by Resident 141, who has Alzheimer's Disease. During a video call with a family member, Resident 141 reached over and rubbed Resident 38's chest area. This incident was witnessed by the family member and a CNA, and the facility substantiated the sexual abuse. The incident was reported, and staff intervened by moving Resident 38 to a different location and escorting Resident 141 back to their unit. In another incident, Resident 108, who has a history of trauma and moderate cognitive impairment, was physically abused by Resident 139, who has dementia, psychotic disturbance, mood disturbance, anxiety, and PTSD. Resident 139's behaviors escalated, leading them to throw a handheld game into Resident 108's room, striking Resident 108 on the side of the face. This incident was witnessed by two CNAs, and although no injuries were identified, the facility did not substantiate the abuse, attributing Resident 139's actions to a PTSD trigger and agitation. Staff continued to monitor Resident 108 for any abnormalities following the incident.
Failure to Timely Investigate Abuse Allegation
Penalty
Summary
The facility failed to timely investigate an abuse allegation involving Resident 38, who has diagnoses including panic disorder, dementia, and PTSD, and Resident 141, who has Alzheimer's Disease. On 4/4/24, while Resident 38 was on a video call with a family member, Resident 141 reached over and rubbed Resident 38's chest area. The family member intervened by telling Resident 141 to keep their hands to themselves. The facility's investigation, which took place from 4/4/24 to 4/10/24, substantiated the sexual abuse. However, Staff 21 confirmed on 5/3/24 that the investigation was not completed in a timely manner.
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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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Nursing homes near Lebanon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Rehabilitation Of Lebanon | 0.8 mi | — | 16 | 0 |
| Mennonite Home | 8.8 mi | — | 8 | 0 |
| Regency Albany | 11 mi | — | 14 | 0 |
| Timberline Post Acute | 11.7 mi | — | 8 | 0 |
| Corvallis Manor | 17 mi | — | 6 | 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.