Deficiency Records for Otterbein Lebanon Retirement Community
Updated as of March 01, 2024
A list of the most recent deficiencies for Otterbein Lebanon Retirement Community. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-10-25 | 2022-11-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-25 | 2022-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-25 | 2022-11-19 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-10-25 | 2022-11-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-10-25 | 2022-11-19 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-10-25 | 2022-11-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-25 | 2022-11-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-10-25 | 2022-11-19 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-10-18 | 2022-11-19 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-10-18 | 2022-11-19 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-10-18 | 2022-11-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-18 | 2022-11-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-18 | 2022-11-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-18 | 2022-11-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-10 | 2022-09-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-03 | 2022-06-01 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-03 | 2022-06-01 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-11-23 | 2021-12-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-21 | 2019-12-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-21 | 2019-12-31 | N |
| Post nurse staffing information every day. | Health | 2019-11-21 | 2019-12-31 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-19 | 2019-12-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-19 | 2019-12-31 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-11-19 | 2019-12-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-19 | 2019-12-31 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-11-19 | 2019-12-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-19 | 2019-12-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-19 | 2019-12-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-19 | 2019-12-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-19 | 2019-12-31 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-19 | 2019-12-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-03 | 2018-12-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-10-03 | 2018-12-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-03 | 2018-12-20 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2018-10-03 | 2018-12-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-03 | 2018-12-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-10-03 | 2018-12-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-03 | 2018-12-20 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-10-03 | 2018-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-03 | 2018-12-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-10-02 | 2018-12-20 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-10-02 | 2018-12-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-02 | 2018-12-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-02 | 2018-12-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-10-02 | 2018-12-20 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-10-02 | 2018-12-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-10-02 | 2018-12-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-02 | 2018-12-20 | N |
