A list of the most recent deficiencies for Lebanon Veterans Home. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-21 | 2023-07-31 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-21 | 2023-07-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-27 | 2023-04-21 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-30 | 2023-03-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-01-30 | 2023-03-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-30 | 2023-03-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-01-30 | 2023-03-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-30 | 2023-03-14 | N |
| Provide activities to meet all resident's needs. | Health | 2023-01-30 | 2023-03-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-30 | 2023-03-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-18 | 2022-12-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-18 | 2022-11-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-29 | 2022-09-25 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-29 | 2022-09-25 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-29 | 2022-09-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-07-29 | 2022-09-25 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-07-29 | 2022-09-10 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-07-29 | 2022-09-02 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-21 | 2021-09-07 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-21 | 2021-09-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-07-21 | 2021-09-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-21 | 2021-09-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-21 | 2021-09-07 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-21 | 2021-09-07 | Y |
| 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 | 2021-07-21 | 2021-09-07 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-07 | 2019-12-01 | 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 | 2019-10-07 | 2019-12-01 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-07 | 2019-12-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-07 | 2019-12-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-03 | 2019-11-15 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-02-26 | 2018-04-24 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-02-26 | 2018-04-24 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-02-26 | 2018-04-24 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-02-26 | 2018-04-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-02-26 | 2018-04-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-02-26 | 2018-04-24 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-02-26 | 2018-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-05 | 2018-04-20 | 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 | 2018-03-05 | 2018-04-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-03-05 | 2018-04-13 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-03-05 | 2018-04-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-03-05 | 2018-04-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-03-05 | 2018-04-02 | N |
