THE VILLAGE OF LEBANON II, LLC

Nursing Home Inspector

105 VILLAGE WAY
LEBANON, KY 40033
Marion County
Phone: 270-692-9000
Provider Number: 185437
Last Inspection: 10/13/2016

About the Nursing Home

Number of Beds: 54
Number of Residents: 41
Beds Available: 13
Percent Occupancy: 76%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Partnership
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

6

Facility
6

County
12

KY
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

6

2016
9

2015
19

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

10/13/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 11/3/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 11/4/2016
 

10/15/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 11/30/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 10/30/2015
 

10/2/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Isolated : Minimal 3 10/22/2014
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 11/13/2014
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 10/28/2014
 
Failed To: Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. Isolated : Minimal 3 10/7/2014
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Pattern : Minimal 4 10/28/2014
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 10/23/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

9/1/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 9/4/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg KY State Avg
Number of Residents 41 55.00 79.68
Registered Nurses 0.75 0.84 0.86
Licensed Practical / Vocational Nurses 1.24 1.21 0.87
Certified Nursing Assistants 3.23 3.31 2.40
Total Staff Hours 5.21 5.36 4.13

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% KY State Avg%
of high risk long-stay residents with pressure ulcers 6 5 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 97 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 98 95
of long-stay residents experiencing one or more falls with major injury 7 5 3
of long-stay residents who have depressive symptoms 0 1 2
of long-stay residents who lose too much weight 13 8 7
of long-stay residents who received an antianxiety or hypnotic medication 22 34 31
of long-stay residents who received an antipsychotic medication 15 20 19
of long-stay residents who self-report moderate to severe pain 6 12 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 62 40 21
of long-stay residents whose need for help with daily activities has increased 10 16 16
of long-stay residents with a catheter inserted and left in their bladder 4 3 2
of long-stay residents with a urinary tract infection 3 5 4
of low risk long-stay residents who lose control of their bowels or bladder 62 55 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 98 82 84
of short-stay residents who had an outpatient emergency department visit 15 17 14
of short-stay residents who made improvements in function 48 64 59
of short-stay residents who newly received an antipsychotic medication 2 4 2
of short-stay residents who self-report moderate to severe pain 18 14 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 93 87 83
of short-stay residents who were rehospitalized after a nursing home admission 18 18 22
of short-stay residents who were successfully discharged to the community 60 60 46
of short-stay residents with pressure ulcers that are new or worsened 2 4 1