01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-09-12 | 3 | 2025-09-12 | 5 |
| Cycle 2 | 2022-10-25 | 10 | 2022-10-25 | 6 |
| Cycle 3 | 2019-11-21 | 3 | 2019-11-21 | 10 |
CMS CCN 3653462026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Otterbein Lebanon Retirement Community
585 North State Route 741 · Lebanon, OH 45036 · Warren County
Certified beds154CMS provider file
Recent citation rows37current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
37 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 8 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-09-12 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Correction field: Deficient, Provider has date of correction · 2025-10-14 · complaint2025-09-12 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-10-14 · complaint2025-09-12 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-10-14 · complaint2025-09-12 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-10-142025-09-12 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-10-142025-09-12 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-10-142025-09-12 · FIREK0761Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2025-10-142025-09-12 · FIREK0920Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2025-10-142025-05-19 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2025-05-30 · complaint2025-05-19 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-05-30 · complaint2022-10-25 · HEALTHF0561Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Correction field: Deficient, Provider has date of correction · 2022-11-192022-10-25 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2022-11-192022-10-25 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2022-11-192022-10-25 · HEALTHF0742Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2022-11-192022-10-25 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2022-11-192022-10-25 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2022-11-192022-10-25 · HEALTHF0803Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2022-11-192022-10-25 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2022-11-192022-10-25 · FIREK0222Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2022-11-192022-10-25 · FIREK0223Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2022-11-192022-10-25 · FIREK0344Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have an alternate power supply for its alarm system.
Correction field: Deficient, Provider has date of correction · 2022-11-192022-10-25 · FIREK0761Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2022-11-192022-10-25 · FIREK0920Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2022-11-192022-10-25 · FIREK0923Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2022-11-1903 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- OTTERBEIN LSC, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 01/01/2016
- OTTERBEIN HOMEOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 12/01/2021
- BOWMAN, ROBERTIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 12/01/2021
- DRAPALIK, JEFFIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2019
- HENSLEY, KIMBERLYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2021
- PATERSON, BARBARAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2023
- STEARNS, RANDYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/29/2015
- TOPPER, SHERRIEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2025
- STEPHENSON, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 05/09/1982
- GREEN, JAMESIndividual · CORPORATE OFFICERNOT APPLICABLE · since 11/21/2005
- HAWKINS, RITAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/16/2006
- MILLER, JASONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/04/2014
- WILSON, JILLIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/01/2009
- FUNCTIONAL PATHWAYS OF TENNESSEE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2018
- OTTERBEIN HOMEOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2021
- ANSARI, SABAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2021
- APP, LYNNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2021
- BARTLETT, VICTORIAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.00per resident day
RN hours0.58per resident day
Weekend nurse hours3.70per resident day
Staff turnover39.8%CMS reported field