New Lebanon Rehab: Missed Psychiatric Meds Violations - OH
The resident, identified in inspection records only as Resident #70, was admitted to the facility on June 20, 2025. A cognitive assessment completed six days later found severely impaired cognition. The resident needed supervision to bathe, use the toilet, and transfer from bed to chair.
On August 8, a physician ordered two medications for the resident: lorazepam, an antianxiety drug, one milligram by mouth at bedtime, and trazodone, an antidepressant, 50 milligrams by mouth at bedtime. Both were to be given nightly.
Neither was consistently given. The medication administration record for August showed Resident #70 did not receive the lorazepam on August 8, 9, or 10. The trazodone was not given on August 8 or 9.
Three missed doses of a prescribed antianxiety medication. Two missed doses of a prescribed antidepressant. For a resident with severely impaired cognition who could not reliably communicate distress or advocate for themselves.
The facility's Director of Nursing, interviewed by inspectors on September 29, 2025, confirmed what the records showed. There was no documentation to support that Resident #70 received the lorazepam on August 8 through August 10, or the trazodone on August 8 or 9. The director did not dispute the gaps.
Before the missed doses, Resident #70 had already been sent to the hospital for behavior issues, then returned to the facility. The inspection report does not specify the dates of that hospitalization or what happened during it. What the record does show is that by September 12, Resident #70 had been discharged to another nursing facility entirely.
The inspection was a complaint investigation, tied to two separate complaints filed with Ohio health authorities. Inspectors reviewed four residents' medication administration records in total. Resident #70 was the only one whose records showed medications going undelivered.
CMS rated the level of harm as minimal harm or potential for actual harm, the lower end of the agency's scale. That designation reflects regulatory classification, not a clinical judgment about what the missed doses meant for a specific person with a specific psychiatric history. Lorazepam is used to manage anxiety and, in some cases, acute agitation. Trazodone is prescribed for depression and sleep. Both were ordered the same day, both went ungiven that night, and the lorazepam was missed again the following two nights.
The facility's own medication policy, reviewed by inspectors, stated that medications shall be administered in a safe and timely manner and as prescribed.
They were not.
New Lebanon Rehabilitation and Healthcare Center operates at 101 Mills Place in New Lebanon, Ohio, with a census of 96 residents at the time of the inspection. The complaint investigation was completed September 30, 2025.
Resident #70 is no longer there. The record does not say whether anyone told the receiving facility about the missed doses, or whether anyone at New Lebanon ever explained to the resident, who had severely impaired cognition and could not have known what medications they were supposed to be taking, that the pills ordered for them three nights in a row simply were not given.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for New Lebanon Rehabilitation and Healthcare Center from 2025-09-30 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
NEW LEBANON REHABILITATION AND HEALTHCARE CENTER in NEW LEBANON, OH was cited for violations during a health inspection on September 30, 2025.
The resident, identified in inspection records only as Resident #70, was admitted to the facility on June 20, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.