Lebanon North Nursing & Rehab: Resident Fracture Fall - MO
The incident happened around 5:00 a.m. The nursing assistant, identified in inspection records as NA D, was in the middle of providing care when she turned away from the resident to grab peri-care supplies. In that moment, the resident rolled off the bed and hit the floor.
A second staff member, CNA G, was in the room at the time. She was assisting another resident and did not prevent the fall.
Federal inspectors cited the facility under F0689, the tag covering protection from accident hazards, at a level of actual harm. The complaint, filed under case number 2669590, was investigated during a November 2025 inspection.
The care plan for this resident specified how many staff members were required for personal cares. CNA G told inspectors she did not know what the care plan said about staffing requirements for this particular resident. That detail sits at the center of what inspectors found: a written plan existed, staff were not following it, and a resident paid for that gap with a broken neck.
What NA D should have done, inspectors concluded, was reposition the resident onto their back before stepping away to grab supplies. That one step, taken before turning away, would have reduced the risk of the resident rolling off the bed. It did not happen.
The facility's own leadership acknowledged the failure. The MDS Coordinator, Director of Nursing, Assistant Director of Nursing, and charge nurses were identified in the inspection report as responsible for making sure nursing staff understand the care plan needs of each resident and carry them out correctly. The ADON was the one who discovered the resident and reported the incident at 5:00 a.m.
A neck fracture in an elderly nursing home resident is not a minor complication. It is one of the most serious injuries a fall can produce, carrying risks that extend far beyond the immediate trauma. The laceration was serious enough to require staples.
What the inspection record shows is a narrow, preventable sequence: a nursing assistant who did not position a vulnerable resident safely before stepping away, a second aide who was present but unaware of what the care plan required, and a facility whose leadership had not ensured that the people delivering hands-on care at 5:00 in the morning understood what was written in that resident's file.
The care plan is not a suggestion. It is the document that translates a resident's specific risks and needs into daily instructions for whoever walks into that room. When the person providing care does not know what it says, the plan does not exist in any practical sense.
CNA G's statement to inspectors, that she did not know what the care plan indicated for the number of staff required for personal cares, points to something beyond one aide's oversight. It points to a system in which the information that should govern every interaction with a high-need resident was not reaching the people who needed it most, at the hour when they needed it most.
The resident who rolled off that bed in the early hours of the morning now has a neck fracture.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lebanon North Nursing & Rehab from 2025-11-20 including all violations, facility responses, and corrective action plans.
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: August 28, 2026 · Our methodology
LEBANON NORTH NURSING & REHAB in LEBANON, MO was cited for violations during a health inspection on November 20, 2025.
The incident happened around 5:00 a.m.
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.