Lebanon North Nursing & Rehab: Abuse Concealed - MO
The complaint inspection, completed August 14, 2025, documented what happened next: inspectors arrived, started asking questions, and found that nearly everyone in the building's chain of command had known something was wrong and done less than they were supposed to.
The resident at the center of the incident was not identified by name in the inspection report. What the report does say is that staff threatened to hurt this person and cursed at them, and that at least some of those staff members then decided the right response was to wedge a towel against the door to stop the resident from leaving their room. Multiple certified nursing assistants participated. CNA G told inspectors the practice was not limited to one shift or one incident. He or she had seen multiple staff put towels on the door, mainly the day shift.
The Director of Nursing said she found the written statements on the morning of August 11, 2025, slid under her door. By that point, the incident had already happened. The aides who witnessed it had reported their concerns to LPN C, the charge nurse. LPN C never told the DON. The DON told inspectors she did not know when the aides had gone to the nurse, only that the nurse had not passed the information up the chain. She said she would have expected the nurse to notify her and the administrator immediately.
She did not say how much time passed between when the aides first told LPN C and when those statements appeared under her door.
The administrator said the same thing everyone else said, just more plainly: it wasn't reported timely. Two staff had written statements and put them under the DON's door. That was not the same as reporting abuse to the state within two hours, which is what the facility's own leadership said was required. The administrator told inspectors he or she had not been aware of any towel ever being placed on a door to keep a resident in their room.
The ADON learned about the towel from two aides who came to ask whether it would be appropriate to block a resident's door that way. He or she told them no. Then told the DON. The DON, the ADON said, was already aware and heading to the unit to remove the towel. Whether the towel came down before or after residents or other staff noticed it, the report does not say. What the ADON did say was that he or she did not know if the incident had been reported to the state on time, because the DON had said she was handling it.
That phrase, that someone else was handling it, runs underneath almost every interview in this report.
The question of what the towel actually was turned out to be one of the few things inspectors did not have to argue about. The ADON said directly that putting a towel on a resident's door, if it hindered the door from opening and kept the resident inside, would be considered a restraint and involuntary seclusion. CNA G said the same: it could be a restraint or involuntary seclusion if the resident was not able to get out. The administrator called it a restraint. Nobody disputed it. The facility's own staff, from the nursing aides to the administrator, agreed on what had happened. They just hadn't stopped it fast enough, or reported it fast enough, or told the right people fast enough.
What they disagreed about, in small ways, was the timeline. The ADON said he or she found out on Monday or Tuesday, late morning or early afternoon. The DON said she found the statements on August 11. The report was completed August 14. The precise sequence of when the aides saw what happened, when they told LPN C, when LPN C did nothing, when two of them wrote statements, when those statements appeared under the DON's door, and when anyone considered calling the state — that sequence is not fully reconstructed in the inspection record.
CNA G's account added a detail that widened the picture. This was not described as a single rogue aide making a bad choice on one difficult night. Multiple staff had put towels on the door. Mainly the day shift. The inspection report does not say how many times this happened before someone thought to ask whether it was appropriate.
The charge nurse, LPN C, does not appear to have been interviewed directly in the portions of the report made available. Her role is described entirely through what others said about her: the aides reported to her, she did not tell the DON, and the DON said she never received notification of the abuse allegations from LPN C at all. The administrator said an aide should report to the charge nurse and the charge nurse should report to the DON. That second step did not happen.
The verbal threats are described consistently but without the specific words used. The administrator called it abuse to threaten to hurt a resident or curse at them. The ADON said it was not appropriate to curse at a resident or make threats, and that this would be verbal abuse. The DON said making threats toward residents would not be appropriate and could be abuse. The hedged phrasing, could be, would be, is notable given that the same leaders also said staff are required to report suspected abuse to the state within two hours. If the incident was suspected abuse from the beginning, the two-hour clock started when the aides first saw it. Nobody in the report claims that clock was met.
What the inspection classified as the level of harm was minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework inspectors apply, not necessarily what the resident experienced when staff cursed at them, threatened them, and then blocked their door.
The resident's own account does not appear in the inspection report. Whether they were interviewed, whether they were able to communicate what happened, whether they knew the door had been blocked, none of that is in the record inspectors made public. The report centers the staff and their statements, the chain of command and where it broke, the two-hour reporting requirement and whether it was met. The person in the room, behind the towel-blocked door, is present in the report mainly as the subject of other people's descriptions of what was done to them.
The charge nurse said nothing. The aides wrote it down and slid it under a door. The ADON was told and told the DON. The DON was already on her way to the unit. The administrator found out later and said it wasn't reported timely.
Everyone agreed on what abuse looks like. Nobody made the call.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lebanon North Nursing & Rehab from 2025-08-14 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 22, 2026 · Our methodology
LEBANON NORTH NURSING & REHAB in LEBANON, MO was cited for abuse-related violations during a health inspection on August 14, 2025.
The resident at the center of the incident was not identified by name in the inspection report.
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.