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Complaint Investigation

Lebanon North Nursing & Rehab

August 14, 2025 · Lebanon, MO · 596 Morton Road
Citations 2
CMS Rating 1/5
Beds 180
Provider ID 265123
Healthcare Facility
Lebanon North Nursing & Rehab
Lebanon, MO  ·  View full profile →
Inspection Summary

LEBANON NORTH NURSING & REHAB in LEBANON, MO — inspection on August 14, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Potential for More Than Minimal Harm

During an interview on 08/14/25, at 3:29 P.M., CNA G said the following:-It was not appropriate to take a resident's belongings from them;-He/she usually works the 2 to 10 shift so when He/she arrives to the unit, the Resident comes to him/her to get the resident's belongings back.

Sometimes he/she has to hunt for the resident's belongings because they might be at the nurses' station, but usually they're in the locked closet;-He/she has found the resident's drawings, backpack, and stuff he/she's thrown when the resident has been upset;-He/she has heard the resident ask staff for his/her belongings and they will tell him/her no.

This has been going on since the resident was admitted ;-He/she doesn't know which staff is taking it, but the resident will obsess on his/her belongings until they're returned;-It's against the resident's rights to take their belongings.

During interviews on 08/14/25, at 8:55 A.M. and 4:45 P.M., the Director of Nursing (DON) said the following:-It was not appropriate to take a resident's belongings when they're misbehaving;-The resident does throw things and he/she questioned staff about taking the resident's belongings and they reported only putting them in the storage room until meal times were over;-It was not appropriate to tell a resident they're not getting their belongings back. If a resident asks for their belongings staff should return them.

During an interview on 08/14/25, at 5:07 P.M., the Administrator said staff should never threaten to take resident's belongings away.

That is against the resident's rights.

Complaint #2587324

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/14/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Lebanon North Nursing & Rehab

596 Morton Road Lebanon, MO 65536

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 08/14/25, at 2:28 P.M., Housekeeper E, said the following:-On 08/11/25, around 10:30 A.M., he/she arrived to the unit and saw a towel wedged at the top of the resident's door, and some of the towel was hanging on both sides of the door a few inches.

The door would not open.

The resident was at the door, crying and saying help me, my door is stuck.

The resident could not get the door to open.

The door was open about an inch, so there was a crack;-He/she told CNA D and another aide about the incident and they said they would report it to the charge nurse. He/she could not locate the DON;-Putting a towel in the door could be considered a restraint or seclusion;-Threatening a resident is abuse;-He/she did go to the Assistant Director of Nursing (ADON) about the towel situation right after it happened, and wrote a statement;-He/she knows abuse is supposed to be reported to the state, but not sure about the timeframes.

During an interview on 08/14/25, at 2:55 P.M., the ADON said the following:-It was not appropriate to curse at a resident or make threats.

This would be verbal abuse;-Putting a towel on a resident's door, if if hinders the door from opening, and keeping the resident in the room would be considered a restraint and involuntary seclusion;-He/she found out about the towel issue on Monday or Tuesday, late morning or early afternoon.

Two aides told him/her about the incident.

The aides asked if it would be appropriate to put a towel on the door so the resident could not get out and he/she told them know. He/she told the DON.

The DON was already aware of it and heading to the unit to remove the towel;-Staff should be reporting suspected about to the charge nurse, ADON or the DON;-Staff are to report abuse to the State within two hours. He/she doesn't know if this incident was reported timely as he/she was told the DON was taking care of things.

During an interview on 08/14/25, at 3:29 P.M., CNA G said the following:-Putting a towel on the door could be considered a restraint, and or involuntary seclusion if the resident was not able to get out;-He/she has seen multiple staff put towels up there, mainly the day shift;-He/she reports abuse to the charge nurse, and they're supposed to report to the State within 24 hours.

During interviews on 08/14/25, at 8:55 A.M. and 4:45 P.M., the DON said the following:-it would not be appropriate for staff to make threats towards residents.

This could be abuse;-He/she found the statements under the door when he/she came in 08/11/25;-The aides reported the concerns to LPN C.

He/she was not sure when they reported it to the nurse, and the nurse never notified him/her of the allegations of abuse;-He/she would expect the nurse to notify him/her and the Administrator immediately;-They're required to call the state within two hours.

During an interview on 08/14/25, at 5:07 P.M., the Administrator said the following:-Staff should never threaten to hurt a resident or curse at that resident, that is abuse;-If staff witness abuse or suspect abuse, they should take it to the supervisor immediately;-An aide should report to their charge nurse and the charge nurse should be reporting to the DON;-They are required to report abuse to the state within two hours;-Two staff reported suspected abuse, and wrote out statements, they put those under the DON's door. It wasn't reported timely;-Staff should not be putting a towel on any resident's door. He/she was not aware of a towel ever being put on the door to keep a resident in their room, That would be a restraint and involuntary seclusion.

Complaint #2587324

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LEBANON, MO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LEBANON NORTH NURSING & REHAB or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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