Lebanon North Nursing & Rehab

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

doors. The resident seems to do this more at night. 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

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lebanon North Nursing & Rehab

596 Morton Road Lebanon, MO 65536

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

abuse as well and should be reported. He/she wrote a statement on 08/11/25 and placed it under the DON's door. 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

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If continuation sheet