Inspection Reports for
Lebanon North Nursing & Rehab

Complaint 2669590 triggered the investigation. The complaint involved a resident fall on 2025-11-17 resulting in a laceration requiring staples and a neck fracture. The fall was substantiated based on observations and interviews.

The facility failed to ensure staff were aware of and followed the care plan requiring two staff for resident care, resulting in a resident falling from bed and sustaining a laceration and neck fracture. Staff did not have all needed supplies within reach and one staff provided care alone when two were required, increasing fall risk.

Complaint #2632714 regarding failure to honor a resident's DNR order was investigated and substantiated.

The facility failed to ensure that Resident #1's DNR order was clearly and consistently documented across all records and communicated to staff, leading to CPR being administered despite the resident's DNR status. Delays in scanning and uploading the DNR order into the electronic medical record and inconsistent code status indicators contributed to the error.

Complaint #2587324 involved allegations that staff withheld a resident's belongings, threatened the resident, used verbal abuse, and placed a towel on the resident's door to keep them confined. The facility reported the allegations approximately 24 hours after staff suspected abuse, which was not timely as required by regulations.

The facility failed to ensure the resident's rights to a dignified existence were honored, as staff withheld the resident's belongings and threatened to remove them, which increased the resident's behaviors. Additionally, the facility failed to report allegations of verbal abuse, threats, and involuntary seclusion (such as placing a towel on the resident's door to keep them confined) to management and the state licensing agency within the required timeframe. Multiple staff interviews and statements confirmed inappropriate staff behavior and delayed reporting.

The facility was found deficient in providing and implementing an infection prevention and control program. The deficiency was noted as causing minimal harm or potential for actual harm affecting some residents.

The facility failed to provide appropriate wound care per physician orders, failed to notify the physician timely about wound condition changes, failed to document wound care and care plan updates, and failed to maintain complete and accurate medical records including catheter orders, hospital transfer documentation, and family notifications for two residents. The facility also lacked wound treatment and skin assessment policies.

The facility failed to ensure resident self-determination regarding bathing preferences and timely assistance with showers for residents. Staff did not consistently document showers offered or completed. The facility was short-staffed and lacked a designated shower aide. Additionally, the facility failed to maintain an effective infection prevention and control program, including lack of staff education on enhanced barrier precautions (EBP) and inadequate availability and use of personal protective equipment (PPE) for residents with catheters and wounds.

The complaint involved an allegation of sexual abuse by a resident who reported that someone put something inside him/her during the night. The allegation was not substantiated by hospital evaluation. The facility delayed reporting the allegation to the State Survey Agency beyond the required two-hour timeframe. The hospital reported the allegation to law enforcement. The facility's investigation included interviews with staff and the resident. The resident was distressed and did not name an alleged perpetrator.

The facility failed to report an allegation of sexual abuse by a resident to the State Survey Agency within the required two-hour timeframe. The resident alleged that someone had put something inside him/her during the night. The facility delayed reporting the allegation to the state agency, following directions from corporate QA nurse and Administrator to wait for hospital findings. The resident was sent to the hospital, where the allegation was not verified. The hospital reported the allegation to law enforcement. Multiple staff interviews confirmed the failure to report timely.

The investigation was complaint-driven due to an incident on 07/09/24 where a resident was not fully secured in a wheelchair during transport, resulting in the resident sliding out and fracturing the right leg. The complaint was substantiated with evidence from staff statements, resident interviews, and medical reports.

The facility failed to secure a resident properly in a wheelchair during transport in the facility van, leading to the resident sliding out and sustaining a fracture to the right leg. The facility lacked a specific policy for van transportation, and staff did not secure the resident's shoulder/lap belt due to obstruction by other wheelchairs. Multiple staff interviews and documentation confirmed the incident and inadequate safety measures.

The facility failed to provide timely Notice of Medicare Non-Coverage to residents, complete significant change assessments for hospice, refer residents for PASARR Level II evaluation, provide adequate activities on the secure unit, ensure resident safety during van transport resulting in a fracture, maintain ongoing dialysis communication, ensure RN coverage for 8 hours on certain days, and document clinical rationale for PRN psychotropic medications beyond 14 days.

The facility failed to complete a comprehensive care plan for one resident that addressed the resident's bathing preferences and potential behaviors during showers. Staff interviews revealed inconsistent communication about the resident's dislike of showers and behaviors exhibited, and the care plan did not document these behaviors or the use of music as a calming intervention.

The investigation was complaint-driven, focusing on Resident #1's pain management. The complaint was substantiated as staff failed to reorder and administer pain medication timely, causing the resident to experience pain and withdrawal symptoms.

The facility failed to ensure a pain management program was provided per standards of practice for Resident #1, who did not receive timely reordering and administration of a Butrans pain patch, resulting in untreated pain and withdrawal symptoms. Staff also failed to administer Tylenol routinely as ordered. Interviews confirmed staff knowledge gaps and procedural failures in medication ordering and administration.

The complaint involved an allegation that Certified Nurse Aide (CNA) B was rough and rude to Resident #1 during care, causing the resident to wince and express distress. Nurse Aide (NA) A reported the incident to the charge nurse (LPN C), but the allegation was not immediately reported to the State Survey Agency or management within the required two-hour timeframe. The facility submitted the self-report over 16 hours after the allegation was made. The investigation was incomplete and delayed, and the accused staff member was not suspended pending investigation.

The facility failed to immediately report an allegation of abuse to management and the State Survey Agency within two hours, and failed to thoroughly and timely investigate the allegation or take appropriate protective actions, including suspending the accused staff member. The facility census was 69.

The complaint investigation found that the facility did not ensure timely scheduling of a mammogram and MRI for Resident #1, delaying diagnosis and treatment of possible breast cancer. The MRI order was missed due to communication breakdowns among nursing, social services, and transportation staff. The physician and surgeon noted the delay impacted treatment timing. The facility corrected the noncompliance by 08/04/23.

The facility failed to have a system in place to ensure timely scheduling of ordered mammogram and MRI appointments for Resident #1, resulting in delayed treatment options. Multiple staff interviews revealed communication failures and lack of follow-up on appointment scheduling. The noncompliance was corrected by 08/04/23.

The complaint was substantiated. The verbal abuse incident occurred on 07/12/23, witnessed by Certified Medication Technician B and the Activities Director. Multiple staff interviews confirmed the abuse. The staff member had a history of agitation related to breaks and had been previously counseled.

The facility failed to protect the resident's right to be free from verbal abuse when CNA A used profane language towards Resident #1. The incident was witnessed and verified by multiple staff members, and the facility investigation confirmed the verbal abuse.

The facility was found deficient in multiple areas including failure to provide required Medicare notices to residents, incomplete employee background and tuberculosis screening, failure to complete baseline and comprehensive care plans for residents, failure to follow physician orders for lab work and thickened liquids, failure to provide restorative therapy as ordered, incomplete documentation of Quality Assessment and Assurance meetings, and inadequate infection prevention and control practices related to tuberculosis screening.

The facility was found deficient in maintaining a clean and homelike environment, proper wound care and pressure ulcer management, timely physician orders for catheter care, dialysis communication and documentation, kitchen sanitation, and pest control related to flies in resident rooms.