Inspection Reports for
Lebanon South Nursing & Rehab
514 WEST FREMONT ROAD, LEBANON, MO, 65536-4244
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
4.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
65 residents
Based on a January 2026 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 1
Date: Jan 6, 2026
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide appropriate care related to the use of a resident's implanted port for IV antibiotic administration.
Complaint Details
Complaint number 2683316. The complaint involved failure to follow physician orders for port use, dressing changes, and de-accessing the port after antibiotic therapy. The physician confirmed staff should have done routine dressing changes and de-accessed the port after the last antibiotic dose.
Findings
The facility failed to ensure staff obtained, clarified, and followed physician's orders for the use of a resident's implanted port, including failure to de-access the port as ordered and lack of orders or follow-up regarding port site dressing changes. The facility also lacked a policy or procedure for port use.
Deficiencies (1)
Failure to provide care per standards when staff failed to ensure physician's orders were obtained, clarified, and followed for use of implanted port for IV antibiotic administration, including failure to de-access port and lack of dressing change orders.
Report Facts
Facility census: 65
Antibiotic doses: 16
Meropenem dosage: 1
Meropenem dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Contacted physician regarding port access and administered IV antibiotic; documented port access and de-access attempts |
| LPN B | Licensed Practical Nurse | Administered IV medications through port after RN accessed it; stated LPNs not allowed to access/de-access port |
| LPN C | Licensed Practical Nurse | Commented on port dressing change frequency; did not access port |
| RN D | Registered Nurse | Had not worked with port at facility; commented on dressing change frequency |
| RN E | Registered Nurse | Accessed resident's port on 11/05/25 but unable to maintain line access; noted port dressing change frequency |
| Director of Nursing | Director of Nursing | Reported no facility policy on port use; described scope of practice for LPNs and RNs regarding port access and dressing changes |
| Physician | Stated nursing staff should have done routine dressing changes and de-accessed port after last antibiotic dose |
Inspection Report
Routine
Census: 74
Deficiencies: 3
Date: Feb 25, 2025
Visit Reason
The inspection was conducted as a routine regulatory oversight visit to assess compliance with professional standards of care, infection control, and safety protocols at Lebanon South Nursing & Rehab.
Findings
The facility was found deficient in providing timely and appropriate treatment for a resident with a fractured ankle due to delayed x-ray and follow-up, improper storage of oxygen and nebulizer equipment, and failure to implement Enhanced Barrier Protection (EBP) policies for residents with indwelling devices and wounds, including lack of staff education and gown use during catheter care.
Deficiencies (3)
Failure to complete an ordered x-ray and follow-up resulting in delayed treatment of a fractured ankle for one resident.
Failure to ensure oxygen and nebulizer tubing were stored properly when not in use for three residents.
Failure to educate staff on and implement Enhanced Barrier Protection (EBP) policy, including failure to wear gowns during catheter care for two residents with indwelling catheters.
Report Facts
Facility census: 74
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in relation to delayed x-ray order and catheter care observations |
| RN E | Registered Nurse | Named in relation to delayed x-ray order and catheter care observations |
| LPN F | Licensed Practical Nurse | Named in relation to delayed x-ray order and catheter care observations |
| Nurse Practitioner | Ordered x-ray and involved in delayed treatment of fractured ankle | |
| Director of Nursing | DON | Interviewed regarding notification and staff expectations for orders and infection control |
| Administrator | Interviewed regarding staff expectations for notification and infection control | |
| Certified Nurse Aide C | CNA | Interviewed regarding notification of pain complaints and infection control practices |
| Certified Medication Tech D | CMT | Interviewed regarding infection control practices |
| Nurse Aide B | NA | Interviewed regarding notification of pain complaints and infection control practices |
Inspection Report
Routine
Census: 64
Deficiencies: 9
Date: Oct 6, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident dignity, self-determination, shower/bathing preferences, transfer and discharge notifications, bed rail use, pharmaceutical services, medication storage, food preparation, infection control, and employee tuberculosis screening.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were appropriately dressed in common areas, failure to honor residents' shower preferences, failure to provide written transfer and bed hold notices, improper use and documentation of bed rails, failure to maintain accurate controlled substance counts, improper medication refrigerator temperature monitoring, failure to serve a resident's pureed diet as ordered, unsafe food handling practices during meal assistance, and incomplete tuberculosis screening documentation for employees.
Deficiencies (9)
Failure to ensure residents were appropriately dressed in common areas, exposing ostomy bags and incontinent briefs.
Failure to honor residents' shower preferences and provide consistent and timely showers.
Failure to provide written notification of transfer/discharge and bed hold policies to residents or their representatives.
Failure to obtain physician orders, complete pre-use assessments, obtain informed consent, and document use of bed rails; failure to measure and inspect bed rails for safety.
Failure to maintain accurate controlled substance counts and document administration properly.
Failure to maintain medication refrigerator temperature within recommended range and lack of system to monitor and adjust temperature.
Failure to serve a resident a physician-ordered pureed diet; resident was served regular food despite swallowing difficulties.
Failure to ensure food safety including stacking wet dishes preventing air drying, open food packages in freezer, cracked lids on cereal bowls, dirty walk-in freezer, and improper hand hygiene and bare hand contact with ready-to-eat food during meal assistance.
Failure to ensure timely administration of two-step tuberculosis screening for employees; missing documentation for three employees.
Report Facts
Facility census: 64
Shower frequency: 2
Medication refrigerator temperature: 31
Medication refrigerator temperature: 32
Medication refrigerator temperature: 33
Medication refrigerator temperature: 34
Medication refrigerator temperature: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN Q | Licensed Practical Nurse | Failed to initial controlled medication administration and narcotic count |
| LPN B | Licensed Practical Nurse | Failed to correctly count controlled medication; explained narcotic count process |
| CNA C | Certified Nurse Aide | Named in findings related to improper meal assistance hand hygiene and resident grooming |
| CNA D | Certified Nurse Aide | Named in findings related to improper meal assistance hand hygiene and bare hand contact with food |
| CNA E | Certified Nurse Aide | Provided statements on shower scheduling and hand hygiene |
| Administrator | Provided statements on policies and procedures related to transfers, bed holds, medication, and infection control | |
| Director of Nursing | DON | Provided statements on policies and procedures related to transfers, bed holds, medication, and infection control |
| Assistant Director of Nursing | ADON | Provided statements on policies and procedures related to transfers, bed holds, medication, and infection control |
| Speech Therapist K | Speech Therapist | Provided statements on diet recommendations and resident swallowing evaluations |
| Speech Therapist J | Speech Therapist | Provided statements on resident diet safety and swallowing |
| Kitchen Manager | Provided statements on dishwashing and food storage practices | |
| Maintenance Director | Provided statements on bed rail installation and maintenance |
Inspection Report
Annual Inspection
Census: 49
Deficiencies: 6
Date: Apr 5, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including resident trust fund management, personal care, respiratory care, staffing adequacy, medication administration, and infection control.
Findings
The facility was found deficient in multiple areas including misappropriation of resident funds by the business office manager, inadequate personal hygiene and nail care for dependent residents, failure to maintain oxygen humidifier water and correct oxygen flow, insufficient staffing leading to delayed care and inadequate meal assistance, medication errors related to insulin dosing, and failure to perform proper hand hygiene during resident care.
Deficiencies (6)
Failure to protect residents from misappropriation of property by the business office manager withdrawing cash without proper documentation or resident receipt.
Failure to provide adequate nail care and personal hygiene assistance for dependent residents following incontinent episodes.
Failure to ensure oxygen humidifier bottles contained water and oxygen was administered at correct liters per minute as ordered.
Failure to maintain sufficient nursing staff to provide timely monitoring, bathing, meal assistance, and call light response.
Failure to ensure residents were free from significant medication errors related to incorrect insulin dosing per physician orders.
Failure to perform hand hygiene before and after resident care and between glove changes during incontinent care and grooming.
Report Facts
Residents affected by misappropriation: 4
Residents affected by personal hygiene deficiency: 2
Residents affected by oxygen care deficiency: 1
Residents affected by staffing deficiency: 6
Residents affected by medication errors: 3
Residents affected by infection control deficiency: 6
Facility census: 49
Cash box shortage: 113.77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| BOM | Business Office Manager | Named in misappropriation of resident funds and cash box reconciliation findings |
| CFC | Corporate Financial Consultant | Conducted investigation and re-trained BOM on resident trust process |
| Administrator | Involved in investigation, suspension of BOM, and staffing interviews | |
| LPN G | Licensed Practical Nurse | Charge nurse during night shift with staffing concerns |
| CNA B | Certified Nursing Assistant | Observed and interviewed regarding personal care and staffing |
| LPN F | Licensed Practical Nurse | Interviewed regarding oxygen care and hand hygiene |
| DON | Director of Nursing | Interviewed regarding insulin administration, staffing, and hand hygiene |
| CNA A | Certified Nursing Assistant | Shower aide interviewed about bathing frequency and meal assistance |
| LPN I | Licensed Practical Nurse | Interviewed about insulin administration errors |
| CNA C | Certified Nursing Assistant | Observed and interviewed regarding hand hygiene and resident care |
| CNA D | Certified Nursing Assistant | Observed and interviewed regarding hand hygiene and resident care |
Inspection Report
Routine
Census: 89
Deficiencies: 3
Date: Apr 8, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including proper notification to residents regarding Medicare Part A coverage and potential liability, mail delivery practices, confidentiality of residents' personal and medical records, and staff screening for prior abuse history.
Findings
The facility failed to provide Skilled Nursing Facility Advance Beneficiary Notices or denial letters to three residents at the initiation, reduction, or termination of Medicare Part A benefits. Mail was not delivered to residents on Saturdays, delaying receipt until Monday. The facility also failed to screen four staff members for prior abuse history via the nurse aide registry check. These deficiencies were associated with minimal harm or potential for actual harm.
Deficiencies (3)
Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or denial letter at Medicare Part A benefit changes for three residents.
Failed to provide prompt mail delivery on Saturdays to residents.
Failed to screen four staff members for prior abuse history via nurse aide registry check.
Report Facts
Residents affected: 3
Facility census: 89
Staff not screened: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding knowledge of SNFABN form requirements |
| Administrator | Administrator | Interviewed regarding expectations for notices and staff screening |
| Director of Nursing | Director of Nursing | Staff member whose personnel file lacked nurse aide registry check |
| Assistant Business Office Manager | Assistant Business Office Manager | Staff member whose personnel file lacked nurse aide registry check and interviewed about registry check knowledge |
| Dietary Aide A | Dietary Aide | Staff member whose personnel file lacked nurse aide registry check |
| Housekeeper B | Housekeeper | Staff member whose personnel file lacked nurse aide registry check |
| Activities Director | Activities Director | Interviewed regarding mail delivery practices |
Viewing
Loading inspection reports...
