Inspection Reports for
Lebanon South Nursing & Rehab
514 WEST FREMONT ROAD, LEBANON, MO, 65536-4244
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
9.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
35% occupied
Based on a January 2026 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate 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
Plan of Correction
Census: 19
Deficiencies: 1
Date: Apr 22, 2025
Visit Reason
The inspection was conducted to assess compliance with tuberculosis screening requirements for residents and staff at Lebanon South Nursing & Rehab.
Findings
The facility failed to ensure the required two-step tuberculosis screening test was completed for all staff prior to employment. Specifically, two of three sampled staff did not have the first step completed before starting work.
Deficiencies (1)
19 CSR 30-86.042(18) TB Screen Resident/Staff: The facility did not complete the required two-step tuberculosis screening test for all staff prior to employment. Two of three sampled staff lacked the first step completed before starting work.
Report Facts
Facility census: 19
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
Plan of Correction
Census: 74
Deficiencies: 3
Date: Feb 25, 2025
Visit Reason
The inspection was conducted to investigate deficiencies related to quality of care, respiratory/tracheostomy care and suctioning, and infection prevention and control at Lebanon South Nursing & Rehab.
Findings
The facility failed to provide care in accordance with professional standards for a resident with a fractured ankle, failed to provide proper respiratory care including storage of oxygen and nebulizer tubing, and failed to maintain an effective infection prevention and control program including staff education and use of enhanced barrier protection.
Deficiencies (3)
F684 Quality of care: The facility failed to provide timely x-ray and follow-up for a resident with leg pain and swelling, resulting in delayed treatment of a fractured ankle. Staff did not document follow-up with the nurse practitioner or notify the physician appropriately.
F695 Respiratory/Tracheostomy Care and Suctioning: Staff failed to ensure oxygen and nebulizer tubing were stored properly and protected when not in use for multiple residents. Tubing and equipment were found on the floor or not covered in a protective bag.
F880 Infection Prevention & Control: The facility failed to establish and maintain an effective infection prevention and control program. Staff did not wear gowns when completing wound care, did not use enhanced barrier protection consistently, and failed to educate staff on infection control policies.
Report Facts
Facility census: 74
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
Life Safety
Census: 64
Capacity: 116
Deficiencies: 5
Date: Oct 6, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations, focusing on fire safety and building construction standards.
Findings
The facility was found deficient in maintaining the fire sprinkler system, egress doors, smoke barrier walls, and electrical system testing. These deficiencies had the potential to affect all residents, staff, and visitors in the event of a fire.
Deficiencies (5)
K161: The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations between the attic and areas below, exposing residents and staff to smoke passage risk.
K222: The facility failed to maintain magnetic locks on emergency exits to release immediately upon fire alarm activation, risking occupant egress during emergencies.
K353: The facility failed to properly maintain the fire sprinkler system by not conducting required semi-annual or quarterly inspections for 2022 and 2023.
K372: The facility failed to maintain smoke barrier walls, with holes and missing drywall around HVAC vents, compromising smoke resistance.
K918: The facility failed to complete an annual fuel test and a required four-hour load test for the diesel-run facility generator within the past three years.
Report Facts
Facility capacity: 116
Resident census: 64
Inspection Report
Plan of Correction
Census: 14
Deficiencies: 2
Date: Apr 27, 2023
Visit Reason
The inspection was conducted to assess compliance with fire safety and building maintenance regulations, specifically regarding sprinkler systems and building condition.
Findings
The facility failed to maintain a complete sprinkler system and did not keep the building in good repair, affecting all fourteen residents present during the inspection.
Deficiencies (2)
19 CSR 30-86.022(11)(A) Complete Sprinkler System-NFPA 13. The facility failed to install and maintain a complete sprinkler system in accordance with NFPA 13, 1999 edition, affecting fourteen residents.
19 CSR 30-86.032(2) Substantially Constructed & Maintained. The facility failed to maintain the building in good repair, with missing vent covers, holes in walls and ceilings, and damaged serial decks, affecting fourteen residents.
Report Facts
Deficiency affected residents: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Diana Knight | Administrator | Signed the inspection report |
Inspection Report
Plan of Correction
Census: 14
Deficiencies: 1
Date: Apr 26, 2023
Visit Reason
The inspection was conducted to assess compliance with personnel record regulations, specifically regarding written statements signed by a licensed physician or designee for employees.
Findings
The facility failed to ensure that two Medication Aide employees had written statements signed by a licensed physician or designee indicating they could work in a long-term care facility. The Business Office Manager was unaware of the requirement, and the Administrator confirmed the statements had not been completed.
Deficiencies (1)
19 CSR 30-86.042(21)(I) Personnel Record requires a written statement signed by a licensed physician or designee indicating the employee can work in a long-term care facility. The facility failed to provide such statements for two Medication Aide employees.
Report Facts
Facility census: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LIMA A | Medication Aide | Named in deficiency for missing physician statement |
| LIMA B | Medication Aide | Named in deficiency for missing physician statement |
| Business Office Manager | Interviewed regarding employee health statements | |
| Administrator | Interviewed regarding responsibility for employee files and missing statements |
Inspection Report
Plan of Correction
Census: 63
Deficiencies: 1
Date: Jan 26, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding the development and implementation of comprehensive care plans for residents, specifically focusing on a resident exhibiting behavioral issues.
Findings
The facility failed to ensure staff reviewed and revised a resident's care plan to accurately reflect the resident's condition and behaviors. Staff did not document new interventions to address the resident's refusals of care or aggressive behaviors, and care plans were not consistently updated or implemented.
Deficiencies (1)
F656: The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with behavioral issues. Staff did not update the care plan to reflect the resident's condition or implement new interventions to address refusals of care and aggressive behaviors.
Report Facts
Facility census: 63
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Knight | Administrator | Signed the statement of deficiencies and plan of correction |
| Director of Nursing | Director of Nursing | Named in plan of correction and interviews regarding care plan updates |
| Registered Nurse B | Registered Nurse | Interviewed regarding resident's refusals of care and behaviors |
| Certified Nurse Aide A | Certified Nurse Aide | Interviewed regarding resident's aggressive behaviors |
| Social Service Director | Social Service Director | Involved in care plan discussions and interviews |
| MDS Coordinator | MDS Coordinator | Responsible for care plan updates and monitoring resident behaviors |
Inspection Report
Plan of Correction
Census: 57
Deficiencies: 2
Date: Dec 7, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to cardiopulmonary resuscitation (CPR) and use of automated external defibrillators (AED) at Lebanon South Nursing & Rehab.
Findings
The facility failed to ensure all staff were properly trained in CPR and AED use as evidenced by an incident involving Resident #1. Staff did not follow proper CPR procedures and AED instructions during an emergency response.
Deficiencies (2)
F678 Cardio-Pulmonary Resuscitation (CPR) requirement not met. Facility staff were not properly trained in CPR and AED use during an emergency involving Resident #1.
A4075 Nursing Care per Resident Condition regulation not met. Refer to F678 for details on deficient nursing care related to CPR and AED use.
Report Facts
Census: 57
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Knight | Administrator | Signed report and plan of correction |
Inspection Report
Plan of Correction
Census: 47
Deficiencies: 2
Date: Dec 15, 2021
Visit Reason
The inspection was conducted to investigate and document deficiencies related to quality of care at Lebanon South Nursing & Rehab, specifically regarding failure to provide appropriate staff assistance for a resident's scheduled physician appointment.
Findings
The facility failed to provide appropriate staff to assist a resident with a scheduled cardiology appointment, resulting in a missed appointment and lack of timely follow-up. The facility has a policy for resident transportation but experienced staffing shortages impacting appointment attendance.
Deficiencies (2)
F684 Quality of care: The facility failed to provide appropriate staff to assist one resident to a scheduled physician appointment, resulting in the appointment being missed and no timely follow-up documented.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation is not met as evidenced by the deficiency cited in F684.
Report Facts
Facility census: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Knight | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
| Director of Nursing | Interviewed regarding resident's missed appointment and pacemaker checks | |
| Certified Nursing Assistant B | CNA | Interviewed about resident's physician appointment cancellations |
| Registered Nurse C | RN | Interviewed about resident's physician appointments and transfer issues |
| Social Service Director | SSD | Interviewed and involved in scheduling and follow-up of resident appointments |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 29, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
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
Life Safety
Census: 49
Capacity: 116
Deficiencies: 10
Date: Apr 5, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and emergency preparedness requirements, including fire drills, smoke barriers, and building construction integrity.
Findings
The facility was found deficient in multiple areas including failure to maintain an updated Emergency Operations Plan, inadequate fire drills, unsealed penetrations in smoke barriers, and electrical receptacles and wiring not maintained in good repair. These deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (10)
E004 Emergency preparedness plan was not reviewed yearly as required, with the facility failing to perform a required yearly review of the Emergency Operations Plan.
K161 The facility failed to maintain the one-hour fire rating of ceilings due to unsealed penetrations between the attic and areas below.
K372 The facility failed to maintain smoke barrier walls, with unsealed penetrations and an irregularly-shaped hole in the smoke barrier wall allowing potential smoke passage.
K712 The facility failed to conduct required quarterly fire drills at unexpected times, with many drills conducted during expected times.
K919 The facility failed to maintain electrical receptacles and wiring in good repair, with exposed wiring and missing covers on junction boxes.
A2054 Smoke section walls/doors were not compliant with one-hour fire-rated wall requirements and self-closing doors.
A2058 Fire drills and emergency preparedness plans were not conducted or maintained as required, lacking proper consultation and documentation.
A2061 Fire drill evacuation requirements were not met, with insufficient unannounced drills and lack of simulated resident evacuation.
A3001 The building was not substantially constructed and maintained in good repair per applicable construction standards.
A3030 Electrical wiring and equipment were not maintained in accordance with NFPA standards, risking resident safety.
Report Facts
Facility capacity: 116
Resident census: 49
Fire drills conducted: 15
Required fire drills annually: 12
Fire drills per shift: 1
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 6, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: Aug 4, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 9, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigation were conducted on July 9, 2020.
Complaint Details
The complaint investigation was related to COVID-19 infection control practices and the facility was found compliant.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Additionally, a prior COVID-19 Focused Emergency Preparedness survey conducted on June 9, 2020, found the facility in compliance with 42 CFR 483.73 related to E-0024 (b)(6).
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 3, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigation were conducted on June 3, 2020.
Complaint Details
The complaint investigation was related to infection control practices and was found to be in compliance.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19 and with 42 CFR 483.73 related to E-0024 (b)(6).
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 2
Date: Feb 21, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding insufficient nursing staff and delayed response to call lights.
Complaint Details
The complaint investigation substantiated that the facility was understaffed, resulting in delayed responses to call lights and unmet resident needs. Interviews with residents, family members, and staff confirmed the staffing issues.
Findings
The facility failed to have sufficient nursing staff to meet residents' needs, resulting in delayed responses to call lights and unmet resident care needs. Multiple resident interviews and observations confirmed staffing shortages and delays in assistance.
Deficiencies (2)
F725 Sufficient Nursing Staff: The facility failed to have sufficient nursing staff to meet residents' needs when call lights were not answered timely. The facility census was 88.
A4044 Nursing Staff Sufficient/Qualified: The facility did not employ sufficient nursing personnel with qualifications to meet residents' needs and maintain the highest practicable level of well-being.
Report Facts
Facility census: 88
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Knight | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Annual Inspection
Census: 86
Deficiencies: 2
Date: Jul 11, 2019
Visit Reason
Annual inspection survey conducted on 07/11/2019 to assess compliance with federal regulations at Lebanon South Nursing & Rehab.
Findings
The facility failed to provide restorative services as ordered by the physician and recommended by therapy for multiple residents. Additionally, deficiencies were found in the labeling and storage of drugs and biologicals, including narcotic counts and documentation.
Deficiencies (2)
F684 Quality of care: The facility did not provide restorative services as ordered by the physician and recommended by physical and occupational therapy for six residents. Documentation and treatment were incomplete or missing for restorative nursing services.
F761 Label/Store Drugs and Biologicals: The facility failed to properly label and store drugs and biologicals, including controlled substances. Narcotic counts were inconsistent and not properly documented, and staff did not follow procedures for medication inventory and accountability.
Report Facts
Facility census: 86
Minutes of occupational therapy: 135
Minutes of physical therapy: 158
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Knight | Administrator | Signed the Statement of Deficiencies and Plan of Correction |
Inspection Report
Plan of Correction
Census: 11
Deficiencies: 2
Date: Jun 17, 2019
Visit Reason
The inspection was conducted to assess compliance with tuberculosis screening and resident record requirements at Lebanon South Nursing & Rehab.
Findings
The facility failed to ensure required two-step tuberculosis screening for one resident and did not complete monthly reviews for three residents' medical records as required by regulations.
Deficiencies (2)
19 CSR 30-86.042(18) TB Screen Resident/Staff: The facility failed to ensure the required two-step tuberculosis screening test was completed for one resident out of three sampled residents.
19 CSR 30-86.042(62)(B) Resident Record Requirements: The facility failed to complete monthly reviews for three residents' medical records, missing required summaries and documentation.
Report Facts
Facility census: 11
Residents sampled: 3
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 |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 4
Date: Apr 8, 2019
Visit Reason
The inspection was conducted due to complaints regarding failure to provide Medicaid/Medicare coverage notices, personal privacy violations, and failure to develop and implement abuse/neglect policies.
Complaint Details
The visit was complaint-related with substantiated findings of failure to provide required notices, mail delivery issues, incomplete staff abuse screening, and incomplete tuberculosis testing.
Findings
The facility failed to provide required Skilled Nursing Facility Advance Beneficiary Notices to Medicaid-eligible residents, failed to provide prompt mail delivery on Saturdays, and did not complete required nurse aide registry checks for staff screening. Additionally, tuberculosis testing for staff was incomplete.
Deficiencies (4)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to provide Skilled Nursing Facility Advance Beneficiary Notices or denial letters to three residents and did not inform residents of changes in coverage or charges as required.
F583 Personal Privacy/Confidentiality of Records: The facility failed to provide prompt mail delivery within 24 hours on Saturdays, denying residents their right to personal privacy and confidentiality.
F607 Develop/Implement Abuse/Neglect Policies: The facility failed to screen all staff for prior history of abuse by not completing nurse aide registry checks for four staff members.
A4029 Communicable Disease-Employees: The facility failed to complete required tuberculosis testing for one staff member and did not ensure annual TB testing compliance.
Report Facts
Facility census: 89
Number of staff sampled for abuse screening: 6
Number of staff with incomplete registry checks: 4
Inspection Report
Life Safety
Census: 89
Capacity: 116
Deficiencies: 1
Date: Apr 8, 2019
Visit Reason
The inspection was conducted to assess compliance with fire drill and emergency preparedness regulations, specifically the annual fire department consultation requirement.
Findings
The facility failed to complete the annual fire department consultation, which could affect residents, staff, and visitors in an emergency. The facility otherwise meets applicable provisions of the 2012 Life Safety Code.
Deficiencies (1)
19 CSR 30-85.022(33)(A) Fire Drill/Emergency Preparedness - Plans: The facility failed to complete the annual fire department consultation, which is required to meet emergency preparedness standards.
Report Facts
Facility capacity: 116
Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Knight | Administrator | Signed the statement of deficiencies and plan of correction |
Inspection Report
Annual Inspection
Census: 82
Deficiencies: 8
Date: May 21, 2018
Visit Reason
Annual inspection survey conducted to assess compliance with federal regulations and identify deficiencies at Lebanon South Nursing & Rehab.
Findings
The facility was found deficient in multiple areas including abuse/neglect policies, accident prevention, dialysis care, nursing staff sufficiency, medication error rates, medication labeling and storage, food safety, and resident call system. Deficiencies were documented with corrective plans submitted.
Deficiencies (8)
F607 Develop/Implement Abuse/Neglect Policies. The facility failed to ensure all staff were screened for prior abuse history with documentation of Nurse Aide Registry checks missing for nine of ten sampled employees.
F689 Free of Accident Hazards/Supervision/Devices. The facility failed to implement new interventions or notify appropriate staff when a resident made a suicidal statement and attempted to leave unassisted.
F698 Dialysis. The facility failed to provide thorough assessments, obtain physician orders, and monitor dialysis care for one resident receiving dialysis.
F725 Sufficient Nursing Staff. The facility failed to have sufficient nursing staff to meet resident needs and provide restorative services.
F759 Free of Medication Error Rates 5 Percent or More. The facility had a medication error rate of 7.4%, exceeding the 5% threshold.
F761 Medication Labeling. The facility failed to ensure all prescription medications were properly labeled with expiration dates and other required information.
F812 Food Procurement, Store, Prepare, Serve-Sanitary. The facility failed to ensure food safety including contamination prevention and proper cleaning of kitchen equipment.
F919 Resident Call System. The facility failed to provide an adequate call system allowing residents to summon staff assistance in public bathrooms and therapy areas.
Report Facts
Facility census: 82
Medication error rate: 7.4
Medication error opportunities: 27
Medication errors: 2
Inspection Report
Annual Inspection
Census: 82
Capacity: 116
Deficiencies: 3
Date: May 21, 2018
Visit Reason
Annual recertification survey to assess compliance with the Life Safety Code and related fire safety regulations.
Findings
The facility failed to maintain the fire sprinkler system, smoke barrier walls, and electrical equipment in compliance with applicable fire safety codes. Deficiencies had the potential to affect all residents, staff, and visitors in the event of a fire.
Deficiencies (3)
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain the fire sprinkler system by allowing insulation to cover 11 sprinklers in the attic and omitting sprinklers in the activities closet. This posed a risk of delayed sprinkler activation in a fire.
K372 Subdivision of Building Spaces - Smoke Barrier: The facility failed to maintain the smoke resistive properties of smoke barrier walls in the attic due to unsealed penetrations, allowing potential smoke passage during a fire.
K919 Electrical Equipment - Other: The facility failed to maintain electrical wiring safely by allowing outlets with damaged or missing protective covers and plugs under pressure, risking electrical short and fire.
Report Facts
Deficiencies cited: 3
Facility capacity: 116
Census: 82
Inspection Report
Life Safety
Census: 13
Deficiencies: 2
Date: Mar 20, 2018
Visit Reason
The inspection was a fire safety inspection conducted to assess compliance with flame resistance of curtains/drapes and the use of portable heaters in the facility.
Findings
The facility failed to ensure that all curtains and drapes were flame resistant and that no portable heaters were used. Observations showed non-compliant curtains in multiple resident rooms and a space heater in one resident's bedroom.
Deficiencies (2)
19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant: The facility failed to ensure all curtains and drapes were certified or treated to be flame-resistant as required. Observations found non-compliant curtains in resident rooms 102, 107, and 205 without documentation of flame retardant treatment.
19 CSR 30-86.032(10) Heaters-Approved Label, Venting, No Portable: The facility failed to ensure no portable heaters were used. An electric space heater was observed in resident room 205, which was removed after discovery.
Report Facts
Facility census: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Teresa Knight | LNHA | Signed the Plan of Correction dated 3/28/18 |
| Maintenance Director | Interviewed regarding curtain replacement and space heater removal |
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