Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Protect each resident from all types of abuse such as physical, mental, sexual abuse,
physical punishment, and neglect by anybody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to protect
residents from abuse when two residents (Resident #3 and #10), with a history of
aggressive behavior, struck other residents. The facility census was 102.
1. Record review of the facility’s Abuse Prohibition Protocol, revised date of January,
(YEAR) showed the following information:
-It is the purpose of the facility to prohibit mistreatment, neglect, abuse,
misappropriation of property, and exploitation of any resident;
-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or
punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of
all residents, irrespectable of any mental or physical condition, cause physical harm,
pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and
mental anguish. Willful, as used in this definition of abuse , means the individual must
have acted deliberately, not that the individual must have intended to inflict injury or
harm;
-Physical abuse is defined as hitting, slapping, pinching, kicking, etc.
2. Record review of Resident #3’s face sheet (a document that gives a resident’s
information at a quick glance) showed the following information:
-admitted [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS) a federally mandated
assessment instrument completed by facility staff, dated 04/03/18, showed the following
information:
-Cognitively intact;
-The mood score indicated the resident had felt down and depressed with little interest or
pleasure in doing things;
-Verbal behaviors directed towards others for one to three days (out of the previous seven
days);
-Received an anti-psychotic medication seven of the previous seven days;
-Received an anti-anxiety medication seven of the previous seven days;
-Received an anti-depressant medication seven of the previous seven days.
Record review of the resident’s care plan, dated 01/01/18 and last update 4/16/18, showed
direction for staff to do the following:
-Notify the charge nurse if the resident becomes agitated or combative;
-Acknowledge the resident’s situations may be difficult, but getting upset is not helping;
-Administer anti-[MEDICAL CONDITION], anti-anxiety, and anti-depressant medications as
ordered;
-Document behaviors every shift;
-Psychological Services will continue to consult with the resident due to his/her
emotional and behavioral concerns;
-The goal is the resident will verbalize his/her feelings of anger and depression in an
appropriate manner rather than getting verbally upset and aggressive.
Record review of the resident’s behavior monitoring record showed on 5/19/18 staff
documented the resident exhibited a behavior of hitting. The intervention was redirection.
Record review of the residents’ progress notes showed the following information:
-On 5/19/18 at 2:10 P.M., a nurse documented the resident was sitting in the dining room
before lunch, became angry, threw a butter knife bouncing it off the table, hitting the

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
television and cracking the screen;
-On 5/19/18 at 7:00 P.M., a nurse documented another resident reported after a verbal
altercation in the smoking courtyard, Resident #3 propelled his/her wheel chair over to
the other resident and struck him/her on the right arm. The nurse reported the incident to
the administrator, Director of Nursing (DON), and left a message for the resident’s
physician and guardian. The nurse received instructions from the administrator to start 30
minute checks on Resident #3.
-On 5/20/18, staff observed the resident coming down the hall, cursing at other residents;
-On 6/0718 at 10:06 A.M., a nurse documented the resident had a verbal altercation yelling
at another resident. The staff intervened before physical actions were made. The physician
gave an order for [REDACTED].>-On 7/11/18 at 4:09 P.M., a nurse documented he/she
notified the nurse practitioner that social services had made multiple attempts for an
inpatient psychiatric evaluation and was unsuccessful. The physician order
[REDACTED].>Record review of the resident’s medical record showed the following
information:
-On 5/19/18, staff did not document 30 minute checks;
-On 5/20/18, from 6:00 A.M. until 3:00 PM, staff documented every 30 minute checks. Staff
did not document 30 minute checks from 3:30 P.M. to 6:30 P.M. From 7:00 P.M. until 5:30
A.M. on 5/21/18, staff documented the 30 minute checks were completed.
Record review of the social service progress notes dated 5/22/18 at 1:51 P.M., showed the
residents’ behaviors were worsening. The resident had been cussing at other residents,
calling them inappropriate names and also became physically aggressive with another
resident.
Record review of the residents’ physician’s monthly progress notes dated 1/15/18 through
7/17/18 showed the physician documented the resident had displayed no new behaviors.
Observation on 7/23/18 at 8:57 A.M., showed Resident #3 in bed watching television. The
resident’s roommate was in the room.
During an interview on 7/25/18 at 10:45 A.M., Resident #3 said he/she has had physical
altercations with other residents. He/she got mad at his/her roommate and hit the roommate
in the back. He/she also hit another resident in the arm. Staff were aware of both
incidences and staff didn’t do anything about it.
During an interview on 7/27/18 at 9:43 A.M., CNA C said the following:
-All types of abuse should be reported immediately to the charge nurse and to
administration;
-Resident-to-resident altercations are abuse and need to be reported to the charge nurse
and other residents need to be protected;
-He/She was aware of Resident #3 hitting another resident but is unsure who the other
resident was;
-Resident #3 has a history of physical altercations, and it is not the first time Resident
#3 hit another resident;
-Resident #3 is frequently verbally abusive;
-The charge nurse lets staff know what interventions need to be implemented;
-When frequent resident checks are done, the staff should document those on a form kept at
the nursing station.
During an interview on 7/27/19 at 9:55 A.M., LPN D said all abuse should be reported.
He/She is not aware of any resident-to-resident altercations involving Resident #3 because
he/she does not work on the resident’s hall. He/She is familiar with Resident #3 and the
resident does have frequent verbal outbursts directed towards others.
During an interview on 7/27/18 at 2:49 P.M., the DON said she can only find one day of the
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 2)
30 minute check sheets related to Resident #3’s 5/19/18 incident.
3. Record review of Resident# 10’s face sheet showed the following information:
-admitted [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s significant change MDS dated [DATE] showed staff
documented the following:
-Moderately impaired cognition;
-No behaviors were present in the past seven days;
-Received an anti-depressant medication six of the previous seven days.
Record review of the resident’s care plan last updated 05/16/18, showed the following
information:
-Notify the charge nurse when the resident becomes agitated or combative;
-Report any change of behavior to the resident’s physician;
-Document behaviors every shift.
Record review of the physician progress notes [REDACTED].
-On 4/20/18, an Advanced Practice Registered Nurse (APRN) documented he/she saw the
resident for an evaluation of recent behaviors of trying to escape through the front door,
attempting to assault other residents and staff members;
-On 6/4/18, an Adult Gerontology Nurse Practitioner (AGNP) documented the resident had a
long history of [MEDICAL CONDITION] (extreme mood swings) manic (emotional highs)
behaviors with violent behaviors. The goal was to educate the resident to demonstrate
self-control and reduce impulsivity.
Record review of the residents’ nurse’s progress notes showed the following:
-On 7/10/18 at 4:54 P.M., a nurse documented the resident was readmitted from an
in-patient psychiatric hospital for dementia with behaviors:
-On 7/21/18, at 8:00 A.M., a nurse documented he/she heard the resident yelling and
observed him fall in the hall outside of his/her room door. The resident reported he/she
and his/her roommate had a fist fight. The nurse found water all over the resident’s room
floor and the room mate in the room. Staff moved Resident #10 to the room next door with a
different roommate. Staff notified the administrator, the physician, the nursing
supervisor, and the resident’s spouse.
Record review of the resident’s behavioral monitoring record dated 7/1/18 to 7/31/18
showed staff did not document the resident’s 7/21/18 behaviors or interventions.
During an interview on 7/23/18 at 3:17 P.M., LPN A said on Saturday, 7/21/18, there was an
altercation between Resident #10 and Resident #54. Resident #10 was temporarily moved to
another room with a new roommate. Resident #10 reported he/she and his/her roommate got in
a fist fight. Resident #10 had a recent inpatient stay in a psychiatric hospital because
of severe aggressiveness towards other residents and the staff. Resident #10 had a history
of [REDACTED]. Resident #10 does wander and probably went back into his/her previous room
by mistake.
During an interview on 7/24/18 at 2:47 P.M., Resident #10 said he/she and his room mate
(Resident #54) had an altercation on Saturday, 7/21/18. He/She did not like the fact the
roommate wore a pony tail, that is not the way it is done in the military. The resident
people don’t look like that in my army. Him/Her and his/her roommate started yelling and
cursing at each other. He/She walked over to the roommate and pushed and struck him on the
side of the head. The staff moved him/her to the room next door with another roommate
after the incident happened.
During an interview on 7/24/18 at 3:03 P.M., Resident #54 said the following:
-There was an altercation with his/her room mate (Resident #10) on 7/21/18;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
-He/She and Resident #10 began yelling and cursing at each other;
-Resident #10 hit him/her on the side of the head and knocked his/her hat off;
-Resident #10 spilled water on the floor during the altercation.
-Staff moved his/her roommate (Resident #10) out of his/her room;
-Resident #10 came back in the room a few times since then.
Observation on 7/25/2018 at 3:41 P.M., showed Resident #10 walking in the hallway asking
for assistance to find his/her room.
During an interview on 7/27/18 at 8:45 A.M., CNA B said the following:
-He/she considers resident-to-resident altercations to be abuse and should be reported
immediately;
-All observed or suspected abuse should be reported immediately to the charge nurse;-Staff
need to intervene and protect the residents;
-He/She is aware of the resident-to-resident altercation on Saturday 7/21/18, between
Resident #10 and Resident #54;
-Resident #10 reported him/her and Resident #54 were yelling and cursing at each other and
he/she hit Resident #54;
-The resident’s room had water all over the floor and staff had heard the yelling so they
knew there was an altercation;
-Resident #10 was taken to the room next door with another roommate after the incident;
-Resident #10 has had aggressive behaviors before and recently been in a behavior
hospital.
During an interview on 7/27/18 at 9:55 A.M., LPN D said he/she was the charge nurse
on-duty when the altercation between Resident #10 and Resident #54 happened. He/She heard
Resident #10 yelling loudly. He/She looked up and saw Resident #10 fall in the hall
outside his/her door. Resident #10 reported he/she and the roommate Resident #54 had been
in a fist fight. There was water all over the floor and Resident #54 reported the two
residents had got into it and Resident #10 hit him and knocked his hat off. Resident #10
was moved to the room next door with another roommate. He/she informed the facility
administration and he/she was not informed to do anything more.
During an interview on 7/27/18 at 10:29 A.M., the MDS Coordinator said resident’s who have
a history of resident-to-resident altercations should have the behavior identified on the
residents’ care plan. Staff should update the care plan with the information as soon as
staff are aware.
During an interview on 7/27/18 at 1:27 P.M., the DON said the following:
-The administrator investigates all resident-to-resident altercations;
-How the altercations are handled depended on the residents degree of confusion;
-The administrator contacts the state and it is the administrators call whether it is
called in;
-When a resident has an altercation with another resident the violator should be separated
to another area and staff try to deescalate the situation;
-Staff should stay with the violator and the other residents should be protected;
-She was unaware of an altercation involving Resident #10 and Resident # 54;
-She would expect staff to notify her of any resident-to-resident altercations;
-She does have some remembrance of an altercation involving Resident #3 that took place in
May, (YEAR);
-Resident #3 has a history of altercations with other residents. The altercations are
usually more verbal but Resident #3 has hit other residents before. If the incident was
investigated and called in, the administrator would have done the investigation. Staff
should have protected the other residents during the investigation.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0600

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 4)
During an interview on 7/27/18 at 3:55 P.M., the administrator said the following:
-All allegations of abuse should be called into the state no later than 2 hours from the
time of the incident;
-He expects staff to report all incidents of abuse to him immediately;
-All allegations of abuse should be investigated to include witness statements and
interviews to include other residents and the staff;
-He is responsible for contacting the state and completing the investigations;
-He came to the facility for the resident-to-resident altercations involving Resident #3
on (MONTH) 19. (YEAR), and for the the altercation involving Resident #10 on 7/21/18;
-Reported the incident to the state depends on the resident and their cognition, and if
the potential abuse was intentional;
-He investigated the incidents but did not feel the incidents were abusive so the
incidents were not called in;
-Resident # 3 has a history of physical altercations with other residents;
-He did tell staff to put Resident #3 on 30 minute checks at the time of the incident;
-He was aware Resident #10 has a history of aggression and the resident was in a
behavioral hospital recently but has been better since returning;
-The altercation between Resident #10 and Resident #54 took place after Resident #10
returned for the hospitalization ;
-He was aware of Resident #10 being moved into another room with another resident after
the altercation;
-No other interventions were put in place for either incident;
-Residents with potential for abusive behaviors should be identified on the resident’s
care plan.

F 0609

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Timely report suspected abuse, neglect, or theft and report the results of the
investigation to proper authorities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to report
allegations of abuse when two residents (Resident #3 and #10), with a history of
aggressive behavior towards other residents, struck other residents. The facility census
of 102.
1. Record review of the facility’s Abuse Prohibition Protocol, revised date of January,
(YEAR) showed the following information:
-It is the purpose of the facility to prohibit mistreatment, neglect, abuse,
misappropriation of property, and exploitation of any resident;
-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or
punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of
all residents, irrespectable of any mental or physical condition, cause physical harm,
pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and
mental anguish. Willful, as used in this definition of abuse , means the individual must
have acted deliberately, not that the individual must have intended to inflict injury or
harm;
-Physical abuse is defined as hitting, slapping, pinching, kicking, etc.;
-The administrator or designee must report to the State Survey Agency no later than 2
hours after the allegation is made if the event that caused the allegation involved abuse.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 – Some

(continued… from page 5)
2. Record review of Resident #3’s face sheet (a document that gives a resident’s
information at a quick glance) showed the following information:
-admitted [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS) a federally mandated
assessment instrument completed by facility staff, dated 04/03/18, showed the resident
exhibited verbal behaviors directed towards others for one to three days (out of the
previous seven days).
Record review of the resident’s care plan, dated 01/01/18 and last update 4/16/18, showed
direction for staff to do the following:
-Notify the charge nurse if the resident becomes agitated or combative;
-Document behaviors every shift;
-Psychological Services will continue to consult with the resident due to his/her
emotional and behavioral concerns;
-The goal is the resident will verbalize his/her feelings of anger and depression in an
appropriate manner rather than getting verbally upset and aggressive.
Record review of the resident’s behavior monitoring record showed staff documented the
following information:
-On 5/19/18, the resident exhibited a behavior of hitting;
-The intervention was redirection.
Record review of the residents’ progress notes showed the following information:
-On 5/19/18 at 2:10 P.M., a nurse documented the resident was sitting in the dining room
before lunch, became angry, threw a butter knife bouncing it off the table, hitting the
television and cracking the screen;
-On 5/19/18 at 7:00 P.M., a nurse documented another resident reported after a verbal
altercation in the smoking courtyard, Resident #3 propelled his/her wheel chair over to
the other resident and struck him/her on the right arm. The nurse reported the incident to
the administrator, Director of Nursing (DON), and left a message for the resident’s
physician and guardian. The nurse received instructions from the administrator to start 30
minute checks on Resident #3.
-On 5/20/18, staff observed the resident coming down the hall, cursing at other residents;
-On 6/0718 at 10:06 A.M., a nurse documented the resident had a verbal altercation yelling
at another resident. The staff intervened before physical actions were made. The physician
gave an order for [REDACTED].>-On 7/11/18 at 4:09 P.M., a nurse documented he/she
notified the nurse practitioner that social services had made multiple attempts for an
inpatient psychiatric evaluation and was unsuccessful. The physician order
[REDACTED].>Record review of the social service progress notes dated 5/22/18 at 1:51
P.M., showed the residents’ behaviors were worsening. The resident had been cussing at
other residents, calling them inappropriate names and also became physically aggressive
with another resident.
During an interview on 7/25/18 at 10:45 A.M., Resident #3 said he/she has had physical
altercations with other residents. He/she got mad at his/her roommate and hit the roommate
in the back. He/she also hit another resident in the arm. Staff were aware of both times
incidences and staff didn’t do anything about it.
During an interview on 7/27/18 at 9:43 A.M., CNA C said the following:
-All types of abuse should be reported immediately to the charge nurse and to
administration;
-Resident-to-resident altercations are abuse and need to be reported to the charge nurse
and other residents need to be protected;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 – Some

(continued… from page 6)
-He/She was aware of Resident #3 hitting another resident but is unsure who the other
resident was;
-Resident #3 has a history of physical altercations, and it is not the first time Resident
#3 hit another resident;
-Resident #3 is frequently verbally abusive;
-The charge nurse lets staff know what interventions need to be implemented;
During an interview on 7/27/19 at 9:55 A.M., LPN D said all abuse should be reported.
He/She is familiar with Resident #3 and the resident does have frequent verbal outbursts
directed towards others.
Review of the Department of Health and Senior Services (DHSS) record did not show staff
notified DHSS of the resident-to-resident abusive incidents.
3. Record review of Resident# 10’s face sheet showed the following information:
-admitted [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s significant change MDS dated [DATE] showed staff
documented the following:
-Moderately impaired cognition;
-No behaviors were present in the past seven days.
Record review of the resident’s care plan last updated 05/16/18, showed the following
information:
-Notify the charge nurse when the resident becomes agitated or combative;
-Report any change of behavior to the resident’s physician;
-Document behaviors every shift.
Record review of the physician progress notes [REDACTED].
-On 4/20/18, an Advanced Practice Registered Nurse (APRN) documented he/she saw the
resident for an evaluation of recent behaviors of trying to escape through the front door,
attempting to assault other residents and staff members;
-On 6/4/18, an Adult Gerontology Nurse Practitioner (AGNP) documented the resident had a
long history of [MEDICAL CONDITION] (extreme mood swings) manic (emotional highs)
behaviors with violent behaviors.
Record review of the residents’ nurse’s progress notes showed the following:
-On 7/10/18 at 4:54 P.M., a nurse documented the resident was readmitted from an
in-patient psychiatric hospital for dementia with behaviors:
-On 7/21/18, at 8:00 A.M., a nurse documented he/she heard the resident yelling. The
resident reported he/she and his/her roommate had a fist fight. Staff moved Resident #10
to the room next door with a different roommate. Staff notified the administrator, the
physician, the nursing supervisor, and the resident’s spouse.
During an interview on 7/23/18 at 3:17 P.M., LPN A said on Saturday, 7/21/18, there was an
altercation between Resident #10 and Resident #54. Resident #10 was temporarily moved to
another room with a new roommate. Resident #10 reported he/she and his/her roommate got in
a fist fight. Resident #10 had a recent inpatient stay in a psychiatric hospital because
of severe aggressiveness towards other residents and the staff. Resident #10 had a history
of [REDACTED]. Resident #10 does wander and probably went back into his/her previous room
by mistake.
During an interview on 7/24/18 at 2:47 P.M., Resident #10 said he/she and his room mate
(Resident #54) had an altercation on Saturday, 7/21/18. He/She and his/her roommate
started yelling and cursing at each other. He/She walked over to the roommate and pushed
and struck the roommate. The staff moved him/her to the room next door with another
roommate after the incident happened.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 – Some

(continued… from page 7)
During an interview on 7/24/18 at 3:03 P.M., Resident #54 said the following:
-There was an altercation with his/her room mate (Resident #10) on 7/21/18;
-Resident #10 and he/she began yelling and cursing at each other;
-Resident #10 hit him/her on the side of the head and knocked his/her hat off.
During an interview on 7/27/18 at 8:45 A.M., CNA B said the following:
-He/she considers resident-to-resident altercations to be abuse and should be reported
immediately;
-All observed or suspected abuse should be reported immediately to the charge nurse;-Staff
need to intervene and protect the residents;
-He/She is aware of the resident-to-resident altercation on Saturday 7/21/18, between
Resident #10 and Resident #54;
-Resident #10 reported him/her and Resident #54 were yelling and cursing at each other and
he/she hit Resident #54;
-Resident #10 has had aggressive behaviors before and recently been in a behavior
hospital.
During an interview on 7/27/18 at 9:55 A.M., LPN D said he/she was the charge nurse
on-duty when the altercation between Resident #10 and Resident #54 happened. He/She heard
Resident #10 yelling loudly. He/She looked up and saw Resident #10 fall in the hall
outside his/her door. Resident #10 reported he/she and the roommate Resident #54 had been
in a fist fight. Resident #54 reported the two residents had got into it and Resident #10
hit him and knocked his hat off. He/she informed the facility administration and he/she
was not informed to do anything more.
During an interview on 7/27/18 at 1:27 P.M., the DON said the following:
-The administrator investigates all resident-to-resident altercations;
-How the altercations are handled depended on the resident’s degree of confusion;
-The administrator contacts DHSS and it is the administrators call whether it is called
in;
-She was unaware of an altercation involving Resident #10 and Resident # 54;
-She would expect staff to notify her of any resident-to-resident altercations;
-She does have some remembrance of an altercation involving Resident #3 that took place in
May, (YEAR);
-Resident #3 has a history of altercations with other residents. The altercations are
usually more verbal but Resident #3 has hit other residents before. If the incident was
investigated and called in, the administrator would have done the investigation.
During an interview on 7/27/18 at 3:55 P.M., the administrator said the following:
-All allegations of abuse should be called into the state no later than 2 hours from the
time of the incident;
-He expects staff to report all incidents of abuse to him immediately;
-All allegations of abuse should be investigated to include witness statements and
interviews to include other residents and the staff;
-He is responsible for contacting DHSS and completing the investigations;
-He came to the facility for the resident-to-resident altercations involving Resident #3
on (MONTH) 19. (YEAR), and for the the altercation involving Resident #10 on 7/21/18;
-Reporting the incident to DHSS depends on the resident and their cognition, and if the
potential abuse was intentional;
-He investigated the incidents but did not feel the incidents were abusive so the
incidents were not called in;
-Resident # 3 has a history of physical altercations with other residents;
-The altercation between Resident #10 and Resident #54 took place after Resident #10
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 – Some

(continued… from page 8)
returned for the hospitalization .

F 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Respond appropriately to all alleged violations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to complete a
thorough investigations regarding resident-to-resident allegations of abuse when two
residents (Resident #3 and #10) with a history of aggression behavior, struck other
residents. The facility census was 102.
1. Record review of the facility’s Abuse Prohibition Protocol, revised date of January,
(YEAR) showed the following information:
-It is the purpose of the facility to prohibit mistreatment, neglect, abuse,
misappropriation of property, and exploitation of any resident;
-Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or
punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of
all residents, irrespectable of any mental or physical condition, cause physical harm,
pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and
mental anguish. Willful, as used in this definition of abuse, means the individual must
have acted deliberately, not that the individual must have intended to inflict injury or
harm;
-Physical abuse is defined as hitting, slapping, pinching, kicking, etc.
2. Record review of Resident #3’s face sheet (a document that gives a resident’s
information at a quick glance) showed the following information:
-admitted [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s quarterly Minimum Data Set (MDS) a federally mandated
assessment instrument completed by facility staff, dated 04/03/18, showed the resident
exhibited verbal behaviors directed towards others for one to three days (out of the
previous seven days.
Record review of the resident’s care plan, updated on 4/16/18, showed direction for staff
to do the following:
-Notify the charge nurse if the resident becomes agitated or combative;
-Document behaviors every shift;
-Psychological Services will continue to consult with the resident due to his/her
emotional and behavioral concerns.
Record review of the resident’s behavior monitoring record dated 5/19/18 showed staff
documented the resident exhibited a behavior of hitting. The intervention was redirection.
Record review of the residents’ progress notes showed the following information:
-On 5/19/18 at 2:10 P.M., a nurse documented the resident was sitting in the dining room
before lunch, became angry, threw a butter knife bouncing it off the table, hitting the
television and cracking the screen;
-On 5/19/18 at 7:00 P.M., a nurse documented another resident reported after a verbal
altercation in the smoking courtyard, Resident #3 propelled his/her wheel chair over to
the other resident and struck him/her on the right arm. The nurse reported the incident to
the administrator, Director of Nursing (DON), and left a message for the resident’s
physician and guardian. The nurse received instructions from the administrator to start 30
minute checks on Resident #3.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 9)
Record review of the facility investigation report for an allegation of abuse on 5/19/18
involving Resident #3 showed the following:
-An unusual occurrence investigation report with names of two resident witnesses;
-Staff noted no abuse on the resident abuse report summary and to monitor and redirect the
resident;
-A copy of the resident’s physician order [REDACTED].
-A copy of nurse’s notes documenting the abuse incident;
-The report did not include witness interviews;
-The report did not include staff interviews;
-The report did not include the residents’ assessment’s.
Record review of the residents’ progress notes dated 5/20/18, showed staff observed the
resident coming down the hall, cursing at other residents.
Record review of the social service progress notes dated 5/22/18 at 1:51 P.M., showed the
residents’ behaviors were worsening. The resident had been cussing at other residents,
calling them inappropriate names and also became physically aggressive with another
resident.
Record review of the residents’ progress notes showed the following information:
-On 6/0718 at 10:06 A.M., a nurse documented the resident had a verbal altercation yelling
at another resident. The staff intervened before physical actions were made. The physician
gave an order for [REDACTED].>-On 7/11/18 at 4:09 P.M., a nurse documented he/she
notified the nurse practitioner that social services had made multiple attempts for an
inpatient psychiatric evaluation and was unsuccessful. The physician order
[REDACTED].>Record review of the residents’ physician’s monthly progress notes dated
1/15/18 through 7/17/18 showed the physician documented the resident had no new behaviors.
During an interview on 7/25/18 at 10:45 A.M., Resident #3 said he/she has had physical
altercations with other residents. He/she got mad at his/her roommate and hit the roommate
in the back. He/she also hit another resident in the arm. Staff were aware of both
incidences and staff didn’t do anything about it.
During an interview on 7/27/18 at 9:43 A.M., CNA C said the following:
-Resident-to-resident altercations are abuse and need to be reported to the charge nurse
and other residents need to be protected;
-He/She was aware of Resident #3 hitting another resident but is unsure who the other
resident was;
-Resident #3 has a history of physical altercations, and it is not the first time Resident
#3 hit another resident;
-Resident #3 is frequently verbally abusive;
-The charge nurse lets staff know what interventions need to be implemented.
During an interview on 7/27/19 at 9:55 A.M., LPN D said all abuse should be reported.
He/She is familiar with Resident #3 and the resident does have frequent verbal outbursts
directed towards others.
3. Record review of Resident# 10’s face sheet showed the following information:
-admitted [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s significant change MDS dated [DATE] showed staff
documented the following:
-Moderately impaired cognition;
-No behaviors were present in the past seven days;
-Received an anti-depressant medication six of the previous seven days.
Record review of the resident’s care plan last updated 05/16/18, showed the following
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 10)
information:
-Notify the charge nurse when the resident becomes agitated or combative;
-Report any change of behavior to the resident’s physician;
-Document behaviors every shift.
Record review of the resident’s physician progress notes [REDACTED].
-On 4/20/18, an Advanced Practice Registered Nurse (APRN) documented he/she saw the
resident for an evaluation of recent behaviors of trying to escape through the front door,
attempting to assault other residents and staff members;
-On 6/4/18, an Adult Gerontology Nurse Practitioner (AGNP) documented the resident had a
long history of [MEDICAL CONDITION] (extreme mood swings) manic (emotional highs)
behaviors with violent behaviors. The goal was to educate the resident to demonstrate
self-control and reduce impulsivity.
Record review of the residents’ nurse’s progress notes showed the following information:
-On 7/10/18 at 4:54 P.M., a nurse documents the resident was readmitted from an in-patient
psychiatric hospital for skilled dementia with behaviors:
-On 7/21/18 a nurse documents at 8:00 A.M., he/she heard the resident yelling and observed
him fall in the hall outside of door to room. The resident states he/she and their room
mate had a fist fight. The nurse entered the room to find water allover the floor and the
room mate in room. Resident #10 was moved to room next door with another room mate. The
administrator , physician, nursing supervisor, and spouse were notified.
Record review of the resident’s behavioral monitoring record dated July, (YEAR), showed
staff did not document behaviors or interventions on 7/21/18.
Record review of the facility investigation report for an allegation of abuse on 7/21/18
involving Resident #10 showed the following:
-An unusual occurrence investigation report with names of two resident witnesses;
-Staff noted no abuse on the resident abuse report summary and to monitor and redirect the
resident;
-A copy of the resident’s physician order [REDACTED].
-A copy of nurse’s notes documenting the abuse incident;
-The report did not include witness interviews;
-The report did not include staff interviews;
-The report did not include the residents’ assessment’s.
During an interview on 7/23/18 at 3:17 P.M., LPN A said on Saturday, 7/21/18, there was an
altercation between Resident #10 and Resident #54. Resident #10 was temporarily moved to
another room with a new roommate. Resident #10 reported he/she and his/her roommate got in
a fist fight. Resident #10 had a recent inpatient stay in a psychiatric hospital because
of severe aggressiveness towards other residents and the staff. Resident #10 had a history
of [REDACTED]. Resident #10 does wander and probably went back into his/her previous room
by mistake.
During an interview on 7/24/18 at 2:47 P.M., Resident #10 said he/she and his room mate
(Resident #54) had an altercation on Saturday, 7/21/18. He/She did not like the fact the
roommate wore a pony tail, that is not the way it is done in the military. The resident
people don’t look like that in my army. Him/Her and his/her roommate started yelling and
cursing at each other. He/She walked over to the roommate and pushed and struck him on the
side of the head. The staff moved him/her to the room next door with another roommate
after the incident happened.
During an interview on 7/24/18 at 3:03 P.M., Resident #54 said the following:
-There was an altercation with his/her room mate (Resident #10) on 7/21/18;
-Resident #10 and he/she began yelling and cursing at each other;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
-Resident #10 hit him/her on the side of the head and knocked his/her hat off;
-Resident #10 spilled water on the floor during the altercation.
-The staff moved the roommate out of his/her room;
-Resident #10 came back in the room a few times since then.
During an interview on 7/27/18 at 8:45 A.M., CNA B said the following:
-He/She considers resident-to-resident altercations to be abuse and should be reported
immediately;
-Staff need to intervene and protect the residents;
-He/She is aware of the resident-to-resident altercation on Saturday 7/21/18, between
Resident #10 and Resident #54;
-Resident #10 reported him/her and Resident #54 were yelling and cursing at each other and
he/she hit Resident #54;
-Resident #10 was taken to the room next door with another roommate after the incident;
-Resident #10 has had aggressive behaviors before and recently been in a behavior
hospital.
During an interview on 7/27/18 at 9:55 A.M., LPN D said he/she was the charge nurse
on-duty when the altercation between Resident #10 and Resident #54 happened. He/She heard
Resident #10 yelling loudly. Resident #10 reported he/she and the roommate Resident #54
had been in a fist fight. Resident #54 reported the two residents had got into it and
Resident #10 hit him and knocked his hat off. Resident #10 was moved to the room next door
with another roommate. He/She informed the facility administration and he/she was not
informed to do anything more.
During an interview on 7/27/18 at 1:27 P.M., the DON said the following:
-The administrator investigates all resident-to-resident altercations;
-How the altercations are handled depended on the residents degree of confusion;
-When a resident has an altercation with another resident the violator should be separated
to another area and staff try to deescalate the situation;
-Staff should stay with the violator and the other residents should be protected;
-She was unaware of an altercation involving Resident #10 and Resident # 54;
-She would expect staff to notify her of any resident-to-resident altercations;
-She does have some remembrance of an altercation involving Resident #3 that took place in
May, (YEAR);
-Resident #3 has a history of altercations with other residents. The altercations are
usually more verbal but Resident #3 has hit other residents before. If the incident was
investigated and called in, the administrator would have done the investigation. Staff
should have protected the other residents during the investigation.
During an interview on 7/27/18 at 3:55 P.M., the administrator said the following:
-All allegations of abuse should be investigated to include witness statements and
interviews to include other residents and the staff;
-He is responsible for contacting the state and completing the investigations;
-He came to the facility for the resident-to-resident altercations involving Resident #3
on (MONTH) 19. (YEAR), and for the the altercation involving Resident #10 on 7/21/18;
-He investigated the incidents but did not feel the incidents were abusive;
-Resident #3 has a history of physical altercations with other residents;
-He did tell staff to put Resident #3 on 30 minute checks at the time of the incident;
-He was aware Resident #10 has a history of aggression and the resident was in a
behavioral hospital recently but has been better since returning;
-The altercation between Resident #10 and Resident #54 took place after Resident #10
returned for the hospitalization ;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0610

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
-He was aware of Resident #10 being moved into another room with another resident after
the altercation;
-No other interventions were put in place for either incident.

F 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide enough food/fluids to maintain a resident’s health.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, and interview, the facility failed to maintain
accurately and fully care plan the eating habits and nutritional interventions in place;
failed to complete weights as ordered; and failed to provide monitoring and cueing to eat
for one resident (Resident #10) who was identified as a weight loss risk. A sample of 21
residents was selected for review in a facility with a census of 102.
Record review of the facility’s Nutritional and Dining Services, dated (MONTH) 2011,
showed the following information:
-The individual conation of each resident at nutritional risk must be considered when
instituting nutritional interventions;
-Continued refusal of meals is to be communicated to the dietary manager.
1. Record review of Resident# 10’s face sheet showed the following information:
-admitted [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s weight record showed staff documented an admission weight
of 154 pounds on 3/12/18.
Record review of the resident’s significant change Minimum Data Set (MDS – a federally
mandated assessment completed by facility staff), dated 4/9/18, showed the following
information:
-Moderately impaired cognition;
-Requires set up assistance with meals;
-Requires supervision, oversight, encouragement, and cueing for eating;
-Weight 149 pounds;
-No weight loss of 5% of more in past month;
-No presence of mood problems.
Record review of the resident’s physician order [REDACTED].
-Regular diet ordered 7/10/18;
-Fortified foods ordered 7/10/18;
-Ice cream with lunch and supper ordered 7/10/18;
-Weekly weights times four weeks ordered 7/10/18;
-[MEDICATION NAME] (a drug to stimulate appetite) 100 milligrams two times daily.
Record review of the resident’s nutritional care plan, dated 07/11/18, showed the
following information:
-Eats most meals in the main dining room;
-Staff to encourage oral intake and fluids;
-Interventions will be initiated as needed for adequate nutrition;
-Monitor and record intake of food.
(The care plan did not address what specific interventions were in place.)
Record review of the resident’s medical record showed the following information:
-Weight meeting with Director of Nursing (DON) and dietary manager on 7/20/18;
-Occasionally comes to the main dinning room for meals;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 13)
-Current weight 140 pounds, previous weight 148 pounds;
-Resumed fortified foods and ice cream with lunch and supper on readmit 7/10/18 from
psychiatric stay;
-Weekly weights in place.
Record review of the resident’s weight record showed the following information:
-Staff did not record weights 7/10/18 to 7/22/18;
-Weight 137 pounds on 7/23/18.
Observations at the following time and dates showed the following information:
-On 7/24/18 at 8:32 A.M., the resident in bed with his/her eyes closed. The resident’s
room was dark. A breakfast tray was untouched on the bedside table. The resident was thin
with loose fitting clothing;
-On 7/26/18 at 8:28 A.M., resident in bed with eyes closed. A breakfast tray was on
bedside table. The plate cover was covering plate and bowls were covered with foil wrap;
-On 7/26/18 at 12:12 P.M., resident in bed, covered up with blanket and eyes closed. The
residents’ lunch tray sat on bedside table with cover in place over the meal. No light was
on in the room and the shades were pulled down on the window;
-On 7/27/18 at 8:20 A.M., resident in bed with eyes closed. A breakfast tray sat on the
bedside table still covered and untouched. The room was dark and no staff was in room.
During an interview on 7/27/18 at 8:45 A.M., Certified Nurse Aide (CNA) B said the nurses
let the staff know who is at risk for nutrition and weight loss and what interventions are
needed. He/she said the resident usually eats in his/her room and has not been eating
well. Staff need to wake him/her up frequently to get him/her to eat. He/she is not aware
if the residents is receiving any supplements.
During an interview on 7/27/18, at 9:55 A.M., Licensed Practical Nurse (LPN) D said the
resident required a lot of assistance with activities of daily living (dressing, grooming,
bathing, eating, and toileting). He/She said the resident sleeps a lot and staff need to
encourage him/her with meals. He/she said the resident is not eating much. He/she is not
aware if the resident receives any supplements related to poor nutrition. He/She said
staff should cue, encourage, and offer an alternate if the resident is not eating.
During an interview on 7/27/18, at 10:29 A.M., the MDS Coordinator said all residents at
risk for weight loss should have interventions and assistance needed documented on the
care plan. She said she reviews the weekly weight meeting notes and adds any interventions
identified to the care plan. She said she does not review each week, but reviews when the
resident’s comprehensive assessment is due.
During an interview on 7/27/18, at 10:37 A.M., the Dietary Manger (DM) said all residents
at risk for nutrition are discussed in a weekly weight meeting with the DON and the DM.
She said they decide at the meeting the approaches to be started for the resident. She
said the resident has had a significant weight loss. She has not observed the resident eat
as he most always eats in his/her room. She said the care plan should address the amount
of assistance needed for the resident. She said fortified foods and ice cream would not be
appropriate interventions if the resident is not eating. She said the resident should be
reassessed.
During an interview on 7/27/18, at 1:27 P.M., the DON said if a resident is not eating she
would expect the staff to encourage and assist the resident. She said she would expect
staff to monitor the residents during meal times that eat in their room. She said she
would expect the charge nurse to follow up visually to assure residents are being assisted
as needed.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0692

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

F 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide safe and appropriate respiratory care for a resident when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
respiratory care in accordance with professional standards of practice when facility staff
administered oxygen to one resident (Resident #18) without a physician’s orders
[REDACTED].
Record review of facility’s policy titled Oxygen Administration, dated (MONTH) (YEAR),
showed the following:
-Check physician’s orders [REDACTED].
-Set the flow meter to the rate ordered by the physician.
1. Record review of Resident #18’s face sheet (admission information) showed the
following:
-admitted on [DATE];
-[DIAGNOSES REDACTED].
Record review of the resident’s care plan, with a start date of 3/19/18, showed the
following:
-The resident had anxiety, pain, and ineffective airway clearance due to acute sinusitis;
-Staff to assess resident’s nasal congestion.
Record review of the resident’s nurse’s note dated 4/12/18, at 4:39 P.M., showed staff
asked resident if he/she had shortness of breath, resident reported he/she was short of
breath and had just removed his/her oxygen. This nurse feels this to be an untrue
statement, that he/she was not on his/her oxygen. All lung fields clear of crackles,
wheezes with strong breath sounds heard. Oxygen saturation 97% (normal adult saturation is
90-100%).
Record review of the resident’s hospital discharge summary, dated 4/17/18, showed
discharge instructions pertaining to respiratory system as room air.
Record review of the resident’s significant change Minimum Data Set (MDS – a federally
mandated assessment tool completed by facility staff), dated 4/26/18, showed the
following:
-No cognitive impairment;
-No respiratory treatment in the last 14 days.
Record review of the resident’s nurse’s note dated 4/30/18, at 5:21 P.M., shows staff
noted a new piece arrived for bi-pap to allow use of oxygen while in place, assisted
resident in connecting oxygen hose to the new bi-pap attachment on mask.
Record review of resident’s (MONTH) (YEAR) Physician order [REDACTED].
-ProAir HFA ([MEDICATION NAME] sulfate – a medication used to treat asthma and shortness
of breath) aerosol inhaler for shortness of breath.
(The POS did not include an order for [REDACTED].>During an interview and observation
on 7/23/18, at 11:47 A.M., the resident had oxygen nasal cannula in place receiving two
liters of oxygen per minute. The oxygen tubing was marked with a date of 7/8. The resident
said he/she uses oxygen during the day and a bi-pap machine during the night, except for
the last few nights, as the mask was broken.
Observation on 07/26/18, at 8:42 A.M., showed the resident with nasal cannula in place
with a portable oxygen tank on his/her electric wheelchair.
During an interview on 7/26/18, at 8:51 A.M., the resident said he/she had used a bi-pap
only, then about three months ago he/she was hospitalized and oxygen was started at the
hospital. He/she was ordered oxygen during waking hours and bi-pap while sleeping. The
facility nursing staff explained the orders when he/she returned to the facility.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0695

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
During an observation on 7/26/18, at 8:51 A.M., showed resident’s oxygen concentrator set
at 2 liter per minute and nasal cannula in place.
During an interview on 7/26/18, at 11:59 A.M., Certified Medication Technician (CMT) N
said the facility usually has a physician order [REDACTED]. The physician determines the
amount of oxygen and a nurse sets that amount on the oxygen concentrator. Nurses are
responsible for cleaning filters and tubing is changed by nurses weekly.
During an interview on 7/26/18, at 12:05 P.M., Licensed Practical Nurse (LPN) O said
nurses are responsible for setting the oxygen flow and nurses change the oxygen
concentrator tubing weekly. A physician orders [REDACTED]. A physician order [REDACTED].
If oxygen is ordered during a hospital stay, it should be on the transfer orders.
During an interview on 7/27/18, at 11:10 A.M., the Director of Nurses (DON) said the
charge nurses monitor the oxygen equipment by cleaning and changing tubing once per week.
The physician order [REDACTED]. A physician order [REDACTED]. The resident did not have an
order for [REDACTED].
During an interview on 7/27/18, at 1:46 P.M., the administrator said he would expect a
physician order [REDACTED]. Administrator said staff told him that somehow that was missed
for the resident.

F 0732

Level of harm – Potential for minimal harm

Residents Affected – Many

Post nurse staffing information every day.

Based on observation and interview, the facility failed to post the required nurse
staffing in a prominent place readily accessible to residents and visitors on a daily
basis. The facility census was 102.
1. Observations made in the facility on 7/23/18, at 10:12 A.M., showed the facility staff
did not post the nurse staffing in a prominent place readily visible and accessible to
residents and visitors.
Observations made on 7/24/18, at 9:06 A.M., showed the facility staff did not post the
nurse staffing in a prominent place readily visible and accessible to residents and
visitors.
Observations made on 7/26/18, at 11:48 A.M., showed the facility staff did not post the
nurse staffing in a prominent place readily visible and accessible to residents and
visitors.
Observations made on 7/27/18, at 2:25 P.M., showed the facility staff did not post the
nurse staffing in a prominent place readily visible and accessible to residents and
visitors.
During an interview on 7/27/18, at 2:30 P.M., Licensed Practical Nurse (LPN) E said that
the nurse staffing sheet has been kept at the nurses’ desk for review by staff.
During an interview on 7/27/18, at 2:45 P.M., LPN F said that the nurse staffing sheet is
kept on a clipboard at the nurses’ desk.
During an interview on 7/27/18, at 3:35 P.M., the administrator and Director of Nursing
(DON) said that nurse staffing information used to be posted at wall in the front part of
the building. However, during a renovation process several months ago the list was taken
down and not replaced. Currently the nurse staffing information is posted at nurse
station, by the computer (behind the counter), and not currently posted where residents or
visitors could observe the staffing. The Administrator and the DON said they were aware
that nurse staffing should be posted in a readily visible area, accessible to residents

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0732

Level of harm – Potential for minimal harm

Residents Affected – Many

(continued… from page 16)
and visitors.

F 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

Procure food from sources approved or considered satisfactory and store, prepare,
distribute and serve food in accordance with professional standards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure food was
stored and served in accordance with professional standards for food safety when undated,
unsealed, and expired food was kept in refrigerators and freezers; staff did not
consistently monitor the temperature of all refrigerators and freezers; and staff served
food on wet dishes. This could lead to contamination of food and food borne illness
potentially affecting all residents. The facility had a census of 102.
1. Record review of the Missouri Food Code, published 2013, showed the following:
-Refrigerated, potentially hazardous food prepared and held for more than 24 hours shall
be clearly marked to indicate the date or day by which the food shall be consumed on the
premises or discarded when held at a temperature of forty-one degrees Fahrenheit (41
degrees F) or less for a maximum of seven days or when held at a temperature of forty-five
degrees Fahrenheit (45 degrees F) or less for a maximum of four days.
Observations on [DATE], at 9:45 A.M., of the walk-in cooler and unit #1 freezer showed the
following:
-Unsealed and undated boiled eggs;
-Undated waffles in two plastic bags;
-Unsealed and undated white sliced cheese;
-Unsealed and undated partially dried out yellow sliced cheese;
-Unsealed and undated sliced ham in plastic bag;
-Unsealed and undated sliced lunch meat and sliced turkey; and
-Unsealed hash browns.
Observations on [DATE], at 12:00 P.M., of the C-Wing assisted dining room
refrigerator/freezer, showed:
-Five undated glasses of milk;
-Two cups of unlabeled and undated, partially consumed, cups of juice;
-Three undated cups of pudding; and
-A bowl of unsealed and undated sliced pears.
Observations on [DATE], at 3:15 P.M., of the B-Wing assisted dining room
refrigerator/freezer showed:
-A cup of undated juice;
-Three cups of unsealed and undated fruit cocktail;
-A bowl of unsealed and undated pudding; and
-An undated and unsealed bag of grated cheese marked with a resident name, with
manufacturer use by date of [DATE].
During an interview on [DATE], at 3:40 P.M., Certified Nursing Assistant (CNA) J said
housekeeping staff monitors for expired food and cleans Special Care Unit refrigerator.
During an interview on [DATE], at 8:39 A.M., CNA K said housekeeping staff cleans the
refrigerator/freezers in the assisted dining rooms.
During an interview on [DATE], at 8:48 A.M., Housekeeper (HSKP) L said maintenance staff
monitors for expired food and cleans the refrigerators in the assisted dining rooms and
the Special Care Unit.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 17)
Observations on [DATE], at 11:20 A.M., of walk-in freezer showed two unsealed pans of
lasagna.
During an interview on [DATE], at 4:00 P.M., the Housekeeping Supervisor said housekeeping
staff cleans the refrigerators in the assisted dining areas and Special Care Unit. Nursing
and dietary staff date leftover food and monitors for expired food. Dietary staff marks
foods, such as covered puddings and applesauce, with the date it was prepared. Nursing
staff label food brought in for residents.
During an interviews on [DATE], at 11:20 A.M., and [DATE], at 1:27 P.M., the Dietary
Manager (DM) said dietary staff checks all refrigerators daily, or two to three times per
week, for out of date food. Nursing staff dates and seals food in assisted dining rooms
and Special Care Unit. Leftover food is dated when stored and thrown out within three
days. She expects all food stored in sealed containers or packaging. Lunch meat and cheese
should be dated with date the package is opened. Lunch meat stored should be thrown out
within 6 days of opening.
Observations on [DATE], at 11:00 A.M., of the B-Wing assisted dining room refrigerator
showed 12 covered, undated, cups of fruit cocktail.
During an interview on [DATE] at 11:20 A.M., Director of Nursing, (DON) said nursing staff
is responsible for dating food stored in the assisted dining room refrigerators and
Special Care Unit. She would expect them to date and seal any food stored in the
refrigerators. Dietary staff checks for food that is expired.
During an interview on [DATE], at 1:46 P.M., the administrator said he expects that all
food, not eaten at a meal, would be dated and stored properly.
2. Record review of the facility’s policy titled Refrigerator and Freezer Temperatures,
dated (MONTH) 2011, showed the following:
-Temperature of refrigerators should be 33 to 40 degrees F;
-There should be a thermometer in all refrigerator and freezers. Thermometers should be
located in the front of the unit;
-Temperatures should be checked regularly in all refrigerators, at least every morning and
every night;
-Refrigerator and freezer temperatures will be logged twice daily.
Record review of the (MONTH) Daily Refrigerator Temperature Log for the kitchen walk-in
cooler showed staff did not document temperatures for [DATE], [DATE], [DATE], [DATE],
[DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].
Record review of the (MONTH) Daily Refrigerator Temperature Log for C-Wing
refrigerator/freezer showed staff did not document temperatures for the refrigerator
section on [DATE], [DATE], [DATE], and [DATE], and did not document temperatures for the
freezer section.
Record review of the (MONTH) Daily Refrigerator Temperature Log for B-Wing
refrigerator/freezer showed staff did not document temperatures for refrigerator section
on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], and did not document temperatures
for the freezer section.
Record review of the (MONTH) Daily Refrigerator Temperature Log for Special Care Unit
showed staff did not document temperatures for [DATE], [DATE], [DATE], [DATE] through
[DATE], [DATE], [DATE], [DATE], and [DATE].
Observations on [DATE], at 12:00 P.M., of the C-Wing assisted dining room
refrigerator/freezer showed no thermometer in the freezer section.
Observation on [DATE], at 3:15 P.M., of the B-Wing assisted dining room
refrigerator/freezer showed no internal thermometer in the refrigerator or freezer
sections.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0812

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Many

(continued… from page 18)
During an interview on [DATE], at 3:40 P.M., CNA J said dietary staff logs the
temperatures of refrigerator/freezers.
During an interview on [DATE], at 8:39 A.M., CNA K said nursing staff monitors
refrigerator temperatures.
Observation on [DATE], at 11:20 A.M., of the walk-in freezer showed no internal
thermometer.
During an interview on [DATE], at 4:00 P.M., the Housekeeping Supervisor said he/she
receives the temperature logs. There has not been an issue with freezer temperatures so
there has not been thermometers placed in the freezer sections. She expects staff to log
temperatures using internal thermometers.
During an interviews on [DATE], at 11:20 A.M. and [DATE] at 1:27 P.M., the Dietary Manager
(DM) said staff use internal thermometers to log refrigerator and freezer temperatures.
The DM receives kitchen temperature logs. The housekeeping supervisor receives temperature
logs for refrigerators in assisted dining rooms and the Special Care Unit. Temperatures
should be checked daily for refrigerators and freezers. She expects a thermometer in each
kitchen refrigerator and freezer and expects temperatures logged twice a day.
During an interview on [DATE], at 1:46 P.M., the administrator said every refrigerator and
freezer should have a thermometer and temperatures logged daily.
3. Record review of the facility’s policy titled Dishwashing, dated (MONTH) 2011, showed
the following:
-Allow items to thoroughly dry before unloading racks or storing items.
Observations on [DATE], at 11:55 A.M., of the C-Wing assisted dining room showed staff
served beverages to residents from wet glasses and from coffee cups on a tray with
standing water.
Observations on [DATE], at 11:10 A.M., of the main dining room, by the coffee and beverage
dispenser, showed wet glasses and coffee cups.
Observation of a hall cart in the kitchen serving area on [DATE], at 11:35 A.M., showed
water standing on tray of coffee cups turned upside down on tray.
During an interview on [DATE], at 11:35 A.M., Dietary Aide (DA) M said dishes are dried in
the dishwashing area before using them for food or beverages.
During an interviews on [DATE], at 11:20 A.M., and [DATE], at 1:27 P.M., the Dietary
Manager (DM) said dishes are dried on shelves next to dishwasher until dry. Beverages and
food should not be served on wet dishes.
During an interview on [DATE], at 1:46 P.M., the administrator said he expected dishes to
be dry before residents are served from them.

F 0919

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Make sure that a working call system is available in each resident’s bathroom and
bathing area.

Based on observation and interview, the facility failed to provide a switch in all toilet
rooms which would activate the resident call light system when activated by omitting the
switches in two toilet rooms located near the front entrance and one toilet room located
near the A wing nurses desk. The facility had a census of 102.
1. Observations on 7/24/18, at 11:00 A.M., showed the following:
-The two public toilet room located near the dining room remained without a call light
activation switch.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/31/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265123

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

NAME OF PROVIDER OF SUPPLIER

LEBANON NORTH NURSING & REHAB

STREET ADDRESS, CITY, STATE, ZIP

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 0919

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
-The toilet room located near the A wing nurses’ desk remained without a call light
activation switch.
During an interview on 7/24/18, at 4:30 P.M., the administrator said they had added some
call light switches to toilet rooms, but missed those three rooms.