Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lebanon South Nursing & Rehab during CMS and state inspections, most recent first.
A CNA lay in bed next to a cognitively impaired hospice resident with Alzheimer’s disease and generalized anxiety disorder, who was dependent for all ADLs, while the resident was sleeping, placing an arm around the resident in a hugging manner to try to wake the resident for a meal. Facility policies state residents must be treated with respect and dignity and afforded privacy in care. A photograph and staff interviews confirmed the CNA’s actions, and multiple staff, including CNAs, a CMT, an LPN, an RN, the DON, and the Administrator, stated that it is inappropriate for staff to lie on a resident’s bed, especially when the resident cannot communicate.
The facility failed to follow its grievance policy by not documenting, tracking, or resolving multiple grievances voiced over several resident council meetings, including repeated concerns about unanswered call lights, rude or disrespectful CNAs, missing clothing and blankets, lack of hot water, inadequate towels and wash rags, flies, Hoyer lifts left in rooms, staff playing with hair in the dining room, missed two-hour checks, and lack of showers. Although the written policy required the SSD to log grievances, inform the Administrator, and evaluate trends, the grievance log showed no entries for several months, and resident council minutes showed no documented resolutions. Interviews with the RN, SSD, AD, DON, and Administrator revealed inconsistent understanding of what constitutes a grievance, lack of awareness of resident council complaints, and uncertainty about where and how grievances were to be logged, resulting in resident concerns not being formally recorded or systematically addressed.
A resident with an implanted chest port for prior cancer treatment and current IV meropenem therapy for UTI did not receive care consistent with physician orders and standards of practice. Staff used the port for IV antibiotics without obtaining or documenting any orders for port dressing change frequency, and there was no facility policy guiding port use. Although an RN accessed the port using a Huber needle and a physician ordered the port to be de‑accessed after completion of IV therapy, staff documented the de‑access order as on hold when the antibiotic course was extended and never entered a new scheduled de‑access time or documented that the port was de‑accessed after the final dose. Interviews with LPNs, RNs, the DON, and the physician confirmed that LPNs could not access/de‑access ports, that dressings should have been changed routinely, that no port policy existed, and that nursing staff should have obtained and clarified all necessary treatment and dressing change orders.
A resident with a history of stroke, heart failure, and bone density disorder experienced leg pain and swelling, leading a nurse practitioner to order an x-ray. The order was denied by the primary physician due to miscommunication about which leg required imaging, and staff did not follow up with the NP or document the reason for the denial. The x-ray was not completed until several days later, after which fractures were discovered and the resident was sent to the ER. Staff interviews revealed gaps in communication and follow-up regarding the resident's change in condition.
Staff did not ensure that oxygen and nebulizer tubing were stored in protective coverings when not in use, resulting in equipment being left on the floor, on chairs, and exposed to air. This occurred for three residents with respiratory conditions, despite facility policy and staff knowledge requiring proper storage to maintain cleanliness.
Staff did not follow Enhanced Barrier Precautions (EBP) protocols during high-contact care for two residents with indwelling urinary catheters, as they failed to wear gowns and did not have PPE or signage available at the point of care. Multiple staff members, including CNAs, nurses, and leadership, demonstrated a lack of awareness and training regarding EBP requirements, resulting in non-compliance with facility policy and CDC guidance.
Staff Lying in Bed With Resident Violates Dignity and Respect
Penalty
Summary
The deficiency involves a failure to ensure a resident was treated with respect and dignity when a CNA lay in bed next to the resident while the resident was sleeping. The facility’s resident rights policies state that residents have the right to a dignified existence and to be treated with consideration, respect, and full recognition of their dignity and individuality, including privacy in treatment and care of personal needs. The resident involved had Alzheimer’s disease, generalized anxiety disorder, and hypertension, was on hospice services, had severe cognitive impairment, and was dependent on staff for all ADLs. The resident’s care plan directed staff to maintain a calm environment and approach due to anxiety and confusion related to Alzheimer’s disease. According to interviews and a photograph reviewed by the Administrator, CNA B lay on the resident’s bed, fully dressed in scrubs, beside the resident who was under the covers and lying on their side facing the wall. The CNA was positioned on their side with one arm around the resident in a hugging manner, with no indication of sexual contact. CNA B reported that they lay down beside the resident to see if the resident was ready to get out of bed for dinner and to help the resident wake up in a good mood, and acknowledged not thinking about the inappropriateness of the action at the time. Other staff, including CNAs, a CMT, an LPN, an RN, the DON, and the Administrator, stated that it would be inappropriate for staff to lie on a resident’s bed, particularly when the resident was unable to communicate, and one CNA reported the behavior as inappropriate hugging and joking with the resident.
Failure to Document, Track, and Resolve Resident Grievances Raised in Resident Council
Penalty
Summary
The deficiency involves the facility’s failure to implement an effective and complete grievance policy, including failure to document, track, and promptly resolve residents’ grievances, and failure to provide written summaries of conclusions regarding grievances raised in resident council. The facility’s written Grievance Protocol states that the SSD is responsible for the grievance program, that grievances are to be recorded on a monthly grievance log, and that the Administrator and SSD are to evaluate the log for trends and develop action plans. Despite this, the facility’s grievance/complaint log contained no entries for three consecutive months, even though multiple concerns were documented in resident council minutes during that same period. Resident council minutes over several meetings documented repeated complaints and concerns from residents that met the facility’s own definition of grievances. These included reports of call lights not being answered in a timely manner, a CNA refusing to assist with compression socks and displaying a bad attitude, missing personal items such as sweatpants, coats, blankets, and a horse blanket, trash on floors in rooms and hallways, lack of hot water, no towels or wash rags, staff not knocking before entering rooms, flies, Hoyer lifts left in rooms, staff playing with their hair in the dining room, two-hour checks not being done, no shower aides resulting in no showers, and staff talking nastily to residents and showing bad attitudes. The resident council minutes for January, February, and March all showed that staff did not document any resolution of these concerns. Interviews with staff and leadership showed inconsistent understanding and implementation of the grievance process and confirmed that grievances raised in resident council were not being entered into the grievance log or consistently investigated. RN E stated grievances should be documented but was not aware of any grievances filed. The SSD reported that grievances should be referred to department heads and logged, but was unaware of the complaints documented in the resident council minutes and stated that he/she would only complete a grievance form if residents came directly to him/her. The AD stated that grievances were documented in resident council minutes, were sometimes taken to department heads, and were discussed in morning meetings, but was unaware of any grievance log and acknowledged complaints were not always handled immediately. The DON believed the SSD kept a grievance log and distinguished between formal grievances and undocumented complaints, while the Administrator stated grievances should be filed with the SSD, documented, and logged, but was unaware of specific complaints about staff and repeated call light issues documented in resident council. Together, these findings show that grievances voiced by residents were not consistently documented, tracked, or resolved in accordance with the facility’s grievance policy.
Failure to Follow Orders and Standards for Implanted Port Use and Care
Penalty
Summary
The deficiency involves the facility’s failure to obtain, clarify, and follow physician orders and standards of practice for the use and care of an implanted port used to administer IV meropenem to a resident. The resident had a history of cancer with a port in the right upper chest, chronic kidney disease, vascular implants and grafts, altered mental status, chronic autoimmune liver disease, urinary retention, and a UTI. The care plan noted the presence of the port and the goal that the resident have no issues from the implanted device. The discharge MDS documented mild cognitive impairment, dependence on others for most ADLs, an indwelling catheter, and the indication for and use of an antibiotic. The facility lacked a policy or procedure pertaining to the use of a port for treatments or medications. Physician orders dated early in November directed that meropenem be given IV every eight hours for a UTI, and on 11/04 a physician order was obtained to access the port for IV therapy and to access the port monthly and flush with 10 cc normal saline, then de‑access. However, there was no documentation of any orders or follow‑up regarding port site dressing changes. On 11/05, an order was written to access the port once for IV antibiotic therapy and then de‑access once treatment was complete, again without any documented orders for dressing changes. Nursing notes showed that on 11/05 an RN accessed the port using a Huber needle with sterile technique and the resident initially tolerated the procedure, but later that day the resident complained of pinpoint pain at the port site with flushing and no blood return was noted. The RN adjusted the needle without success and then de‑accessed the port due to continued pain and contacted the physician for further instruction. The resident was transferred to the hospital later on 11/05 at the family’s insistence for possible sepsis and was readmitted two days later with meropenem therapy reinstated and continued IV antibiotic infusions documented through the remainder of the month. Orders dated 11/07 and 11/12 continued IV meropenem, including a dose reduction to 500 mg twice daily for one more week, but again there was no documentation of any orders or follow‑up regarding port dressing change frequency. The eMAR showed a one‑time order to de‑access the port after the final antibiotic dose, but staff documented this as “Not administered: on hold” when the antibiotic course was extended and did not enter a new scheduled de‑access time. There was no documentation that the port was ever de‑accessed after the final antibiotic dose was administered. Interviews with LPNs, RNs, the DON, the Administrator, and the physician confirmed that LPNs were not permitted to access or de‑access ports, that staff believed port dressings should be changed at least weekly or every 72 hours, that the facility had no policy on port use, and that staff should have performed routine dressing changes and followed the order to de‑access the port after the last antibiotic dose. The physician stated that nursing staff should obtain and clarify all orders regarding treatments and dressing changes.
Failure to Complete Ordered X-ray and Notify Provider Results in Delayed Fracture Treatment
Penalty
Summary
Facility staff failed to provide care in accordance with professional standards by not completing an ordered x-ray and failing to follow up with the ordering provider for a resident who had complaints of leg pain and swelling. The resident, who had a history of cerebral infarction, heart failure, bone density disorder, and chronic pain, was cognitively intact and dependent on staff for mobility. The care plan required staff to monitor pain, administer medications as ordered, and notify the physician and responsible party of any changes in care. A nurse practitioner ordered a left ankle x-ray due to the resident's pain and swelling, but the order was denied by the primary physician, who was not informed of which leg required imaging and believed it was a repeat request for the right leg. Staff did not document any follow-up with the nurse practitioner regarding the denied x-ray order, nor did they provide a reason for the denial. The nurse practitioner was not notified that the x-ray was not completed until several days later, at which point the order was clarified and approved, and the x-ray was performed. The x-ray revealed fractures in the tibia and fibula, and the resident was sent to the emergency room for treatment. Interviews with staff indicated a lack of communication and follow-up regarding the denied order and the resident's change in condition. The facility did not provide a policy related to resident change in condition, and staff were unclear about the process for notifying providers and following up on uncompleted orders.
Failure to Properly Store Oxygen and Nebulizer Tubing
Penalty
Summary
Staff failed to provide respiratory care in accordance with standards of practice by not ensuring that oxygen and nebulizer tubing were stored properly when not in use. Observations revealed that for one resident with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, the nebulizer tubing and mouthpiece were found directly on the floor without any protective covering. For another resident with shortness of breath and a cognitive communication deficit, the nebulizer tubing and mouthpiece were observed on a bedside chair, also without protective covering. In a third case, a resident with Parkinson's disease and a history of respiratory illness had an oxygen tank on the back of their wheelchair, with the nasal cannula and tubing exposed to air and not stored in a protective bag. Facility policy required that oxygen and nebulizer tubing be placed in a plastic bag or protective covering when not in use to maintain cleanliness and prevent contamination. The care plans and physician orders for the affected residents included instructions for the use of oxygen and nebulizer treatments, as well as protocols for changing and cleaning the equipment. However, staff did not consistently follow these protocols, as evidenced by the improper storage of respiratory equipment observed during the survey. Interviews with multiple staff members, including CNAs, CMTs, RNs, LPNs, the DON, and the Administrator, confirmed that the expected practice was to keep oxygen and nebulizer tubing in a plastic bag or protective covering when not in use. All staff interviewed acknowledged that tubing should not be left on the floor, on chairs, or exposed to air without protection. Despite this, the observed deficiencies indicated a failure to adhere to facility policy and standard infection control practices regarding respiratory care equipment.
Failure to Implement Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program by not educating staff on, or implementing, Enhanced Barrier Protection (EBP) protocols for residents with indwelling medical devices. Specifically, staff did not wear gowns when providing catheter care to two residents who had indwelling urinary catheters, despite facility policy and CDC guidance requiring gown and glove use during high-contact care activities for such residents. Observations showed that staff only used gloves and did not don gowns, and there was no signage or PPE available near the residents' rooms to support EBP implementation. Both residents involved had physician orders for catheter care and were care planned for their indwelling catheters, but there was no care planning related to EBP. During direct care activities, such as draining catheter bags and changing catheters, staff were observed using gloves but not gowns, and EBP protocols were not followed. Supplies for PPE were not readily accessible at the point of care, and there was no clear signage indicating the need for EBP or the type of PPE required. Interviews with various staff members, including CNAs, nurses, and the Director of Nursing, revealed a lack of awareness and training regarding EBP. Staff generally associated gown use with isolation precautions or specific infections, not with routine care of residents with wounds or indwelling devices as required by EBP. The Director of Nursing and Administrator were also unaware of the need for gowns and gloves during high-contact care for these residents, and PPE was only available in storage rooms, not at the point of care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lebanon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lebanon North Nursing & Rehab | 2 mi | ★★★★★ | 22 | 0 |
| Richland Care Center Inc | 20.9 mi | ★★★★★ | 0 | 0 |
| Buffalo Prairie Center For Rehab And Healthcare | 23.9 mi | ★★★★★ | 17 | 1 |
| Colonial Springs Healthcare Center | 24 mi | ★★★★★ | 7 | 0 |
| Marshfield Care Center For Rehab And Healthcare | 25.6 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.