LEBANON SOUTH NURSING & REHAB

Nursing Home Inspector

514 WEST FREMONT ROAD
LEBANON, MO 65536
Laclede County
Phone: 417-532-5351
Provider Number: 265428
Last Inspection: 06/22/2017

About the Nursing Home

Number of Beds: 116
Number of Residents: 99
Beds Available: 17
Percent Occupancy: 85%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

34

Facility
28

County
21

MO
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

34

2017
40

2016
10

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

6/22/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 8/6/2017
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 8/6/2017
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Pattern : Minimal 4 8/6/2017
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Pattern : Minimal 4 8/6/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 8/6/2017
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Pattern : Minimal 4 8/6/2017
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 8/6/2017
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Minimal 4 8/6/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 8/6/2017
 

4/11/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Widespread : Potential 4 6/9/2016
 
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 6/9/2016
 
Failed To: Allow residents to easily view the results of the nursing home's most recent inspection. Pattern : Potential 3 6/9/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Widespread : Potential 4 6/9/2016
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 6/9/2016
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 6/9/2016
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 6/9/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 6/9/2016
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 6/9/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 6/9/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/9/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 6/9/2016
 

2/6/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Isolated : Minimal 3 3/17/2015
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 3/17/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 3/17/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MO State Avg
Number of Residents 99 103.50 74.26
Registered Nurses 0.46 0.41 0.60
Licensed Practical / Vocational Nurses 0.69 0.62 0.72
Certified Nursing Assistants 1.98 2.45 2.43
Total Staff Hours 3.13 3.47 3.75

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MO State Avg%
of high risk long-stay residents with pressure ulcers 9 9 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 96 87 88
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 93 92 93
of long-stay residents experiencing one or more falls with major injury 3 3 4
of long-stay residents who have depressive symptoms 0 8 3
of long-stay residents who lose too much weight 6 7 7
of long-stay residents who received an antianxiety or hypnotic medication 23 31 26
of long-stay residents who received an antipsychotic medication 5 26 18
of long-stay residents who self-report moderate to severe pain 3 5 7
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 22 22 15
of long-stay residents whose need for help with daily activities has increased 14 15 14
of long-stay residents with a catheter inserted and left in their bladder 2 3 2
of long-stay residents with a urinary tract infection 2 4 4
of low risk long-stay residents who lose control of their bowels or bladder 35 34 32
of short-stay residents assessed and appropriately given the pneumococcal vaccine 92 67 74
of short-stay residents who had an outpatient emergency department visit 21 19 12
of short-stay residents who made improvements in function 61 66 68
of short-stay residents who newly received an antipsychotic medication 2 1 2
of short-stay residents who self-report moderate to severe pain 4 8 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 90 71 73
of short-stay residents who were rehospitalized after a nursing home admission 22 20 22
of short-stay residents who were successfully discharged to the community 55 55 50
of short-stay residents with pressure ulcers that are new or worsened 1 0 1