Cycle 1
Health 2023-10-06 · Fire 2023-10-06
12 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lebanon, MO
Lebanon South Nursing & Rehab
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
514 West Fremont Road, Lebanon, MO
(417) 532-5351
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
116
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
James & Judy Lincoln
Operator or chain grouping
Approved since
1990-05-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
58 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.35
Registered nurse staffing · state 0.46 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.92
All reported nurse hours · state 3.47 · national 3.89
Licensed hours
0.78
RN + LPN hours · state 1.14 · national 1.54
Weekend hours
2.55
Weekend nurse staffing · state 3.04 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.33 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
3.43
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 51% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 57% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,757
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9815
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 16.92% · Performance 21.28% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.29
Baseline 7.39% · Performance 6.55% · Measure score 4.29 · Achievement 4.29 · Improvement 2.99
Total nurse turnover
1.88
Baseline 70.00% · Performance 59.26% · Measure score 1.88 · Achievement 1.08 · Improvement 1.88
Adjusted total nurse staffing
0
Baseline 3.39 hours · Performance 2.79 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.75% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 18.18% · Lower 95% interval 9.14% |
| Discharge to community | 45.66% |
50.57%
4.9 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 40.68% · Lower 95% interval 36.37% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 10 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | 6.55% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 3.23% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 96 |
| Staff flu vaccination coverage | 47.31% |
42%
5.3 pts better
|
Numerator 44 · Denominator 93 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
84.8%
15.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
90.9%
7.7 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
4.1%
0.1 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.4% · Q3 4.8% · Q4 4.8% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.6% |
14.7%
2.9 pts worse
|
11.4%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 15.4% · Q3 11.9% · Q4 16.1% · 4Q avg 17.6% |
| Percentage of long-stay residents who lose too much weight | 0.9% |
5.5%
4.6 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 1.9% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.0% |
25.3%
6.3 pts better
|
19.6%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 13.3% · Q3 20.4% · Q4 25.9% · 4Q avg 19.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.9% |
25.0%
4.1 pts better
|
16.7%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 20.8% · Q3 20.4% · Q4 18.4% · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.1% |
20.3%
8.8 pts worse
|
16.3%
12.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 39.3% · Q3 40.1% · Q4 13.1% · 4Q avg 29.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.1% |
19.8%
1.3 pts worse
|
14.9%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 39.7% · Q3 18.5% · Q4 13.0% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.7% |
1.4%
2.3 pts worse
|
1.0%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 5.3% · Q3 5.4% · Q4 2.9% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
2.6%
1.1 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 1.6% · Q4 1.6% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.8% |
18.1%
3.3 pts better
|
19.8%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 11.1% · Q3 25.4% · Q4 14.1% · 4Q avg 14.8% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
5.0%
3.5 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.5% · Q3 2.2% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
66.4%
33.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
2.2%
0.5 pts better
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 3.2% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.2% |
63.5%
17.7 pts better
|
79.7%
1.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-04-05 · Fire 2021-04-05
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2019-04-08 · Fire 2019-04-08
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-10-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-10-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-10-06
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-10-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-10-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-21
F · Potential for more than minimal harm
2021-04-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-05-17
F · Potential for more than minimal harm
2021-04-05
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-05-17
F · Potential for more than minimal harm
2021-04-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-05-17
E · Potential for more than minimal harm
2021-04-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-05-17
E · Potential for more than minimal harm
2021-04-05
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2021-05-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-23
G · Actual harm
2025-02-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-02-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-26
E · Potential for more than minimal harm
2025-02-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-26
F · Potential for more than minimal harm
2023-10-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-10-06
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-10-06
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-10-06
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-10-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-06
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-06
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-10-06
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-11-20
E · Potential for more than minimal harm
2021-04-05
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2021-05-17
E · Potential for more than minimal harm
2021-04-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2021-05-17
E · Potential for more than minimal harm
2021-04-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-05-17
E · Potential for more than minimal harm
2021-04-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-05-17
D · Potential for more than minimal harm
2021-04-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-05-17
D · Potential for more than minimal harm
2021-04-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-17
E · Potential for more than minimal harm
2019-04-08
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-05-08
E · Potential for more than minimal harm
2019-04-08
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-05-08
E · Potential for more than minimal harm
2019-04-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-05-08
Penalties and ownership
What sits behind the stars
Ownership
Lincoln, James
5% Or Greater Direct Ownership Interest · Individual
Lincoln, Judy
5% Or Greater Direct Ownership Interest · Individual
Knight, Theresa
W-2 Managing Employee · Individual
Ltc Management Services LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Lebanon North Nursing & Rehab
Lebanon, MO
1-star overall rating with 1-star inspections with $50,907 in total fines with 19 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Richland Care Center Inc
Richland, MO
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Buffalo Prairie Center For Rehab And Healthcare
Buffalo, MO
1-star overall rating with 1-star inspections with 28 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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