New Lebanon Rehabilitation And Healthcare Center

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and resident interviews, and policy review, the facility failed to provide medical records to a resident upon his or her request. This affected one (#37) out of one residents reviewed for medical record request. The facility census was 96.Findings include:Medical record review for Resident #37 revealed she was admitted to the facility on [DATE REDACTED]. Her diagnoses included candidiasis, multiple sclerosis, obstructive sleep apnea, obesity, essential primary hypertension, anemia, anxiety, post-traumatic stress disorder, asthma, major depressive disorder, and chronic obstructive pulmonary disease (COPD). Review of the Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident # 37 was cognitively intact. Resident #37 was dependent on staff for medication administration. Resident #37 is independent with eating, upper body dressing, and personal hygiene. She required assistance with oral hygiene and supervision with toilet use, bathing, and lower body dressing. Interview on 09/24/25 at 1:33 P.M. with Resident #37 revealed she requested a copy of her medical records on 03/09/25, however, she has never received a copy of the records. Resident #37 stated she was told by the Medical Records Manager (MRM) #218 manager that the copy machine was broken, however, once repaired she would have copies. Interview with the MRM #218 on 09/24/25 at 3:17 P.M. confirmed Resident #37 had asked for medical records on 03/09/25. MRM #218 stated she told Resident #37 the copier was broken and MRM #218 confirmed she told Resident #37 she could have copies of Resident #37's medical records once it was repaired. However, MRM #218 pointed at a pile of records on a desk and revealed Resident #37 had never ask for her records again, so the record have been in the office. MRM #218 confirmed she had not offered the records to Resident #37 since the copier was repaired on 03/09/25. Observation on 09/24/25 at 3:17 P.M. revealed a stack of medical records copied for Resident #37 that had not been distributed to Resident #37. Review of the facility policy titled Release of Information dated September 2021 confirmed a resident has the right to access his/her medical records at any time.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

New Lebanon Rehabilitation and Healthcare Center

101 Mills Place New Lebanon, OH 45345

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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

reported clothing items were missing. The facility asked Resident #26's spouse to provide a list of missing items and never received a list. The Administrator stated the spouse continued to visit several times a week and never mentioned the missing items again. The administrator stated he did not follow up any further.

During an interview on 09/25/2025 at 11:41 A.M. SS #231 verified she had six (6) copies of Resident #76's list of missing items. SS #231 stated Resident #231 approached her in May with a list of missing clothing items and gave a different list every day for three days. SS #231 looked in Resident #76's room and laundry and found some of the clothing. SS #231 marked off what was found on the list. SS #231 advised Resident #76 to speak to her husband about items potentially sent home or recently donated. SS #231 stated she never heard anything else about the remaining items and never followed up with Resident #76 or her husband to ensure the issue was resolved. SS #231 stated she assumed the issue was resolved since it was not mentioned again. During an observation on 09/25/2025 at 12:01 P.M. SS #231 showed Resident #76 the handwritten list titled Missing Items Resident #76 reviewed the list and verified to SS #231 the unchecked items on the list were still missing. During a telephone interview on 09/25/2025 at 12:10 P.M. revealed Resident #76's spouse stated he had purchased a bunch of clothing for Resident #76 from Woman Within, due to her size. The family labeled her clothing with her name. The facility did her laundry, and items kept coming up missing. The spouse stated he talked to the Administrator a few months ago, and

he said they would check on it. The spouse stated Resident #76 had provided the facility a list of the missing clothing items. The family did not hear anything back, and the next time the spouse spoke to the Administrator, he said the facility would not reimburse for the clothing. The spouse stated the facility had always done Resident #76's laundry. He denied taking large amounts of clothing home with him and stated

he had taken home a blouse and a pair of shoes to spot clean them since they did not provide stain removal services. The family had to replace all of Resident #76's missing clothing, worth around $600.

During an interview on 09/25/2025 at 3:02 P.M. the Director of Nursing (DON) confirmed Resident #76 did not have a list of personal items and her concerns for missing items was absent but should have been listed on the grievance log. Review of policy titled Resident Grievances and Concerns dated 09/2021 revealed residents had the right to make complaints and voice grievances about any concern regarding the resident's stay. Upon receipt of any oral, written, or anonymous grievance submitted, the facility took immediate action to complete a timely investigation and prevent further potential violations.This deficiency represents noncompliance investigated under Complaint Numbers 2630213, 2618777, 2574379, 1260775 (OH00165907), 1260773 (OH00165246) and 1260770 (OH00163975).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

New Lebanon Rehabilitation and Healthcare Center

101 Mills Place New Lebanon, OH 45345

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 0677 Level of Harm - Minimal harm or potential for actual harm

#37 on 09/07/25. Review of the shower sheet documentation revealed a shower was completed for Resident #37 on 09/05/25 and 09/19/25. A shower was documented as refused on 09/23/25.

Interview on 09/29/25 at 1:52 P.M. with Resident #37 revealed she was scheduled for showers twice a week and voiced a concern did not always receive them.

Residents Affected - Few

Interview on 09/29/25 at 3:24 P.M. with the Director of Nursing (DON) verified Resident #37 should receive bathing assistance twice weekly. The DON acknowledged the facility had documentation Resident #37 had received three showers and refused one from 09/01/25 through 09/29/25.

1. 3. Review of the medical record for Resident #92 revealed an admission date of 01/29/25 with medical

diagnoses of necrotizing fasciitis, chronic obstructive pulmonary disease, left spastic hemiplegia, cerebral infarction, and bipolar disorder.

Review of the medical record for Resident #92 revealed a quarterly MDS assessment, dated 08/07/25, which indicated Resident #92 was cognitively intact and required substantial/maximum staff assistance with bathing/showers, partial/moderate staff assistance with transfers, and was dependent upon staff for toilet hygiene.

Review of the medical record for Resident #92 revealed the August 2025 shower sheets which indicated Resident #92 did not receive his shower as scheduled on 08/07/25 due to short staffed. Review of Resident #92's shower sheets for September revealed documentation to support Resident received showers as scheduled. The shower sheets did not contain documentation to support the if facility staff shaved Resident #92.

Interview with observation on 09/22/25 at 10:00 A.M. with Resident #92 stated he didn't get his showers as scheduled and they don't shave his face with showers. Resident #92 stated his face had not been shaved in several days. Observation of Resident #92 revealed facial hair stubble.

Interview on 09/25/25 at 2:59 P.M. with Director of Nursing confirmed Resident #92 did not receive a shower as scheduled on 08/07/25.

Review of the facility policy titled, Activities of Daily Living (ADLs) stated residents who are unable to carry out ADLs independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy stated hygiene included bathing, dressing, grooming, and oral care.

This deficiency represents non-compliance investigated under Complaint Numbers 2618777, 2582623, 1260777 (OH00167022), 1260775 (OH00165907), 1260770 (OH00163975), 1260768 (OH00163266), 1260767 (OH00163258) and 1260766 (OH00162690).

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

New Lebanon Rehabilitation and Healthcare Center

101 Mills Place New Lebanon, OH 45345

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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

hiding behind bushes. Resident #70 was placed on one-on-one supervision, skin assessment was completed with no injuries noted, and no complaints of pain noted. A note dated 08/12/25 at 2:52 A.M. stated Resident #70 was sent to a behavioral hospital. Review of the facility timeline for Resident #70's elopement on 08/11/25 revealed the Resident #70 eloped from the mental health unit at 5:45 P.M. and was found at 6:45 P.M. The timeline indicated Resident #70 was evaluated by Emergency Medical Services at 6:50 P.M. and returned to the facility at 7:15 P.M. The timeline indicated Resident #70 was placed on one-one one supervision at 7:15 P.M. and discharged to the behavioral hospital on [DATE REDACTED] at around 3:00 A.M.Interview on 09/29/25 at 9:46 A.M with Licensed Practical Nurse (LPN) #212 confirmed she was the nurse on the Mental Health Unit on 08/11/25 and that she was notified by staff that Resident #70 had eloped from the unit. LPN #212 confirmed Resident #70 had tried to leave the facility multiple times during

the day on 08/11/25. LPN #212 stated the interventions in place at the time of Resident #70's elopement was for staff to provide redirection and for staff to keep a close eye on him. LPN #212 confirmed Resident #70 was not placed on one-on-one supervision until after his return to the facility on [DATE REDACTED]. Interview on 09/29/25 at 10:06 A.M. with Administrator and Director of Nursing (DON) stated Resident #70 was on frequent staff checks on 08/11/25 due to his increase in behaviors. DON confirmed Resident #70 had not been placed on one-on-one supervision until after his elopement on 08/11/25. DON confirmed Resident #70 eloped from the facility on 08/11/25 at 5:45 P.M. and stated staff were unable to determine which direction he had gone because Resident #70 was fast and ran out of their site. DON confirmed Resident #70 was found on 08/11/25 at 6:45 P.M. in the bushes about 50 feet behind the building. DON confirmed Resident #70 was assessed and had no injuries noted. Administrator confirmed the facility elopement policy only indicated the process to following a resident elopement.This deficiency represents non-compliance investigated under Complaint Number 2574379.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

New Lebanon Rehabilitation and Healthcare Center

101 Mills Place New Lebanon, OH 45345

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

is to be used with a flow rate of 10 to 15 Liters per minute of oxygen. This deficiency represents non-compliance investigated under Complaint Number 1260767 (OH00163258).

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

New Lebanon Rehabilitation and Healthcare Center

101 Mills Place New Lebanon, OH 45345

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to administer medications as ordered. This affected one (#70) out of four residents reviewed for medication administration. The facility census was 96.Findings include:Review of the medical record for Resident #70 revealed an admission date 06/20/25 with medical diagnoses of schizoaffective disorder, HTN, dementia without behavioral disturbances, and bipolar disorder. The medical record indicated Resident #70 was sent to the hospital on [DATE REDACTED] for behavior issues and returned to the facility on [DATE REDACTED]. The medical record indicated Resident #70 discharged to another nursing facility on 09/12/25. Review of the medical record for Resident #70 revealed an admission Minimum Data Set (MDS) assessment, dated 06/26/25, indicated Resident #70 had severely impaired cognition and required supervision with bathing, toilet hygiene, and transfers. Review of

the medical record for Resident #70 revealed physician orders dated 08/08/25 for lorazepam (antianxiety) 1 milligram (mg) one tablet by mouth at bedtime and an order for trazadone (antidepressant) 50 mg one tablet by mouth at bedtime.Review of the medical record for Resident #70 revealed the August 2025 Medication Administration Record (MAR) which indicated Resident #70 did not receive the lorazepam on 08/08/25 through 08/10/25 and did not receive the trazadone on 08/08/25 and 08/09/25. Interview on 09/29/25 at 1:24 P.M. with Director of Nursing (DON) confirmed Resident #70's medical record did not have documentation to support Resident #70 received the lorazepam on 08/08/25 through 08/10/25 or trazadone

on 08/09/25 or 08/09/25 as ordered.Review of the facility policy titled, Administering Medications, stated medications shall by administered in a safe and timely manner, and as prescribed.This deficiency represents non-compliance investigated under Complaint Numbers 1260777 (OH00167022) and 1260763 (OH00161296).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

New Lebanon Rehabilitation and Healthcare Center

101 Mills Place New Lebanon, OH 45345

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Observation on 09/23/25 at 8:00 A.M. of the North Front medication cart revealed an insulin ASPA (aspart) injection flexpen was unopened and in the top drawer of the medication cart. The insulin flexpen was labeled for Resident #97 and was in a pharmacy bag with a label to refrigerate until it was opened.

Interview on 09/23/25 at 8:02 A.M. with Licensed Practical Nurse (LPN) #140 confirmed Resident #97's Insulin flexpen was unopened and not refrigerated.

Review of the facility policy titled, Storage of Medications, dated 09/01/21, stated the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy stated the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals and all drugs should be returned t the dispensing pharmacy or destroyed. The policy stated each medication requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secured location.

This deficiency represents non-compliance investigated under Complaint Number 1260763 (OH00161206).

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

New Lebanon Rehabilitation and Healthcare Center

101 Mills Place New Lebanon, OH 45345

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

Based on observations, staff interview and policy review, the facility failed to prepare, store, and distribute food in a safe manner. This had the potential to affect all 96 residents who received food from the facility.

The facility census was 96Findings include:1.Observation on 09/22/25 at 8:23 A.M. revealed during the initial tour with the DM #155 revealed a swarm of flying gnats throughout the kitchen areas.Interview on 09/22/25 at 8:25 A.M. confirmed the facility has an ongoing issue with fruit flies and gnats. DM #155 stated

she will check to ensure she does not have overripe bananas as she peered over a box of bananas and confirmed that is not the issue to cause the active gnats. DM #155 stated the facility has an ongoing issue with active gnats in the kitchen.2. Observation on 09/23/25 at 3:01 P.M. during the observation of purred and mechanical meal preparation revealed active black flies in the kitchen during meal preparation.

Interview on 09/23/25 at 3:02 P.M. with DM #155 confirmed the active flies in the kitchen while the staff prepared the dinner meal. Interview with DM #155 on 09/23/25 at 5:20 P.M. confirmed the findings identified

on the tray line. The facility confirmed all 96 residents residing in the facility receive their meals from the kitchen.Review of the facility policy titled Food Handling dated September 2021confirmed food will be stored, prepared, handled, and served so the risk of food borne illness will be minimized. This deficiency represents noncompliance investigated under Complaint Numbers 1260765 (OH00161730) and 1260763 (OH00161206).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

New Lebanon Rehabilitation and Healthcare Center

101 Mills Place New Lebanon, OH 45345

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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

assessment, dated 08/13/25, which indicated Resident #49 was cognitively intact and was independent with eating, bed mobility, and transfers, and required partial/moderate staff assistance with toilet hygiene and bathing.

Observation with interview on 09/22/25 at 10:59 A.M. revealed Resident #49 sitting on the side of his bed in his room. The observation revealed multiple gnats flying around his room. Resident #49 stated he always has flies or gnats in his room.

Observation on 09/22/25 at 11:22 A.M. revealed Resident #49 sleeping his in bed. The observation revealed three flies on Resident #49's comforter and two gnats on his pillow.

Interview on 09/22/25 at 11:24 A.M. with Housekeeper #125 confirmed Resident #49 had three flies on his comforter and two gnats on his pillow.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet