Health inspection·January 17, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interview, and policy review, the facility failed to ensure wound dressings were changed in a clean and sanitary manner. This affected two (#56 and #36) of three residents reviewed for wound care. The census was 86. Residents Affected - Few Findings include: 1. Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses of unspecified thoracic thoracolumbar and lumbosacral intervertebral disc disorder, cervical disc disorder with myelopathy, unspecified cervical region, dorsalgia, unspecified, and osteomyelitis of vertebra, lumbar region. with diagnoses of Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) Score of 15 out of 15 indicating the resident was cognitively intact. Review of the care plan dated 12/16/23 revealed Resident #36 had impaired skin integrity. Interventions included Resident #36 will comply with recommendations/treatments to minimize further skin impairment, will show signs of healing and/or improvement to the extent allowed by the resident's age, mobility status, continence status, medication and/or treatment compliance, medical condition and/or comorbidities, and compliance with wound care recommendations, identified skin impairment will be free of signs and symptoms of infection, treatment(s) per physician orders and wound consult as needed (PRN). Observation on 01/17/24 at 9:51 A.M. with Registered Nurse (RN) #37, Wound Nurse revealed dressing change on Resident #36 with dressing change to spine and right lateral ankle. Resident #36 was observed in isolation, RN #37 gowned and gloved up prior to entering room. All supplies brought into room. Dressing removed to spine, spine wound cleansed with Vashe wound cleanser and four by four (4x4) pad, calcium alginate applied and covered with adhesive dressing. Gloves were removed, hands sanitizer used to clean hands and clean gloves applied. Ankle wound dressing removed, wound cleansed with Vashe wound cleanser and 4x4, betadine applied to wound with large swab and covered with adhesive dressing. Gloves and gown removed. Hands washed prior to leaving room. Interview on 01/17/24 at 10:00 A.M. with RN #37 confirmed she did not change her gloves during a dressing change on Resident #36 after removing the dirty dressing and before cleaning the wound and applying a clean dressing. 2. Record review revealed Resident #56 was re-admitted to the facility on [DATE] with diagnoses of acute pancreatitis without necrosis or infection, unspecified, acquired absence of right leg below (continued on next page) 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 Page 1 of 2 Event ID: 365897 Printed: 05/15/2026 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 365897 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 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)