Inspection·July 11, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff, resident and resident representative interviews, the facility failed to provide adequate supervision to ensure a resident, that had an order for supervised Leave of Absence (LOA), did not leave the facility unsupervised. This affected one (#06) out of three reviewed for elopement. The facility census was 96. Findings include: Review of the medical record for Resident #06 revealed an admission date of 12/30/20 with medical diagnoses of epilepsy, right sided hemiplegia due to cerebral infarction, chronic obstructive pulmonary disease, depression, and anxiety. Review of the medical record for Resident #06 revealed an annual Minimum Data Set (MDS) assessment, dated 04/19/24, which indicated Resident #06 had moderate cognitive impairment and required set-up assistance with eating, wheelchair mobility, and bed mobility, partial staff assistance with transfers and supervision with toilet hygiene, and bathing. The MDS did not indicate Resident #06 had any wandering behaviors. Review of the medical record for Resident #06 revealed a quarterly nursing assessment, dated 05/17/24, which included an elopement risk evaluation that indicated Resident #06 was alert and oriented, was able to leave the building, no history of wandering, exit seeking, or attempted elopements noted. Review of the medical record for Resident #06 revealed a physician order dated 05/04/23 that stated the resident may go on Leave of Absence (LOA) independently. The order was discontinued on 07/08/24. Further review of the medical record revealed a physician order dated 06/03/24 which stated the resident may go LOA with medications and supervised and was written by the former Director of Nursing (DON) #218. The order was discontinued on 07/08/24. Further review of the medical record for Resident #06 revealed a physician order, dated 07/08/24, which stated resident may go LOA with supervision of mother and/or her father. Review of the medical record for Resident #06 revealed a nurses' notes dated 07/08/24 at 1:51 P.M. which stated resident signed out LOA and stated she was going to the store. The note stated Resident #06 had a LOA order in place. Review of the nurses' note dated 07/08/24 at 2:56 P.M. stated the nurse received a phone call from a male in the community screaming at the nurse on the phone stating someone come get this lady that almost got hit in front of the McDonald's. The note stated the social service designee and a nurse drove to assist the resident. Further review of the nurses' notes (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 07/11/2024 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)