Inspection·October 9, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, review of hospital documentation, review of Omnicell (automatic medication dispensing cabinet) documentation, and policy review, the facility failed to administer medication as ordered. This affected one (#97) out of three residents reviewed for medication administration. The facility census was 96. Findings include: Review of the medical record for Resident #97 revealed an admission date of 09/13/24 with medication diagnoses of staphylococcal arthritis of left ankle and foot, schizophrenia, anxiety, bipolar disorder, and mild cognitive impairment. Review of the medical record for Resident #97 revealed an admission Minimum Data Set (MDS) assessment, dated 09/20/24, which indicated Resident #97 had severe cognitive impairment and was independent with toilet hygiene, bed mobility, and transfers and required supervision with bathing. The MDS indicated Resident #97 received antipsychotic and antianxiety medications. Review of the medical record for Resident #97 revealed a nurse's progress note dated 09/25/24 at 3:32 A.M. written by Registered Nurse (RN) #111 which stated Resident #97 had shown signs of agitation, anxiety, and confusion. The note also stated Resident #97 had been crying out loud and screaming at staff and residents. The note continued to state Resident #97 was given a schedule dose of Ativan 1 milligram (mg) and an order for Haldol 5 mg intramuscular (IM) was given by the physician. The note stated the nurse was not able to obtain the dose of Haldol from the Omnicell because she did not have the appropriate access. The note stated Resident #97 was sent out to the hospital and family and physician were notified. Further review revealed a nurse's note, dated 09/25/24 at 4:10 A.M. which stated Resident #97 had returned from the hospital and was given a dose of Haldol at the hospital. The note stated Resident #97 was resting with no signs of discomfort. Review of the medical record for Resident #97 revealed no documentation to support the nurse entered the order for the Haldol 5 mg IM on 09/24/24 under physician orders. Review of the medical record for Resident #97 revealed a hospital emergency room (ER) note, dated 09/24/24, which stated Resident #97 was seen in the ER with agitation. The note stated Resident #97 was given Ativan at the facility but was unable to get the one-time dose of haloperidol (Haldol) because the night nurse did not have access to the medication. The ER note stated Resident #97 arrived at the ER on [DATE] at 9:25 P.M., received a dose of haloperidol in the ER, and was discharged back to the facility on [DATE] at 3:39 A.M. (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 5 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 10/09/2024 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)