Health inspection·August 7, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, observations, staff interviews, and policy review, the facility failed to follow infection control procedures. This affected two (#10 and #13) residents out of the three residents reviewed. The facility census was 58. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #10 revealed an admission date of 03/20/23 with medical diagnoses of anoxic brain damage, anxiety, dependence on ventilator, tracheostomy, and seizures. Review of the medical record for Resident #10 revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated Resident #10 was rare/never understood or able to understand others. The MDS indicated Resident #10 was dependent upon staff for all activities of daily living (ADLs). Review the MDS revealed Resident #10 had a gastrointestinal tube (g-tube), tracheostomy, and was on a mechanical ventilator. Review of the medical record for Resident #10 revealed a physician order dated 06/26/24 for Enhanced Barrier Precaution (EBP) related to enteral tube and tracheostomy. Observation on 08/07/24 at 9:47 A.M. revealed upon entering Resident #10's room Registered Nurse (RN) #103 was observed administering Resident #10's medications via g-tube. The observation revealed RN #103 was not wearing a gown but was wearing gloves. The observation revealed Resident #10 had an EBP sign posted on her door and an isolation cart with personal protective equipment (PPE) inside located outside of Resident #13's room. Interview on 08/07/24 at 9:58 A.M. with RN #103 confirmed she had administered Resident #10 rise medications via g-tube. RN #103 confirmed she had not donned a gown prior to administering the medications via g-tube. RN #103 confirmed Resident #10 had an EBP sign posted on her door and an isolation cart located outside of the room. 2. Review of the medical record for Resident #13 revealed an admission date of 07/25/24 with medical diagnoses of acute and chronic respiratory failure with hypoxia, dependence on ventilator, injury of spinal cord, and atrial fibrillation. Review of the medical record for Resident #13 revealed an admission assessment, dated 07/25/24, which indicated Resident #13 was alert and oriented to person, place, time, and situation. The assessment indicated Resident #13 was able to mouth words and required extensive staff assistance with all ADLs. Further review of the assessment revealed Resident #13 had a tracheostomy and was on a (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: 365920 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 365920 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036 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)