Health inspection·February 11, 2026

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of facility water management plan documents, staff interview, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to develop a comprehensive water management plan. This had the potential to affect all 59 residents residing in the facility. The facility census was 59. Findings include:Review of the facility undated water management plan (WMP) revealed a list of the WMP team members, description of the building water systems, diagrams showing water flow and areas where Legionella growth could grow and spread, control measures and monitoring, ways to intervene when control limits are not met, and a process for validation. The facility's control measures and monitoring included storing water at 140 degrees (Fahrenheit) delivering at 120 degrees (Fahrenheit), running water in empty rooms daily and weekly as needed, running water in all rooms monthly, and draining water heaters periodically to remove scale and sediment build up. The plan did not specify the specific areas or sources the water temperatures would be obtained from. Under the section for ways to intervene when control limits were not met the facility identified they would contact the water supplier to report any water issues, adjust temperatures to be within the correct range, and contact an outside contractor if unable to maintain water, pH (potential of Hydrogen) or chlorine. Under the facility validation process to make sure the program was running as designed, there were no specific measurements or processes identified, only to follow control measures to ensure they were effective and keep record of all findings and testing done in the facility.Review of the CDC website at https://www.cdc.gov/control-legionella/php/toolkit/control-toolkit.html revealed a document titled, Toolkit for Controlling Legionella in Common Sources of Exposure (Legionella Control Toolkit), version 1.3 and dated 02/17/26, revealed WMPs are a multiple step process to reduce Legionella growth and spread: including establishing a team, describing building water systems, identifying areas or devices where Legionella might grow or spread to people, determining control measures, monitoring control measures, establishing remediation activities and interventions when control measures are not met, ensuring the program is running as designed and is effective, and documenting all program activities. Further review of the document under the Operation, Maintenance, and Control Limits section, revealed no single measure can ensure Legionella control. A comprehensive WNP allows water system operators to layer a series of complementary control measures to create environmental conditions that prevent bacterial intrusion, growth, and transmission. The WMP should be developed or refined with guidelines in mind including monitoring temperatures, disinfectant residuals, and pH frequently based on performance of WMP or Legionella performance indicators for control. Ensure a disinfectant residual is detectable throughout the potable water system. Do not presume supplemental disinfection systems will control Legionella without adequate WMP. Interview on 02/10/26 at 3:39 P.M. with the Administrator verified she was unable to locate the WMP chlorine logs.Interview on 02/11/26 at 11:43 A.M. with the Administrator stated the facility would obtain a baseline of chlorine for the whole facility, and if there were any adverse findings, would follow the WMP. The Administrator verified there were not Residents Affected - Many Page 1 of 2 365920 365920 02/11/2026 Embassy of Lebanon 700 Monroe Road Lebanon, OH 45036

F 0880 Level of Harm - Minimal harm or potential for actual harm any logs of chlorine testing. Interview on 02/12/26 at 3:31 P.M., the Administrator verified the facility WMP was not a comprehensive plan that included the key elements according to the CDC guidelines. This deficiency represents non-compliance investigated under Complaint Number 2739025. Residents Affected - Many 365920 Page 2 of 2