F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to ensure that the resident records were complete and
accurate for 1 of 3 residents reviewed, Residents #4.
Findings include:
Review of Resident #4's admission record revealed the resident was admitted on [DATE] with the
diagnoses that included cellulitis of right lower limb, cystitis, muscle weakness, difficulty walking, morbid
obesity, hypertension, anemia, and hyperlipidemia.
Review of Resident #4's physician order dated 12/9/2022 read, Tramadol HCl [Hydrochloride] tablet 50 mg
[milligram], give 1 tablet by mouth every 6 hours as needed for pain.
Review of Resident #4's Controlled Drug Disposition log revealed that on 1/13/2024 at 5:30 AM, one
Tramadol 50 mg tablet was taken from Resident #4's stock by Staff A, Registered Nurse (RN), and wasted
by Staff B, Licensed Practical Nurse (LPN). Staff B's initials had a line marked through her initials and error
written with Staff B's initials printed beside the error.
Review of Resident #4's Medication Administration Record (MAR) for January 2024 revealed no Tramadol
HCL tablet 50 mg was administered in January 2024. There was no documentation on 1/13/2024 that
Tramadol was refused.
Review of Resident #5's physician order dated 11/4/2023 read, Tramadol HCl tablet 50 mg, give 1 tablet by
mouth every 8 hours as needed for pain.
Review of Resident #5's Controlled Drug Disposition log revealed 27 Tramadol 50 mg tablets were
delivered on 12/10/2023. On 1/8/2024, zero Tramadol 50 mg tablet was available. The log shows no
Tramadol 50 mg in Resident #5's inventory from 1/8/2024 till 1/20/2024.
Review of Resident #5's Medication Administration Record for January 2024 revealed the resident received
Tramadol HCL 50 mg tablet on 1/13/2024 at 4:48 PM.
During a telephonic interview on 2/23/2024 at 11:10 AM, Staff B, LPN, stated that on 1/13/2024, she was
asked to witness a waste for Tramadol 50 mg for Resident #4 by Staff A, RN. Staff B stated, I signed the
controlled drug disposition as wasted and then was told that the medication was given to [Resident #5's
name]. I crossed my initials off as a witness for waste.
(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:
105196
Printed: 05/28/2026
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
105196
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/23/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Lodge Healthcare and Rehabilitation Center
635 SE 17th Street
Ocala, FL 34471
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)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 2/23/2024 at 3:41 PM, Staff A, RN, stated, I used a Tramadol from [Resident #4's
name] supply to administer to [Resident #5's name] because he was in pain. He did not have any Tramadol.
We need a witness to get medication out of the pyxis. It takes two nurses, and I could not get another
nurse. At change of shift, I told [Staff B's name], so she would sign the narcotic log, so the narcotic count
would be correct. I placed waste on there. I was not aware that she marked it out. I have never done this
before and will not do it again.
During an interview on 2/23/2024 at 3:50 PM, the Director of Nursing stated, The Tramadol issued to
[Resident #4's name' was used to medicate [Resident #5's name] and the controlled drug disposition record
for [Resident #4's name] was completed inaccurately as a wasted narcotic. Residents' medications are not
to be shared and the backup medication emergency kit or pharmacy distribution system (Omnicell) is to be
utilized to obtain medication when a resident stock has been depleted. If narcotics are wasted, it requires
two nurses and the narcotic must visually be seen to witness a narcotic waste.
Review of the facility policy and procedures titled Medication Administration dated 4/1/2022 read,
Procedure . 12. Should a drug be withheld, refused, or given other than at the scheduled time, the
individual administering the medication will document this in the clinical record. 13. Should a medication be
unavailable at the time of medication administration, the nurse should check the EDK/OmniCell system for
availability. If medication is not available, the nurse should notify the physician for new orders and contact
the pharmacy, as needed . 15. Medications ordered for a particular resident may not be administered to
another resident unless permitted by State law or facility policy.
Review of the facility policy and procedures titled Medication Destruction dated 4/1/2022 read, Procedures .
6. Records of personnel access, usage, and disposition of controlled medication with sufficient detail to
allow reconciliation (e.g., the MAR, proof-of-use sheets, or declining inventory sheets).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105196
If continuation sheet
Page 2 of 2
