Health inspection·January 31, 2019

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review the facility failed to ensure edema was treated as ordered. This affected one (Resident #90) of two residents reviewed for edema. The facility census was 107. Residents Affected - Few Findings include: Medical record review revealed Resident #90 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, edema, diabetes, peripheral vascular disease, and chronic respiratory failure. Review of the 14 day minimum data set (MDS) assessment dated [DATE] revealed intact cognitive skills for daily decision making. Extensive assistance was required with bed mobility, transfers, toileting, personal hygiene, and supervision was required with eating. A wheelchair was utilized for mobility. Review of physician order dated 01/04/19 revealed Torsemide 100 milligrams (mg), a diuretic used to treat edema, give half a tablet by mouth once daily for congestive heart failure and Metolazone, a diuretic, 5 (milligrams) mg by mouth every 24 hours as needed for daily weight above 203 pounds. Review of physician order dated 01/17/19 revealed Torsemide was increased to 100 mg by mouth daily for congestive heart failure. Review of Medication Administration Record (MAR) for January 2019 revealed Metolazone 5 mg was administered on 01/21/19, 01/22/19, 01/26/19, 01/28/19, and 01/29/19. Review of weights and vital summary revealed Resident #90 had weights obtained on 01/04/19, 01/06/19, and no further weights were obtained until 01/20/19. On 01/21/19, Resident #90's weight was 207.4 pounds, on 01/22/19 weight was 206.3 pounds, on 01/23/19 weight was recorded as 252.8 pounds, on 01/24/19 weight was 252.7 pounds, on 01/26/19 weight was 206.2 pounds, 01/28/19 weight was 205.8 pounds, and on 01/29/19 weight was 206.6 pounds. Observation on 01/28/19 at 3:04 P.M. revealed Resident #90 had edema to both ankles. Resident #90 reported medications had been adjusted to treat edema. Interview on 01/31/19 at 2:09 P.M. with the Director of Nursing (DON) confirmed weights were not obtained daily, in order to determine the need for administration of Metolazone for edema, and there wasn't any documented reweigh or medication administration on 01/23/19 and 01/24/19 when weights were recorded in excess of 203 pounds. Page 1 of 8 365889 365889 01/31/2019 Lodge Nursing & Rehab Center 9370 Union Cemetery Road Loveland, OH 45140

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents with as needed psychotropic medications were limited to 14 days or had a stop date. The facility also failed to ensure non-pharmaceutical interventions were attempted prior to giving as needed pharmaceutical interventions. This affected two (Resident #66 and Resident #76) of six residents reviewed for unnecessary medications. The facility census was 107. Findings include: 1. Review of Resident #76's chart revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, type two diabetes without complications, unspecified glaucoma, mixed hyperlipidemia, major depressive disorder, muscle weakness and repeated falls. Review of psychiatric note dated 05/02/18 revealed Resident #76 remained on an ordered as needed Ativan. The psychiatric note did not provide a stop date for the as needed Ativan. Review of psychiatric note dated 06/29/18 revealed Resident #76 remained on as needed Ativan. The psychiatric note did not provide a stop date for the as needed Ativan. Review of psychiatric note dated 10/03/18 revealed Resident #76 remained on as needed Ativan. The psychiatric note did not provide a stop date for the as needed Ativan. Review of psychiatric note dated 01/02/19 revealed Resident #76 remained on as needed Ativan. The psychiatric note did not provide a stop date for the as needed Ativan. Review of Resident #76's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to have severe cognitive impairment and required extensive assistance with transfers, bed mobility, dressing, eating, toileting and personal hygiene. Review of Resident #76's physicians orders revealed the resident was ordered Ativan Solution inject 0.5 milligrams (mg) intramuscularly every six hours as needed (PRN) for agitation and anxiety if unable to give it by mouth on 04/21/18. Resident #76's order for Ativan Solution inject 0.5 mg intramuscularly every six hours PRN for agitation and anxiety did not have an end date. The resident also had an order dated 07/06/19 for Lorazepam Intensol Concentrate give 0.5 mg by mouth every four hours PRN for anxiety and agitation. Resident #76's order for Lorazepam Intensol Concentrate give 0.5 mg by mouth every four hours PRN for anxiety and agitation did not have an end date. Review of Resident #76's Medication Administration Record (MAR) from 12/01/18 to 12/31/18 revealed resident received her Lorazepam Intensol Concentrate 0.5 every four hours for anxiety and agitation on 12/11/18. Resident #76 did not receive her Ativan Solution inject 0.5 mg intramuscularly every six hours PRN for agitation and anxiety if unable to give it by mouth from 12/01/18 to 12/31/18. Review of Resident #76's MAR from 01/01/19 to 01/29/19 revealed the resident did not receive Lorazepam Intensol Concentrate give 0.5 mg by mouth every four hours PRN for anxiety and agitation or her Ativan Solution inject 0.5 mg intramuscularly every six hours PRN for agitation and anxiety if 365889 Page 2 of 8 365889 01/31/2019 Lodge Nursing & Rehab Center 9370 Union Cemetery Road Loveland, OH 45140

F 0758 unable to give it by mouth from 01/01/19 to 01/29/19. Level of Harm - Minimal harm or potential for actual harm Interview with the Director of Nursing (DON) on 01/30/19 at 2:51 P.M., verified Resident #76's Lorazepam Intensol Concentrate 0.5 mgs by mouth every four hours PRN for anxiety and agitation and Ativan Solution inject 0.5 mg intramuscularly every six hours PRN for agitation and anxiety were not limited to 14 days and did not have a stop date. The DON also reported the facility does not have a policy regarding as needed medications requiring end dates. Residents Affected - Few 2. Review of Resident #66's medical record revealed an admission date of 03/01/18 with diagnoses including generalized anxiety disorder, major depressive disorder, dementia with behavioral disturbances, unspecified psychosis, metabolic encephalopathy, altered mental status and muscle weakness. Review of the quarterly MDS assessment dated [DATE], revealed Resident #66 was cognitively impaired, required limited to extensive assistance for activities of daily living and required supervision for eating. Review of physician's orders dated 10/04/18, revealed Lorazepam (anxiety medication) 0.5 milligrams (mg) every 12 hours as needed (PRN) for anxiety. Further review of the Lorazepam order revealed there was no duration of use given. The PRN Lorazepam end date was documented as indefinite. Review of psychiatric note dated 12/05/18, revealed Resident #66 remained on PRN Lorazepam. The psychiatric note did not provide a stop date for the PRN Lorazepam. Review of plan of care dated 12/17/18, revealed resident was to have non-pharmacological interventions before giving PRN medications. Review of psychiatric note dated 01/02/19, revealed Resident #66 remained on PRN Lorazepam. The psychiatric note did not provide a stop date for the PRN Lorazepam. Review of the Medication Administration Record (MAR) for January 2019, revealed Resident #66 received 15 doses of PRN Ativan. Resident #66 received a dose of the PRN Lorazepam on 01/01/19, 01/03/19, 01/04/19, 01/06/19, 01/07/19, 01/13/19, 01/15/19, 01/16/19, 01/19/19, 01/24/19, 01/27/19, 01/28/19, 01/29/19 and two doses on 01/11/19. Review of the progress notes for Resident #66, revealed only one note dated 01/03/19, which indicated non-pharmacological interventions were completed before giving PRN Lorazepam. Interview with the DON on 01/30/19 at 3:05 P.M., verified Resident #66 was currently receiving Lorazepam 0.5 mg PRN for anxiety. DON also verified PRN Lorazepam was not limited to 14 days and did not have a stop date. The DON also reported the facility does not have a policy regarding PRN medications requiring end dates. 365889 Page 3 of 8 365889 01/31/2019 Lodge Nursing & Rehab Center 9370 Union Cemetery Road Loveland, OH 45140

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #62 revealed an admission date of 08/29/18 and a re-admission date of 01/11/19. Diagnoses included congestive heart failure, severe sepsis with septic shock, venous insufficiency, atrial fibrillation, hypertension, and gastro-esophageal reflux disease. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed Resident #62 had moderate cognitive impairment. Review of Resident #62's physician orders revealed an order written 09/22/18 with and end date of 12/05/18 for Promethazine HCL Tablet give 25 milligrams (mg) by mouth every six hours as needed for Nausea and Vomiting, may administer rectally as needed. Observation of medication storage review on 01/30/19 at 7:33 A.M., with Licensed Practical Nurse (LPN) #117 revealed the medication cart on the East unit for the front odd rooms contained one package of 11 foiled wrapped, 25 mg promethazine (medication used for nausea and vomiting) suppositories, in a plastic bag with a blue sticker that stated do not freeze, keep in refrigerator with an order date 09/22/18. Interview on 01/30/19 at 7:33 A.M., with LPN #117 verified the suppositories were to be refrigerated and not in the medication cart. Review of a facility policy dated August 2014 revealed under the section titled Temperature section C. Medications requiring refrigeration are kept in a refrigerator at a temperature between 36 degrees Fahrenheit and 46 degrees Fahrenheit with a thermometer to allow temperature monitoring. Based on record review, observation and staff interview, the facility failed to ensure a resident's medications were given and stored in a secured manner. The facility also failed to store suppositories that required refrigeration in a proper manner. This affected one (Resident #27) of 32 residents reviewed during the initial sample for medications being stored securely. This also affected one (Resident #62) of 36 residents reviewed that received medications stored on the medication cart where the suppositories that required refrigeration were not properly stored. The facility census was 107. Findings include: 1. Record review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE] with the following diagnoses; unspecified cirrhosis of liver, esophageal varices without bleeding, essential hypertension, hyperthyroidism, muscle weakness, obstructive and reflux uropathy, insomnia, obesity and retention of urine. Review of Resident #27's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was cognitively intact and required extensive assistance with bed mobility, dressing, toileting and personal hygiene. Resident #27 also required supervision and was not reported to have any occurrence of transfers on the 01/21/19 MDS. Observation of Resident #27 in her room on 01/28/19 at 10:10 A.M., revealed the resident was lying in bed with a cup of six pills, a cup of water and a note pad on her bedside table. No staff were 365889 Page 4 of 8 365889 01/31/2019 Lodge Nursing & Rehab Center 9370 Union Cemetery Road Loveland, OH 45140

F 0761 present in the room at the time of the observation. Level of Harm - Minimal harm or potential for actual harm Interview with Registered Nurse (RN) #101 on 01/28/19 at 10:10 A.M., verified Resident #27 was in her room with a cup of six pills. RN #101 confirmed staff were not present in Resident #27's room. Residents Affected - Few Interview with Licensed Practical Nurse (LPN) #104 verified the six medication in Resident #27's cup to be Pantoprazole Sodium tablet delayed release 40 milligrams (mg), Amlodipine Besylate 5 mg, Cholecalciferol tablet 1000 units, Losartan Potassium tablet 100 mg, Senokot tablet 8.6-50 mg and Metoprolol Tartrate tablet 100 mg. Review of Resident #27's chart revealed resident had a medication self-administration assessment initiated and completed on 1/28/19 at 10:53 A.M. The assessment reported Resident #27 was able to self-administer medications. Further review of Resident #27's chart revealed resident did not have any medication self-administration assessments completed prior to 01/28/19 at 10:53 A.M. Review of Resident #27's care plan revealed resident did not have a care plan for the self-administration of medications. Interview with the Director of Nursing (DON) on 01/30/19 at 2:51 P.M. verified Resident #27 did not have a medication self-administration assessment initiated or completed prior to 01/28/19. The DON also reported Resident #27 did not have a care plan for self-administering medications. Review of the facility's undated Medication Self Administration policy revealed residents may self-administer medications if competent. The nurse would complete a self-administration assessment to demonstrate the resident's ability. 365889 Page 5 of 8 365889 01/31/2019 Lodge Nursing & Rehab Center 9370 Union Cemetery Road Loveland, OH 45140

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation and staff interview, the facility failed to ensure food and drink items in the nourishment refrigerators were maintained in a manner to prevent and protect food against contamination and spoilage. This affected 66 (Resident #2, #3, #4, #5, #6, #7, #10, #11, #12, #13, #14, #15, #16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #39, #40, #42, #44, #45, #46, #48, #53, #55, #56, #57, #58, #59, #60, #64, #66, #69, #70, #71, #72, #73, #76, #77, #78, #79, #80, #83, #84, #86, #95, #96, #99, #351 and Resident #352) who reside on the unit that utilizes the nourishment refrigerators of 107 residents residing at the facility. The facility census was 107. Findings include: Observation of the nourishment refrigerator on the central unit on 01/30/19 at 12:29 P.M., revealed there to be eight honey consistency orange juices with use by date on 11/2018 and one honey consistency orange juice with a use by date of 12/2018. Interview with Licensed Practical Nurse (LPN) #106 on 01/30/19 at 12:29 P.M., verified there to be eight honey consistency orange juices with use by date on 11/2018 and one honey consistency orange juice with a use by date of 12/2018 in the nourishment refrigerator on the central unit. Observation of the nourishment refrigerator on the central unit on 01/30/19 at 4:43 P.M., revealed there to be a brown frozen substance spattered on the inside of the freezer. Interview with Licensed Practical Nurse (LPN) #106 on 01/30/19 at 4:43 P.M., verified there to be a brown frozen substance spattered on the inside of the freezer of the nourishment refrigerator on the central unit. Observation of the nourishment refrigerator on the shelter point unit on 01/31/19 at 7:57 A.M., revealed there to be an undated and unlabeled lemonade that was half consumed and an undated and unlabeled water in a reusable bottle. The refrigerator also contained a brown substance in the bottom of the refrigerator. Observation of the nourishment freezer on the shelter point unit revealed there to be an undated and unlabeled frozen grape flavored bottle of soda that was opened and half consumed, a undated and unlabeled open frozen snack cake that was half consumed with no cover, an unlabeled and undated magic cup with a spoon in bag and an unlabeled and undated open ice cream bar that was half consumed and uncovered in the freezer. The freezer also a frozen yellow substance on the edge of the freezer. Interview with State Tested Nurse Aide (STNA) #60 on 01/31/19 at 7:57 A.M., verified there to be an undated and unlabeled lemonade that was half consumed and an undated and unlabeled water in a reusable bottle in the 300 unit nourishment refrigerator and an undated and unlabeled frozen grape flavored bottle of soda that was opened and half consumed, a undated and unlabeled open frozen snack cake that was half consumed with no cover, an unlabeled and undated magic cup with a spoon in bag and an unlabeled and undated open ice cream bar that was half consumed and uncovered in the freezer in the shelter point unit nourishment unit freezer. STNA #60 also confirmed there to be a brown substance in the bottom of the refrigerator and a yellow frozen substance on the edge of the freezer in the shelter point unit. 365889 Page 6 of 8 365889 01/31/2019 Lodge Nursing & Rehab Center 9370 Union Cemetery Road Loveland, OH 45140

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of an undated list of residents that received no food by mouth (NPO) revealed Resident #49 to be the only resident on the central unit that was NPO. There were no residents residing on the shelter point unit that were NPO. Review of an undated list of residents that received honey consistency liquids on the central unit revealed Resident #47 and Resident #71 to receive honey thickened liquids on the central unit. The facility identified 66 residents (#2, #3, #4, #5, #6, #7, #10, #11, #12, #13, #14, #15, #16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #39, #40, #42, #44, #45, #46, #48, #53, #55, #56, #57, #58, #59, #60, #64, #66, #69, #70, #71, #72, #73, #76, #77, #78, #79, #80, #83, #84, #86, #95, #96, #99, #351 and Resident #352) who reside on the unit that utilizes the nourishment refrigerators. Review of the undated food storage refrigerators on nursing units policies revealed outdated items are to be removed while stocking the refrigerators. The policy also stated refrigerators will be cleaned as needed. 365889 Page 7 of 8 365889 01/31/2019 Lodge Nursing & Rehab Center 9370 Union Cemetery Road Loveland, OH 45140

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 staff interview, the facility failed to ensure a resident's code status was accurately documented in physician progress notes. This affected one (Resident #38) of two residents reviewed for advanced directives. The facility census was 107. Findings include: Record review of Resident #38's record revealed the resident was admitted to the facility on [DATE] with the following diagnoses; essential hypertension, venous insufficiency, long term use of insulin, vascular dementia without behavioral disturbance, mixed hyperlipidemia, history of transient ischemic attack and cerebral infarction without residual deficits, allergic rhinitis, hearing loss, obstructive sleep apnea, gout, muscle weakness, difficulty in walking, major depressive disorder and displaced fracture of posterior wall of left acetabulum. Review of Medical Doctor (MD) #300's progress note dated 11/20/18 revealed Resident #38 to be a do not resuscitate (DNR). Review of Resident #38's progress note dated 11/25/18 revealed the resident's representative wished for him to be a full code. Review of Resident #38's physician's orders revealed resident was ordered to be a full code on 11/25/18. Review of Resident #38's care plan revealed resident's code status was added to the care plan on 11/26/18. The care plan indicated the resident was a full code. Review of Resident #38's admission Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing and personal hygiene. Resident #38 was also reported to be independent with eating and required total dependence with toileting. Review of MD #300's progress note dated 01/21/19 revealed Resident #38 to be a do not resuscitate (DNR). Interview with the Director of Nursing (DON) on 01/30/19 at 10:13 A.M. verified MD #300 had incorrectly documented Resident #38's code status as a DNR on the 11/20/18 and 01/21/19 progress notes. The DON confirmed Resident #38 was a full code at the facility. Review of the facility's undated Advanced Directives policy revealed the facility will notify the attending physician or nurse practitioner of advanced directives so that the appropriate orders can be documented in the resident's medical record. 365889 Page 8 of 8