Health inspection·March 28, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure record of meal intakes were consistently documented. This affected four (Residents #1, #3, #36, and #92) of five residents reviewed for meal consumption. The facility census was 104. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 12/05/23 with diagnoses including need for assistance with personal care and nutritional deficiency. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #1 dated 02/04/24 revealed the resident had intact cognition. Review of the care plan for Resident #1 dated 12/13/23 revealed the resident had nutritional problems and was at risk for malnutrition related to inadequate meal intake. Interventions included to monitor intake and record every meal. Review of the meal intake records for Resident #1 from 02/27/24 through 03/26/24 revealed there were no intakes documented for the following dates: 02/28/24, 02/29/24, 03/08/24, 03/09/24, and 03/10/24. There were only two meal intake documented on the following dates: 02/27/24, 02/28/24, 03/02/24, 03/03/24, 03/06/24, 03/07/24, 03/13/24, 03/16/24, 03/17/24, 03/18/24, 03/21/24, 03/24/24, and 03/25/24. There was only one meal intake documented on 03/11/24 and 03/22/24. 2. Review of the medical record for Resident #3 revealed and admission date of 01/26/24 with diagnoses including nutritional deficiency and adult failure to thrive. Review of the quarterly MDS assessment for Resident #dated 03/12/24 revealed the resident had intact cognition. Review of the care plan for Resident #3 revised 02/01/24 revealed the resident had a nutritional problem or potential risk for malnutrition. Interventions included to monitor intake and to record every meal. Review of the meal intake records for Resident #3 from 02/27/24 through 03/26/24 revealed there were no meal intakes documented for the following dates: 02/28/24, 02/29/24, 03/01/24, 03/04/24, 03/05/24, 03/10/24, and 03/25/24. There were only two meal intakes documented on the following dates: 02/27/24, 03/06/24, 03/07/24, 03/13/24, 03/18/24, 03/21/24, 03/22/24, 03/23/24, 03/24/24. Page 1 of 2 365889 365889 03/28/2024 Lodge Nursing & Rehab Center 9370 Union Cemetery Road Loveland, OH 45140

F 0842 Level of Harm - Minimal harm or potential for actual harm 3. Review of the medical record for Resident #36 revealed an admission date of 08/24/19 with diagnoses including anemia, moderate protein-calorie malnutrition, and dementia. Review of the quarterly MDS assessment for Resident #36 dated 03/02/24 revealed the resident had mildly impaired cognition. Residents Affected - Some Review of the care plan for Resident #36 revised 03/08/24 revealed the resident had increased nutritional needs. Interventions included to monitor intake and to record every meal. Review of the meal intake records for Resident #36 from 02/27/24 through 03/26/24 revealed no meal intakes documented for the following dates: 02/28/24, 02/29/24, 03/08/24, 03/09/24, 03/10/24, and 03/22/24. There were only two meal intakes documented for the following dates: 02/27/24, 03/02/24, 03/03/24, 03/06/24, 03/07/24, 03/11/24,03/13/24, 03/16/24, 03/17/24, 03/18/24, and 03/25/24. There was only one meal intake documented for the following dates: 03/19/24, 03/21/24, 03/25/24. 4. Review of the medical record for Resident #92 revealed an admission date of 11/09/21 with diagnoses including quadriplegia, hypertension, and anxiety disorder. Review of the quarterly MDS assessment for Resident #92 dated 01/16/24 revealed the resident was assessed to have impaired memory upon staff interview. Review of the care plan for Resident #92 revised 10/20/23 revealed the resident had a nutrition problem and a potential risk of malnutrition. Interventions included to monitor intake and to record every meal. Review of the meal intake records for Resident #92 from 02/27/24 through 03/26/24 revealed were no meal intakes documented for the following dates: 02/28/24, 03/08/24, 03/09/24, 03/10/24, 03/11/24, 03/16/24, 03/21/24, and 03/24/24. There were only two meal intakes documented for the following dates: 02/27/24, 02/29/24, 03/02/24, 03/06/24, 03/07/24, 03/13/24, 03/17/24, 03/18/24, 03/23/24. There was only one meal intake documented for the following dates: 03/03/24, 03/19/24, 03/22/24, 03/25/24. Interview on 03/27/24 at 10:38 A.M. with State Tested Nursing Assistant (STNA) #100 on confirmed the percentage of meals consumed by residents should be documented in the residents' medical record for every meal. STNA #100 confirmed there was not always time to document every meal. Interview on 03/27/24 at 10:55 A.M. with the Director of Nursing (DON) confirmed the facility staff should consistently document resident meal intakes. The DON confirmed the facility had not consistently documented meal intakes for Residents #1, #3, #36, and #92 from 02/27/24 to 03/26/24. Interview on 03/07/24 at 2:27 P.M. with the Assistant Director of Nursing (ADON) confirmed Resident #36's family member had requested the amount of meal the resident had consumed and the ADON was unable to provide the amount due to it not being documented in the resident's medical record. Review of the facility policy titled Diet/Meal Consumption reviewed 01/26/21 revealed any resident at risk for unintended weight loss should have their meal intake recorded. This deficiency represents noncompliance investigated under Complaint Number OH00152031. 365889 Page 2 of 2