Resident 23, who has been at the facility since July 2023, depends entirely on staff for personal care due to paralysis affecting his left side. His care plan specifically notes he needs treatment for a rash on his left inner thigh and groin area, with interventions including applying medication per physician's orders.
The doctor's order was clear: cleanse the area with soap and water, pat dry, and apply miconazole antifungal powder every shift. The order began on June 29, 2025.
But treatment records for December show staff skipped the ordered care on day shifts December 9, 11, 13, 14, 18, and 20. No signatures appeared on the treatment administration record for those dates.
When federal inspectors interviewed the resident on December 22, they found a large red area approximately three inches long by two inches wide on his left thigh. The resident told inspectors he received powder to his upper left thigh because it was itchy at times.
"Some staff were better than others at making sure he received it every day," he said.
The resident remains cognitively intact despite his physical limitations. He requires supervision for eating, partial assistance with oral hygiene, and substantial help with personal hygiene. Staff must handle all his toileting and showering needs.
His medical diagnoses include bipolar disorder, depression, muscle weakness, insomnia and respiratory failure in addition to the paralysis. The quarterly assessment from earlier this year noted no skin issues at that time.
By October, his care plan documented an "alteration in skin integrity" evidenced by the thigh and groin rash. The plan called for staff to assess the area for size, color and drainage as needed, provide treatment per physician's orders, and monitor for pain.
Registered Nurse 202 acknowledged during her December 22 interview that she knew about the resident's skin integrity issues related to his groin and legs. She confirmed the facility was responsible for applying treatments as ordered since the resident couldn't do it himself.
The Director of Nursing, interviewed the following day, could provide no evidence that staff had completed the skin treatment as ordered.
The facility's own policy on skin assessment, dated March 15, 2024, states that necessary treatment and services will be provided for skin integrity issues. Areas of altered skin integrity "would be treated according to medical direction and would be followed conscientiously."
Miconazole is a common antifungal medication used to treat skin conditions like rashes in warm, moist areas of the body. For dependent residents in nursing homes, consistent application is essential to prevent worsening infections.
The missed treatments occurred during a period when the resident's condition required daily attention. Each missed application allowed the fungal condition to persist and potentially worsen in the affected area.
Federal inspectors documented the violation under regulations requiring facilities to provide appropriate treatment and care according to physician orders and resident preferences. The citation noted minimal harm or potential for actual harm.
This case emerged from a complaint investigation numbered 2649255, suggesting someone reported concerns about care at the facility to state regulators.
Tamarack Ridge operates 95 beds and this violation affected one of three residents reviewed during the inspection for care and services issues.
The resident continues to experience the itchy, uncomfortable condition while depending on staff who have proven inconsistent in following his doctor's orders. His cognitive awareness means he understands when his care is being neglected, adding psychological distress to his physical discomfort.
The three-inch area of redness observed by inspectors represents the visible consequence of missed treatments over multiple days. For a paralyzed resident who cannot reposition himself or apply his own medication, each skipped treatment extends his suffering.
The facility must now submit a plan of correction to continue participating in Medicare and Medicaid programs. But for Resident 23, the damage from weeks of inconsistent care has already manifested in the form of an inflamed, uncomfortable rash that proper treatment could have prevented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tamarack Ridge Health and Rehabilitation from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Tamarack Ridge Health and Rehabilitation
- Browse all OH nursing home inspections