Vineyards At Concord, The

hands and donned gloves.

The resident was placed on the toilet in the bathroom via two assists and

CNA #117 revealed the resident was supposed to be toileted every hour and a half. CNA #127 stated,

and an incontinence pull-up brief was placed on the resident.

This deficiency represents noncompliance investigated under Complaint Number 2984105.

366360 04/28/2026

Vineyards at Concord, The 119 West High Street Frankfort, OH 45628

Review of the resident's plan of care revealed no care plan addressing the resident's nutritional status, including weight loss.

On 04/15/26 at 3:30 P.M., an interview with [NAME] #118 revealed the house supplement is made with milk and a Whey protein powder blend supplement with creatine and ammino acids.

The cook revealed the house supplement was not for weight loss, but for extra protein. [NAME] #118 revealed she had no recipe she followed to make the supplement from the whey protein powder and at times will add ice cream, fruit or peanut butter.

The cook revealed she made a gallon of the supplement at a time. [NAME] #118 verified the facility does stock Ready Pass.

On 04/15/26 at 4:41 P.M., an interview with the RD, revealed she was aware the facility was using the whey protein powder and recommended to stop the use due to the inconsistency of how the supplement was prepared.

The RD revealed she recommended all residents who were to receive the house supplement was to receive Ready Pass supplement for preventative and/or actual weight loss.

On 04/16/26 at 8:40 A.M., an interview with [NAME] #129 revealed the facility only had two residents (#8 and #16) who received the Ready Pass.

The [NAME] revealed all other residents receive the house supplement made from the Whey protein powder blend supplement with creatine and ammino acids.

On 04/16/26 at 10:08 A.M., an interview with the Medical Director (MD) revealed he was not aware of the facility using the whey protein powder and recommended the use of supplements the RD recommended.

During an interview on 04/16/26 at 12:40 P.M., the Administrator verified the resident had no plan of care addressing the resident's nutritional status and weight loss, no initial comprehensive nutritional assessment at the RD recommendations were not implemented.

This deficiency represents non-compliance investigated under Complaint Number 2984105.

366360 04/28/2026

Vineyards at Concord, The 119 West High Street Frankfort, OH 45628

Observation on 04/15/26 at 12:15 P.M. with [NAME] #118 revealed the lunch meal was pork and sauerkraut, mashed potatoes and bread pudding.

The pork and sauerkraut were made into mechanical texture and served to residents who are on a regular diet.

Associate #118 confirmed pork was mechanical texture and she does this so residents receive the same looking meat and to reduce choking hazard.

Pureed pork and sauerkraut was made with milk.

Associate #118 confirmed she used milk to puree pork and sauerkraut because it adds calories and nutrients.

Review of the medical records revealed 18 ( #1, #2, #4, #6, #7, # 8, #11, #13, #14, #18, #21, #22, #23, #24, #25, #26, #27, and #29) residents received a regular diet.

Interview on 04/15/26 at 1:58 P.M. with Administrator confirmed mechanical textured meat served to all regular diet residents is not appropriate and confirmed puree recipe exists for lunch meal but was not followed.

This deficiency represents noncompliance investigated under Complaint Number 2984105.

366360 04/28/2026

Vineyards at Concord, The 119 West High Street Frankfort, OH 45628

Review of the resident's five-day Minimum Data Set (MDS) assessment dated [DATE] revealed the

pyothorax and received antibiotic medications.

The assessment indicated the resident was receiving intravenous medications.

Review of the resident's monthly physician orders for April 2026 identified orders dated 03/27/26 maintain midline intravenous (IV) patency, flush IV line with normal saline (NS) per policy for antibiotic infusion, 03/30/26 assess midline site every shift, maintain dressing to IV site, change dressing every seven days and as needed, 04/07/26 Ceftriaxone Sodium IV solution 2 grams IV daily for pyothorax until 04/19/26.

Further review of the resident's physician orders both active and discontinued revealed no physician order for enhanced barrier precautions related to the midline IV therapy.

On 04/13/26 at 10:06 A.M., observation of the Director of Nursing (DON) administered the physician ordered medication Ceftriaxone Sodium IV solution 2 grams IV revealed she washed her hands, administered the resident her by mouth medications and set-up IV medication to administer.

The DON then washed her hands, donned gloves and flushed the resident's peripherally inserted central catheter (PICC) line with five milliliters (ml) of normal saline (NS).

She then connected the medication.

The DON had donned no gown or mask for enhanced barrier precautions (EBP).

On 04/13/26 at 10:42 A.M., an interview with the DON verified she had not donned personal protection equipment for EBP while administering the IV medications.

She verified the resident had not been on EBP, although should have been.

Review of facility policy titled Enhanced Barrier Precautions dated 01/25, states Appropriate PPE of gowns and gloves shall be worn when coming in close contact with residents whom have open routes to their interior body and or colonized MDRO infections.

This includes but is not limited to: Feeding tubes, IV and PPE stations shall be set up with gowns and gloves outside or right inside the doorway of rooms.

This deficiency represents noncompliance investigated under Complaint Number 2984105.