Tamarack Ridge Health And Rehabilitation

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

record review, observation, interview and facility policy review, the facility failed to ensure Resident #23's skin care was completed as ordered by the physician. This affected one resident (Resident #23) of three residents reviewed for care and services. The facility census was 95.Findings include: Review of the medical record for Resident #23 revealed an admission date of 07/20/23. Diagnoses included paralysis affecting the left non-dominant side, bipolar disorder, depression, muscle weakness, insomnia and respiratory failure.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] revealed Resident #23 was cognitively intact. He required supervision for eating, partial assistance for oral hygiene, substantial assistance for personal hygiene and was dependent on staff for toileting and showering. He had no noted skin issues.Review of the care plan dated 10/10/25 revealed Resident #23 had an alteration in skin integrity as evidenced by a rash to his left inner thigh/groin area. Interventions included assessing the area for size, color and drainage as needed, providing treatment per physician's orders and assessing for pain.Review of the physician's orders for December 2025 revealed in order to cleanse Resident #23's left inner thigh/groin area with soap and water, pat dry and apply house stock powder (miconazole), an antifungal powder, to the area every shift for a rash. The order began on 06/29/25.Review of the treatment administration record (TAR) for December 2025 revealed the ordered treatment of miconazole powder to Resident #23's left inner thigh/groin area was not signed off as completed per physician's orders on day shift on 12/09/25, 12/11/25, 12/13/25, 12/14/25, 12/18/25, and 12/20/25. Interview and observation on 12/22/25 at 8:08 A.M. with Resident #23 revealed he received a powder to his upper left thigh because it was itchy at times. He revealed some staff were better than others at making sure he received it every day.

Observation at the time of the interview revealed a large, red area approximately three inches long by two inches wide on Resident #23's left thigh.Interview on 12/22/25 at 10:09 A.M. with Registered Nurse (RN) #202 revealed she was aware Resident #23 had some issues with skin integrity related to his groin and legs. She revealed the facility was responsible for applying treatments as ordered, since Resident #23 was unable to do so himself.Interview on 12/23/25 at 9:58 A.M. with the Director of Nursing (DON) confirmed

she could provide no other evidence the skin treatment ordered for Resident #23 had been completed as ordered.Review of the facility policy titled Skin Assessment, dated 03/15/24, revealed the facility would ensure necessary treatment and services were provided for the completion and documentation of skin integrity. Areas of altered skin integrity would be treated according to medical direction and would be followed conscientiously.This deficiency represents noncompliance investigated under Complaint Number

1. 2649255. Residents Affected - Few

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

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Tamarack Ridge Health and Rehabilitation

5113 State Route 43 Kent, OH 44240

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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was contacted early this morning about Resident #96's Norco and pregabalin, and she sent prescriptions for both to the pharmacy. NP #210 stated she was not contacted on 12/22/25 about Resident #96's Norco or pregabalin and maybe the on-call NP or Physician was contacted. NP #210 confirmed she verified Resident #96's medications with a nurse from the facility, but the nurse did not tell her prescriptions were needed for pregabalin and Norco, and if the nurse did not tell her a prescription was needed then I don't know'.Review of the facility policy titled Pain Assessment and Management, dated 03/31/16, included assessment and adequate treatment of pain was central to the management of the physical and psychological well-being of residents.

Event ID:

Facility ID:

If continuation sheet