Gateway Springs Health Campus

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to discard expired resident medications. This affected one (Resident #6) of two residents observed for medication administration. The facility census was 32 residents.

Findings include:

Review of the medical record for Resident #6 revealed an admission of 11/17/21 with diagnoses including hypertension and type two diabetes mellitus.

Review of functional assessment for Resident #6 dated 01/01/25 revealed the resident had intact cognition.

Review of the physician's orders for Resident #6 dated March 2025 revealed orders pantoprazole 40 milligrams (mg) daily and gabapentin 400 mg daily.

Observation on 03/05/25 at 8:30 A.M. of medication administration for Resident #6 per Licensed Practical Nurse (LPN) #44 revealed the resident's pantaprazole had expired on 07/26/24 and the resident's gabapentin had expired 01/02/25.

Interview on 03/05/25 at 8:30 A.M. with LPN #44 confirmed Resident #6's pantaprazole and gabapentin were expired and should have been discarded.

Interview on 03/05/25 at 4:45 P.M. with the Administrator and the Director of Health Services (DOHS) confirmed the expired medications should have been removed from the medication cart.

Review of the facility policy titled Medication Storage revealed staff should remove outdated medications from the cart to prevent unintentional use.

Based on medical record review, observation, staff interviews, and review of the facility policy, the facility failed to ensure staff practiced proper hand hygiene during medication administration. This affected two (Residents #2 and #6) of two residents observed for medication administration. Based on online review and staff interview, the facility also failed to designate a staff person to serve as the Infection Control Coordinator (ICC) and to list the ICC in the state agency's Enhanced Information Dissemination and Collection (EIDC) website. This had the potential to affect all of the residents residing in the facility. The facility census was 32 residents.

Findings include:

1. Review of the medical record for Resident #2 revealed an admission date of 02/20/23 with diagnoses including myasthenia gravis without exacerbation, dementia, emphysema, supraventricular tachycardia, and spinal stenosis.

Review of the functional assessment for Resident #2 dated 01/13/25 revealed the resident was cognitively impaired.

Review of medical record for Resident #6 revealed an admission of 11/17/21 with diagnoses including hypertension, type two diabetes mellitus, chronic kidney disease, and major depressive disorder.

Review of functional assessment for Resident #6 dated 01/01/25 revealed the resident had intact cognition.

Observation of medication administration on 03/05/25 at 8:18 A.M. to Resident #2 per Licensed Practical Nurse (LPN) #44 revealed the nurse checked the resident's blood pressure and administered medications. LPN #44 returned to the medication cart, prepared Resident #6's medications and administered them to the resident in her room. LPN #44 did not wash or sanitize her hands after medication administration to Resident #2 and prior to preparing and administering Resident #6's medications.

Interview on 03/05/25 at 8:40 A.M. with LPN#44 confirmed she did not wash or sanitize her hands after checking Resident #2's blood pressure and administering medications before she began to prepare and administer medications for Resident #6.

Interview on 03/05/25 at 4:45 P.M. with the Administrator and the Director of Health Services (DOHS) confirmed nurses should wash or sanitize hands between residents during medication administration.

Review of the facility policy titled Guideline for Handwashing/Hand Hygiene dated 12/17/24 revealed staff should practice hand hygiene before and after resident contact and all healthcare workers should utilize hand hygiene appropriately.

2. Review of the Ohio Department of Health (ODH) EIDC website revealed the facility had not designated an ICC.

Interview on 03/05/25 at 4:45 P.M. with the Administrator confirmed the facility had not designated an ICC on the ODH EIDC website.

Based on observation and staff interview, the facility failed to post the most recent survey results or a notice of availability of survey results upon request. This had the potential to affect all of the residents in the facility. The facility census was 32 residents.

Findings include:

Observation on 03/05/25 at 11:50 A.M. revealed neither a copy of the most recent survey results nor a notice of availability of survey results on request were posted prominently in the facility.

Interview on 03/05/25 at 4:45 P.M. with the Administrator confirmed the facility had not posted the most recent survey results nor had the facility posted a notice of availability of survey results.

Based on medical record review, staff interview, and policy review, the facility failed to ensure a resident's dressing changes and wounds were monitored every seven days. This affected one (Resident #6) of one resident reviewed for dressing changes. The facility census was 24.

Findings included:

Medical record review for Resident #6 revealed an admission date of 10/12/22 and discharge date of 07/13/23. Medical diagnoses included heart failure, coronary artery disease (CAD), atrial fibrillation, diabetes, arthritis, and chronic lung disease.

Review of the service plan dated 04/13/23 revealed Resident #6 was cognitively intact and required assistance with mobility and transfers.

Further review of the medical record revealed Resident #6 admitted to the facility with cellulitis to her bilateral extremities (BLE). Review of physician orders dated 10/12/22 revealed orders to cleanse BLE with normal saline and pat dry and apply abdominal pads and wrap with kerlix and ace wraps twice a day. Review of physician orders dated 11/11/22 revealed an order to apply Aquaphor to intact skin on the left lower extremity (LLE) during dressing changes. On 07/01/23, Resident #6 was prescribed Clotrimazole cream 1% topical to apply to BLE feet and lower legs twice a day for two weeks and leave open to air. On 07/12/23, a new order was received for ACE wraps to be applied in the A.M. and off in the P.M.

Review of the medical record from 05/01/23 through 07/13/23 revealed there was no documentation every seven days showing Resident #6's cellulitis was monitored.

Interview with the Administrator on 08/22/23 at 3:00 P.M. revealed there was no documentation Resident #6's cellulitis, which required dressings/wound care, was being evaluated every seven days.

Review of the policy titled, Pressure, Stasis, Diabetic Wound Guidelines