Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Convalarium Of Dublin during CMS and state inspections, most recent first.
Activities Program Not Directed by a Qualified Professional: The facility allowed an unlicensed Activities Director to oversee the activities program and complete resident activity assessments for all sampled residents. Records showed the employee had not completed the required certification, and both the new Activities Director and the Administrator confirmed the prior director was not qualified. Observations later showed the employee working as an activity assistant and conducting activities with residents.
Kitchen equipment was not operating correctly. An employee was seen using a plastic scoop to break up ice because the ice machine was producing large sheets instead of cubes, and the DS confirmed the issue. A steamer also had a nonworking drain, with dirty water collected in a tray under the doors; the DS said administration was aware, and the Maintenance Director said he had been told about the drain issue but could not repair it because the unit was old and parts were obsolete.
Surveyors found that staff failed to follow infection control protocols for both shared equipment and isolation precautions. An LPN checked a resident’s blood glucose using a shared glucometer and cleaned it only with an alcohol wipe, despite facility policy requiring a low-level disinfectant wipe and the regional nurse’s acknowledgment that alcohol wipes would not prevent bloodborne illnesses. In a separate case, a resident on contact isolation for C. diff had a posted sign instructing staff to wear gloves and a gown upon room entry, yet a respiratory therapist entered without any PPE and a CNA performed incontinence care without a gown, later admitting she needed to read the door sign to know what PPE was required.
A resident with significant neurologic and functional impairments, including hemiplegia, aphasia, vascular dementia, and ADL deficits, was care planned to require assistance with meal set up and clean up. After a meal, the resident was observed in bed with food (corn) on their shirt, indicating they had not been cleaned up as required. The resident reported being unaware of the food on their clothing and expressed upset about not being cleaned after the meal. An LPN confirmed the presence of food on the resident and the resident’s distress. Facility policy on dignity required staff to groom residents as they wish to be groomed and to promote resident independence, which was not followed in this situation.
A resident with severe cognitive impairment, total dependence for ADLs, and multiple complex medical conditions was admitted with moisture-associated dermatitis to the coccyx. Although the care plan identified risk for skin breakdown and called for wound assessment and treatment per facility protocol, staff did not complete ongoing skin assessments for several weeks and did not obtain treatment orders for the coccyx dermatitis until well after admission. The wound nurse confirmed the lack of documented assessments and delayed treatment orders, and the DON stated that staff were expected to chart and treat skin issues until resolution, in contrast to the facility’s wound care policy requiring wound measurement and treatment as indicated.
A resident with multiple comorbidities, including Alzheimer’s disease, diabetes, COPD, schizophrenia, peripheral vascular disease, and a history of a heel pressure ulcer, was assessed as cognitively impaired and needing assistance with self-care and mobility, and had a physician order to wear Prevalon boots on both feet at all times except during hygiene care. Over multiple observations on consecutive days, the resident was repeatedly seen without the ordered boots in place, and an RN confirmed the resident had not been wearing them during his shift. This failure to follow the physician’s order for pressure ulcer prevention devices resulted in a cited deficiency related to pressure ulcer care and prevention.
A resident with multiple comorbidities and moderately impaired cognition, care planned as a fall risk and requiring assistance with toileting transfers, developed increasing right shoulder pain that interfered with therapy and was later confirmed by x-ray as a displaced scapular fracture. Documentation included a risk assessment stating the resident walked into a door post while going to the bathroom and an NP note indicating the resident ran into a door jamb, but the assessment was kept outside the medical record, lacked follow-up details, and did not specify whether staff were assisting. The incident was not entered on the incident/accident log, the medical record contained no clear description of how the injury occurred, and staff interviews yielded no recollection of the event, while the resident and family reported the injury occurred during a toilet transfer with staff assistance. Facility leadership acknowledged that the event was not thoroughly investigated and that staff statements and complete documentation of the cause of the injury were lacking.
A resident with multiple complex conditions, including CHF, DMII, morbid obesity, and chronic respiratory failure, who was cognitively intact but dependent on staff for several ADLs and used a wheelchair, was transported to the wrong location for a scheduled PET scan. Appointment documentation from a cardiology visit listed one testing site and time, while the physician order in the facility record listed a different site and date, resulting in the resident being taken to the incorrect testing center and missing the scan. The resident and spouse later contacted the facility from the wrong location and ultimately chose to walk back rather than wait for arranged transportation, contrary to the facility’s transportation policy that requires arranging and ensuring transport to and from outside appointments.
A resident with multiple chronic conditions and dementia reported missing dentures, which were later found broken in a toilet. The care plan directed staff to monitor for oral/dental problems and to coordinate dental care and transportation, and the guardian reportedly agreed to arrange for the resident to be seen by a dentist. However, over the following months there was no documentation of any dental visits or of attempts to contact the guardian regarding dental care, despite the requirement for a completed dental consent form. The SSD confirmed the lack of documentation of guardian contact and was unaware of any policy on the frequency of guardian contact to resolve such issues.
Two residents received psychotropic medications in a manner not supported by the record. One resident with depression and multiple chronic conditions had concurrent orders and administration of Lexapro and Zoloft, while psychiatric notes only documented continuation of Lexapro. Another resident with depression, anxiety, dementia, and hallucinations was ordered a dose reduction of Remeron to mirtazapine 7.5 mg, but the MAR showed both the 15 mg and 7.5 mg doses were given the same day; the DON confirmed the duplicate administration.
A resident with Alzheimer’s disease, DM, COPD, schizophrenia, and PVD had impaired cognition and was identified as at risk for malnutrition, but the comprehensive care plan was not updated to include a physician-ordered house supplement given 3 times per day. An LPN confirmed the nutrition care plan did not contain the supplement intervention, despite the facility policy assigning the care planning team responsibility for a comprehensive care plan.
Failure to provide fingernail care for a dependent resident. A resident with AFib, COPD, DM, dysphagia, and cognitive impairment had a BIMS of 12 and needed assistance with ADLs and personal hygiene. Staff documentation showed fingernail care was last completed and then declined on later occasions. During observation, the resident’s fingernails were long and dirty, with debris caked under several nails, and the resident said he preferred shorter, cleaner nails. A CNA and RN both confirmed the nails were longer than preferred and dirty, and the regional nurse stated staff, not the podiatrist, should clean and trim fingernails as needed and upon request.
A resident with dysphagia, COPD, diabetes, and cognitive impairment did not receive ordered feeding support during meals. Staff observed the resident being served liquids in a carton instead of cups, and the CNA, RN, DON, and Regional Nurse were unaware of or unsure about the resident’s documented swallowing and feeding instructions, despite hospital discharge paperwork and posted bedside guidance.
A facility failed to provide adequate PPE, specifically eye protection, for staff caring for a COVID-19 positive resident. Additionally, a resident exposed to COVID-19 refused isolation and frequently mingled in common areas without a mask. The facility did not notify residents or their representatives about the COVID-19 case, and mask-wearing was not enforced among residents, increasing the risk of virus spread.
The facility failed to maintain sanitary conditions in food storage and preparation areas, affecting 55 residents. Unlabeled and undated food containers were found in the refrigerator, and significant ice build-up was observed in the freezer. Additionally, ceiling vents over a food preparation area were covered in a brown and black fuzzy substance, all confirmed by the Dietary Manager.
The facility failed to educate and offer influenza vaccinations to residents as required, affecting five residents. Medical records showed that these residents either did not receive the flu vaccination since admission or were not offered it in the current year. Additionally, there was no documentation of education on the risks and benefits of the vaccination. The facility's policy required offering the vaccine and providing education, but this was not followed, as confirmed by the DON.
The facility failed to educate and offer COVID-19 vaccinations to residents, affecting several individuals. Despite previous vaccinations, some residents were not educated or offered the vaccine upon admission, and refusals were not documented. The DON confirmed these deficiencies, and a related policy was not provided during the survey.
The facility failed to follow a resident's DNR-CCA order, performing CPR without verifying the code status, which was accessible. Additionally, the facility did not adhere to physician orders for weight monitoring of another resident, missing several checks and failing to notify the MD of significant weight gains. The DON confirmed these deficiencies.
A resident with multiple stage four pressure ulcers did not receive proper wound monitoring in accordance with facility policy. Despite the requirement for weekly assessments, the resident's wounds were not measured upon readmission on two occasions, and there was a twenty-eight-day gap without visualization or measurement by a wound specialist. Staff interviews confirmed the deficiency, although no adverse outcomes occurred, the potential for harm was present.
A resident with acute and chronic respiratory failure was found with a pill cup containing eight tablets on the nightstand while asleep with a bipap. The medications were left by the night shift nurse from the 6:00 A.M. medication pass. An LPN confirmed the oversight, which violated the facility's medication storage policy.
A facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. An LPN administered incorrect doses of Tylenol and Morphine to a resident, deviating from the physician's orders. The LPN acknowledged the error, indicating a possible change in the resident's medication order. The facility's policy requires correct medication preparation and administration, which was not followed.
Two residents in the facility did not receive their prescribed insulin doses on multiple occasions, and there was no documentation explaining the missed doses. One resident reported that the insulin was not administered due to a lack of stock. The facility's policy requires timely medication administration and proper documentation, which was not followed.
A facility failed to store a catheter bag properly, as it was found on the floor under a resident's bed, contrary to policy. Additionally, another resident with a peg tube did not have Enhanced Barrier Precautions (EBP) in place, lacking necessary signage and PPE, until surveyor intervention. These deficiencies were confirmed by staff interviews.
A resident with Parkinson's disease and vascular dementia experienced a fall in a LTC facility. Although the physician was notified promptly, the resident's spouse, who was the POA, was informed about 15 hours later. This delay in family notification was against the facility's policy, which requires immediate communication with the resident's legal representative or family member after such incidents.
A facility failed to complete physician-ordered lab tests for a resident with Alzheimer's, diabetes, and dementia. Despite orders for HbA1c and BMP tests every six months, these were not conducted over a specified period. The facility's policy requires nurses to execute such orders, but this was not followed, as confirmed by the Administrator and DON. This deficiency was found during a complaint investigation.
An LPN failed to perform hand hygiene during medication administration for two residents under enhanced barrier precautions. The LPN did not clean hands before and after preparing and administering medications, contrary to facility policy and signage requirements. This was confirmed during an interview and noted during a complaint investigation.
The facility failed to conduct pre-employment background checks for two STNAs and an OT, as required by policy, potentially affecting all 81 residents. Employee files lacked evidence of completed checks, confirmed by interviews with the Administrator and HR. This deficiency was investigated under a specific complaint number.
The facility failed to conduct performance evaluations for two STNAs, affecting all residents. STNAs hired over a year apart lacked documented evaluations, confirmed by the Administrator and HR. This deficiency was identified during a complaint investigation, with the facility census at 81.
The facility failed to document the required 12 hours of training for two STNAs, as confirmed by HR. This deficiency, affecting the entire resident population, was identified through personnel file reviews and staff interviews.
The facility did not follow the prepared lunch menu, substituting mixed vegetables for cauliflower and omitting garlic toast without a substitute. The Dietary Manager confirmed the lack of cauliflower and the oversight regarding the garlic toast.
The facility failed to ensure meals were served within a 14-hour window, resulting in a 15-hour gap between dinner and breakfast. The Dietary Manager confirmed the lack of substantial snacks during this period. Residents expressed dissatisfaction with the long interval and insufficient snack distribution, with some not receiving snacks at all. This issue was investigated under a specific complaint.
The facility failed to provide scheduled showers for two residents, despite their medical needs and care plans indicating the necessity for assistance with ADLs. One resident received only one shower over two weeks, while another received one shower in a month. Both residents confirmed not refusing care, and the DON verified the lack of documentation for the scheduled showers.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified professional. Review of the employee file for Activity Aide #517 showed she worked at the facility as the Activities Director from 03/24/23 to 11/10/25, but there was no evidence that she was licensed or registered by the state. An email from Corporate Representative #800 to the Administrator and Activity Aide #517 dated 06/25/25 stated that she was to enroll in a course to become certified through the National Certification Council for Activity Professionals, with the facility to reimburse costs after completion. A written statement from Activity Aide #517 dated 01/06/26 stated she started activity courses to become certified and finished part one in June 2025, but did not complete all courses. Review of 30 sampled residents' medical records showed the previous Activities Director/Activity Aide #517 completed all activity assessments for residents from 03/24/23 to 11/10/25. The new Activities Director #582 stated in interview on 01/06/25 at 10:30 A.M. that she was hired on 11/07/25 because the previous director was not qualified for the position, and that as of 11/10/25 the previous Activities Director was working as an activity assistant. The Administrator also confirmed on 01/06/25 at 10:45 A.M. that the facility Activities Director from 03/24/23 to 11/10/25 was not qualified to be the Activities Director. Observations from 01/05/25 to 01/08/25 at random times showed Activity Aide #517 working as an activity assistant and conducting activities with residents. The facility job description for Activities Director required the position to direct the overall operations of the Activities Department and listed qualifications including a licensed or certified activities professional.
Kitchen Equipment Not Operating Correctly
Penalty
Summary
The facility failed to ensure kitchen equipment was operating correctly. During a kitchen tour, an employee was observed using a plastic scoop to break up ice in the ice machine while the machine was producing large sheets of ice instead of cubes, requiring staff to physically break up the ice so it would fit into drinking glasses. The Dietary Supervisor confirmed the ice machine findings during the observation and stated he did not know whether maintenance was aware of the problem. The steamer was also observed with a metal tray of dirty water sitting directly under the doors, while the drain tray connected to the steamer was rusty orange and empty. The Dietary Supervisor confirmed the steam table drain did not work and stated administration was aware. The Maintenance Director later confirmed he was not aware of the ice machine problem and stated he had been informed about the steam table drain issue previously, but could not fix it because the steamer was an old unit and the parts were obsolete.
Failure to Properly Disinfect Shared Glucometer and Use PPE for Contact Precautions
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to shared glucometer disinfection and use of personal protective equipment (PPE) for residents on isolation precautions. For one resident with multiple diagnoses including diabetes, hepatic encephalopathy, cirrhosis, and chronic viral hepatitis B and C, an LPN was observed checking the resident’s blood glucose using a shared facility glucometer and then cleaning the device only with an alcohol wipe. The LPN confirmed this was the method used to cleanse the glucometer. Review of the facility’s Shared Glucometer Cleaning Protocol showed that staff were required to use a fresh approved low-level disinfectant wipe each time the glucometer was used, and the Regional Nurse confirmed that cleaning a shared glucometer with an alcohol wipe would not prevent blood illnesses such as hepatitis. The deficiency also includes failure to follow required PPE use for a resident on contact isolation precautions for Clostridioides difficile (C. diff). This resident had diagnoses including atrial fibrillation, COPD, diabetes, dysphagia, and cognitive communication deficit, and was ordered contact isolation precautions. A sign on the resident’s door instructed staff to don gloves and a gown before room entry. A respiratory therapist was observed entering the room without any PPE, and a CNA was later observed performing incontinence care for the same resident without wearing a gown, with her scrub top visible. The CNA acknowledged that PPE should be worn in the room and had to read the sign after exiting to determine what PPE was required and for which resident. The unit manager confirmed the resident had been on contact isolation for C. diff and that contact precautions required the use of appropriate PPE, including gown and gloves upon entering the resident environment, as outlined in the facility’s Standard Precautions policy.
Failure to Provide Post-Meal Clean-Up Compromising Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to provide post-meal care necessary to maintain a resident’s dignity. Resident #32, admitted on 03/22/23, had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, morbid obesity due to excess calories, aphasia following cerebrovascular disease, cerebral infarction due to occlusion or stenosis of the right middle cerebral artery, major depressive disorder, anxiety, bipolar disorder, vascular dementia, hyperlipidemia, chronic kidney disease, and lack of coordination. The resident’s care plan, last revised on 11/03/25, identified a risk for ADL performance deficits related to generalized weakness, decreased strength and endurance, decreased activity tolerance, impaired mobility, and incontinence related to a cerebrovascular accident. The care plan specified that the resident required increased assistance with ADL performance and was able to eat with set up and clean up assistance. On 01/05/26 at 3:46 P.M., surveyor observation revealed Resident #32 resting in bed watching television with corn on his shirt from lunch, indicating that post-meal clean up assistance had not been provided. During an interview at the time of observation, the resident stated he was not aware of the corn on his shirt and expressed upset that he had not been cleaned up after lunch. At 3:48 P.M., an interview with LPN #604 confirmed that the resident had corn on him and that he was upset about not being cleaned up from lunch. Review of the facility’s “Dignity” policy, last revised 8/25, showed that staff were expected to groom residents as they wish to be groomed and to promote resident independence, which was not followed in this instance.
Failure to Timely Assess and Treat Non-Pressure Skin Condition
Penalty
Summary
The deficiency involves the facility’s failure to timely assess and implement treatment for a non-pressure skin condition in one resident. The resident was admitted with multiple serious diagnoses, including respiratory failure with hypoxia, cerebral edema, protein-calorie malnutrition, cerebral infarction, metabolic encephalopathy, hypokalemia, convulsions, paroxysmal atrial fibrillation, peripheral vascular disease, and pneumonia. An MDS assessment documented that the resident had severe cognitive impairment and was fully dependent on staff for all ADLs. The resident’s care plan, last revised on 11/19/25, identified risk for skin alteration related to generalized weakness, decreased strength and endurance, decreased activity tolerance, impaired mobility, impaired cognition, and incontinence, with interventions to administer treatments as ordered, monitor effectiveness, and assess and record wound healing, including measurements of length, width, and depth, following facility protocol. Despite these identified risks and care plan interventions, the admission assessment documented that the resident was admitted with moisture-associated dermatitis to the coccyx, and the facility did not perform any skin assessments from 09/02/25 through 09/29/25. Additionally, there were no treatment orders in place for the coccyx moisture-associated dermatitis until 09/25/25. Wound Nurse #586 confirmed the absence of documented skin assessments during this period and the lack of treatment orders for the dermatitis until that later date. The DON confirmed the expectation that staff should chart and treat skin issues until they are resolved. Facility policy on wound care, last revised 8/25, required staff to measure wounds, including length, width, and depth, and apply treatments as indicated. This non-compliance was investigated under multiple complaint numbers as cited in the report.
Failure to Implement Ordered Pressure Ulcer Prevention Devices
Penalty
Summary
Surveyors identified a deficiency in pressure ulcer prevention when a resident with Alzheimer’s disease, diabetes mellitus, COPD, schizophrenia, and peripheral vascular disease, who had a history of a right heel pressure ulcer and was care planned as at risk for additional skin breakdown due to immobility, was not provided ordered pressure-relieving devices. The resident’s quarterly MDS showed moderately impaired cognition with a BIMS score of 08 and a need for assistance with self-care and mobility. Physician orders dated 09/17/24 directed that the resident wear Prevalon boots on both feet at all times except during hygiene care. However, during random observations over two days, from the morning of 01/07/26 through the evening of 01/08/26, the resident was repeatedly observed without the Prevalon boots in place, and an RN confirmed the resident had not been wearing the boots that day and did not have them on at the start of his shift. This failure to implement the ordered pressure ulcer preventative intervention constituted the cited deficiency, which was investigated under multiple complaint numbers.
Failure to Thoroughly Investigate and Document Resident Shoulder Fracture Incident
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough investigation into a resident accident with injury, specifically a displaced scapular fracture, and to adequately document the circumstances of the incident. The resident was admitted with multiple serious diagnoses, including respiratory failure with hypoxia, sepsis, heart failure, heart disease, a displaced scapula fracture, cognitive communication deficit, and muscle weakness. An MDS assessment showed moderately impaired cognition and a need for supervision and touching assistance, and the care plan identified the resident as at risk for falls with interventions such as anticipating needs, ensuring call light access, appropriate footwear, and PT evaluation. Occupational therapy documented that the resident required contact guard assistance for toileting transfers and had requested a higher toilet. Over several days, progress notes and therapy notes documented new and increasing right shoulder and upper arm pain, with pain scores ranging from two to eight out of ten, interfering with therapy. On one date, the resident complained of right shoulder pain, the NP was notified, and a stat x-ray of the right shoulder was ordered along with an ice pack and a lidocaine 4% patch. The radiology report showed a displaced fracture of the scapula with degenerative changes, and the result was reviewed by the medical provider. An occupational therapy note recorded that the family requested a bedside commode over the toilet due to the resident recently injuring her right shoulder during a transfer. A risk assessment documented that the resident reported walking into a door post while going into the bathroom, with a pain level of six, but the assessment was marked privileged and confidential, not part of the medical record, and did not include follow-up on the injury, the x-ray results, the timing of the injury, or whether staff were assisting at the time. The medical record, including progress notes, contained no details on how the fracture occurred, and the incident/accident log had no entry for any fall or injury for this resident. The NP note stated the resident ran into a door jamb two days prior, but there was no corroborating detail in the record. Interviews with nursing and CNA staff who worked with the resident during the relevant period yielded no recollection of the resident or the incident. The resident’s family member reported that the resident fractured her shoulder after a toilet transfer with staff assistance and that both the resident and family informed management, who allegedly told them the resident had just bumped into the wall. The DON and Regional Nurse stated the resident was alert and oriented, referenced unnamed staff who said the resident bumped into the wall, and asserted it was not an unknown injury, but they could not state whether staff were present when the injury occurred, confirmed the event was not on the incident log, and acknowledged that staff statements were not obtained and there was no evidence in the medical record related to the cause of the fall or explanation for the discrepancy between the family’s account and facility documentation.
Failure to Provide Accurate Transportation for Outside PET Scan Appointment
Penalty
Summary
The facility failed to ensure adequate transportation was provided for an outside radiology appointment for Resident #96. The resident, admitted on 10/03/24, had diagnoses including acute chronic systolic heart failure, type II diabetes mellitus, morbid obesity, chronic respiratory failure, and major depression bipolar disorder. An MDS assessment dated [DATE] showed she was cognitively intact but dependent on staff for toileting, bathing, footwear, and turning in bed, and she used a wheelchair for mobility. Nursing progress notes confirmed multiple outside appointments, including a PET scan scheduled for 04/03/25. The after-visit summary from a cardiology appointment on 04/03/25 documented a PET scan scheduled at a testing location in Columbus, Ohio at 2:00 P.M., but the physician order in the medical record listed the PET scan for 04/16/25 at a different testing location in [NAME], Ohio at 1:30 P.M. A concern form completed by the Administrator documented that on 04/03/25 the resident was taken to the wrong testing center for the PET scan, causing the test to be missed and requiring rescheduling. A written statement by the Administrator dated 04/16/25 confirmed a transportation mistake was made for the 04/03/25 appointment and that the resident and her spouse contacted the facility to arrange pick-up from the incorrect location. During an interview, the Administrator confirmed the resident was taken to the wrong location and that Administrator Assistant #596 worked with the resident to ensure her return to the facility, but the resident and her spouse did not wait for transportation and decided to walk back to the facility. Review of the facility’s Transportation policy dated 08/24 showed the facility was responsible for arranging and ensuring transportation to and from outside appointments based on information received from the resident, family, transportation company, or doctor’s office. This failure affected one of three residents reviewed for transportation to outside appointments, with a facility census of 80, and was investigated under Complaint Numbers 2572222, 1376015 (OH00165472), and 1376014 (OH00165055).
Failure to Coordinate and Document Timely Dental Services for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely provision and coordination of dental services for a resident who required dentures. The resident, admitted with multiple medical diagnoses including COPD, hemiplegia, CHF, major depressive disorder, anxiety disorder, dementia, hallucinations, and muscle weakness, reported via a concern form that his dentures were missing. The concern form documented that the dentures were later found broken and lodged in a toilet, and that the resident’s guardian was notified and indicated they would contact the dental company for the resident to be seen by a dentist. The resident’s care plan, dated shortly after this event, directed staff to monitor and notify the medical provider as needed for oral/dental problems and stated that the facility would coordinate arrangements for dental care and transportation as needed or ordered. Despite these care plan directives and the identified need for dental services, review of progress notes from early November through early January showed no documentation of any dental visits for the resident and no documentation of attempts to contact the guardian regarding dental care. In an interview, the Social Service Director confirmed that there were no documented guardian contact attempts in the medical record during this period and stated that the guardian was required to complete a dental consent form for the resident to receive dental care at the facility. The Social Service Director reported that the guardian was last contacted in mid-November and given information on the consent form but acknowledged that this contact was not documented and that there were no further contacts with the guardian through early January. The Social Service Director also stated they were unaware of any facility policy specifying how many times a guardian should be contacted to resolve resident issues.
Unnecessary Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure psychotropic medications were not unnecessarily provided for two residents. One resident with cerebral palsy, depression, COPD, chronic respiratory failure, alcohol abuse, atrial fibrillation, and insomnia had active orders for Lexapro 5 mg and Zoloft 50 mg at the same time. Psychiatric progress notes stated the plan was to continue Lexapro 5 mg, but they did not document the Zoloft order. The resident’s MAR showed both antidepressants were administered concurrently, and the NP confirmed the Zoloft was not reflected in the psychiatric progress notes and that it was inappropriate for the resident to be on both medications because they are in the same class. Another resident with COPD, major depressive disorder, anxiety disorder, dementia, unspecified hallucinations, CHF, and muscle weakness had an order to reduce Remeron from 15 mg to mirtazapine 7.5 mg. The progress note stated the resident requested a trial reduction because mood and sleep were good, and another note documented new orders to decrease Remeron to 7.5 mg at night. However, the MAR showed the resident received Remeron 15 mg at 9:00 P.M. and also received mirtazapine 7.5 mg at bedtime on the same day. The DON confirmed both doses were administered in error.
Care Plan Missing Nutrition Intervention
Penalty
Summary
The facility failed to ensure Resident #35’s comprehensive care plan was updated to include all interventions implemented to address nutritional concerns. Resident #35 was admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, chronic obstructive pulmonary disease, schizophrenia, and peripheral vascular disease, and the quarterly MDS showed impaired cognition with a BIMS score of 08 and a need for self-care and mobility assistance. The care plan dated 11/05/25 identified the resident as at risk for malnutrition/alteration in nutritional status related to chronic progression illness, but the physician later ordered a house supplement 237 mL three times per day on 01/07/26. During interview, LPN #606 confirmed the nutrition care plan did not include the house supplement order, and the facility policy stated the care planning team was responsible for developing a comprehensive care plan for each resident.
Failure to Provide Fingernail Care for Dependent Resident
Penalty
Summary
The facility failed to ensure adequate fingernail care was provided for a dependent resident. The resident was admitted with diagnoses including atrial fibrillation, COPD, diabetes, dysphagia, and cognitive communication deficit. The care plan identified the resident as at risk for ADL self-performance deficit, with interventions including eating with supervision or touching assistance and being dependent on personal hygiene. The MDS showed a BIMS of 12, indicating moderately impaired cognition, and the resident required set-up assistance with oral hygiene and substantial to maximum assistance for showering and bathing. Shower documentation showed the resident’s nails were last cleaned and trimmed on one date, then the task was declined on two later dates. During observation, the resident’s fingernails were long, about a half-inch past the nailbed, and three fingers on the right hand had a dark brownish/red substance caked under the nails. The resident stated he preferred shorter fingernails and wanted them cleaned. A CNA confirmed the nails were longer than preferred and dirty, and stated she would speak with the nurse because the resident was diabetic and the podiatrist trimmed his fingernails. Later observation still showed long, dirty fingernails, and the resident reported no staff had returned to trim and clean them. An RN confirmed the fingernails were longer than the resident’s preference and dirty, and the regional nurse stated the podiatrist does not clean and trim fingernails and that staff should do so as needed and upon resident request.
Failure to Provide Ordered Feeding Equipment and Instructions
Penalty
Summary
Special eating equipment and utensils were not provided for Resident #21 during meals as specified in the resident’s documented feeding instructions. Resident #21 was admitted with diagnoses including atrial fibrillation, COPD, diabetes, dysphagia, and cognitive communication deficit. The MDS showed a BIMS score of 12 and indicated the resident required set up assistance with eating. The care plan identified risk for malnutrition or alteration in nutritional status and included interventions for adaptive equipment as ordered, assistance with meals as ordered, and monitoring the resident’s ability to chew and swallow. The dietician note documented modified barium swallow study recommendations to eat slowly, alternate solids and liquids, swallow twice after each bite, take small sips, and place liquids in cups. Observation showed feeding instructions posted by the resident’s bed, including no straws, all liquids in cups, two swallows between each bite, and alternating food and liquid. During a meal observation, the resident received puree food, juice in a cup, milk in the carton, and applesauce; the CNA sat the resident up, placed a clothing protector on him, and set up the tray, but confirmed the resident did not get drinks in cups and was unaware of the signage and its meaning. The RN stated she was not aware of the resident’s needs, and the DON and Regional Nurse said they were unsure where the feeding recommendation came from but confirmed it was in hospital discharge paperwork. The NP stated active orders should be implemented if appropriate, and the dietician said the recommendations likely came from the barium swallow evaluation after hospitalization for aspiration pneumonia and increased difficulty swallowing.
Inadequate PPE and Isolation Protocols for COVID-19
Penalty
Summary
The facility failed to ensure proper personal protective equipment (PPE) was available for staff providing care for a resident with a confirmed COVID-19 infection. Specifically, the PPE bin outside the room of the COVID-19 positive resident did not contain eye protection, which is required according to CDC guidelines for healthcare personnel entering the room of a patient with suspected or confirmed SARS-CoV-2 infection. This oversight was confirmed by an LPN during an observation. Additionally, the facility did not adhere to appropriate isolation protocols for a resident who had been exposed to COVID-19. The exposed resident initially agreed to move to a private room for isolation but later refused to stay there, demanding to return to the shared room with the COVID-19 positive resident. Despite being educated about the risks, the resident did not believe they would contract the virus and frequently left the room to socialize in common areas without wearing a mask, as confirmed by multiple staff and resident interviews. The facility also failed to notify residents and their representatives about the presence of a COVID-19 positive case within the facility, although a sign was placed on the entrance doors for the public. The Director of Nursing confirmed that while employees were required to wear surgical masks during an outbreak, residents were not required to wear masks. This lack of communication and enforcement of mask-wearing among residents potentially increased the risk of virus transmission within the facility.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and preparation areas, which had the potential to affect 55 residents who consumed food prepared by the facility. During an observation of the kitchen's walk-in refrigerator, it was found that containers of de-stemmed grapes, shredded lettuce, and diced yellow fruit were unlabeled and undated. The Dietary Manager confirmed the issue and was unable to verify when these food items were initially opened, indicating a lapse in following the facility's food storage policy. Further observations revealed significant ice and frost build-up in the walk-in freezer, with ice accumulation on food boxes and the freezer door frame. Additionally, two ceiling vents over a food preparation area were covered in a brown and black fuzzy substance. These conditions were confirmed by the Dietary Manager, highlighting a failure to adhere to the facility's policy that requires food to be stored in clean, dry areas free from contaminants, with proper labeling and dating to prevent contamination or cross-contamination.
Failure to Educate and Offer Influenza Vaccinations
Penalty
Summary
The facility failed to educate residents on the risks and benefits of influenza vaccinations and did not offer the vaccinations as required. This deficiency affected five residents who were reviewed for immunizations. The medical records of these residents showed that they either did not receive the flu vaccination since their admission or there was no evidence of being offered the vaccination in the current year. Additionally, there was no documentation of education provided to the residents or their representatives regarding the risks and benefits of the flu vaccination. The review of the facility's policy on Influenza and Pneumococcal Disease Prevention revealed that it required offering the seasonal influenza vaccine to all residents and providing education on the benefits and potential side effects before offering the immunization. However, the facility did not adhere to this policy, as confirmed by the Director of Nursing (DON), who acknowledged the deficiencies in vaccination practices. The DON confirmed that consents from residents had not been obtained, and the facility was not in compliance with its vaccination policy.
Deficiency in COVID-19 Vaccination Education and Offering
Penalty
Summary
The facility failed to educate residents and their representatives on the risks and benefits of the COVID-19 vaccination and did not offer the vaccine to eligible residents as required. This deficiency was identified through a review of medical records, immunization records, staff interviews, and facility policy review. Five residents were specifically affected by this oversight. For instance, Resident #42, admitted with multiple medical diagnoses, had received COVID-19 vaccinations previously but was not educated or offered the vaccine upon admission. Similarly, Resident #44 refused a COVID-19 booster, but there was no documentation of education or offer of the vaccine in the medical record. Other residents, such as Resident #61, had no evidence of receiving or refusing the COVID-19 vaccination, nor was there documentation of education or an offer being made. Resident #72 also refused a booster without a documented date or evidence of education and offer. Resident #89, despite having received previous vaccinations, was not educated or offered the vaccine upon admission. The Director of Nursing confirmed these findings and acknowledged the deficiencies in vaccination processes. Additionally, a facility policy related to COVID-19 vaccination was requested but not provided during the survey.
Failure to Follow Code Status and Weight Monitoring Orders
Penalty
Summary
The facility failed to adhere to the code status orders for a resident with a Do Not Resuscitate (DNR) Comfort Care Arrest (CCA) status. Despite the resident being unresponsive, staff initiated Cardiopulmonary Resuscitation (CPR) without verifying the code status, which was accessible both electronically and in hard copy at the nurse's station. The error was realized only after paramedics arrived, at which point CPR was ceased, and the resident subsequently expired. Interviews with the Registered Nurses and the Director of Nursing confirmed the oversight in checking the code status before performing CPR. Additionally, the facility did not follow physician orders regarding weight monitoring for another resident. The orders required daily and weekly weight checks with specific parameters for notifying the medical director of significant weight gains. However, there were instances of weight gains outside the set parameters without notification to the medical director, and numerous dates where weight checks were not documented. The Director of Nursing confirmed the lapses in following the weight monitoring orders and the lack of documentation for missed checks or resident refusals.
Failure in Wound Monitoring for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide proper wound monitoring for a resident with multiple stage four pressure ulcers. The resident, who had a history of chronic respiratory failure, protein calorie malnutrition, paraplegia, and other serious conditions, was admitted with these ulcers already present. Despite the facility's policy requiring a complete skin check upon admission and readmission, the resident's wounds were not measured upon readmission on two occasions. Additionally, there was a significant gap in wound monitoring, as the wounds were not visualized or measured by a wound specialist for twenty-eight days. Interviews with staff, including a registered nurse and the Director of Nursing, confirmed the lack of wound assessments during this period. The facility's policy expected weekly assessments by a wound nurse or specialist, which were not conducted. Although the resident did not suffer any adverse outcomes from this lapse, the potential for harm was present due to the extended period without proper wound monitoring.
Medication Left at Bedside
Penalty
Summary
The facility failed to ensure medications were not left at the bedside, affecting one resident. Resident #55, who was admitted with acute and chronic respiratory failure, was observed asleep with a bipap on his face. A pill cup containing eight tablets was found on the nightstand beside the bed. There was no nurse present in the room at the time, and a certified nurse aide entered with the resident's breakfast tray. The resident attempted to take the pills, stating they were from the night before. A surveyor intervened and asked the resident to wait for a nurse to verify the medications. An interview with LPN #187 confirmed that the medications were left by the night shift nurse from the 6:00 A.M. medication pass. The facility's medication storage policy, which was undated, stated that medication should be stored in a manner that ensures the safety of the residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an eight percent error rate. This deficiency was identified during an observation of medication administration for a resident. The resident had physician orders for Tylenol 325 mg, two tablets every six hours for general discomfort, and Morphine Sulfate oral solution 20 mg per 5 ml, to be administered 0.5 mg by mouth four times a day and 0.5 ml every two hours for pain and shortness of breath. However, during the medication administration, the resident was given Tylenol 500 mg, two tablets, and 0.75 mg of Morphine, which did not align with the physician's orders. The LPN responsible for administering the medication explained that the resident received 0.5 mg of Morphine as a routine medication and an additional 0.25 mg as needed, totaling 0.75 mg, which was reportedly written by hospice. Upon verification, the LPN acknowledged that the medications given were not the correct doses as ordered by the physician, suggesting that the order might have been changed from what the resident was previously receiving. The facility's policy on medication dispensing requires that all medications be prepared and administered in accordance with the correct medication name and dose, which was not adhered to in this instance.
Failure to Administer Insulin and Document Missed Doses
Penalty
Summary
The facility failed to prevent significant medication errors affecting two residents. Resident #44, who has chronic obstructive pulmonary disease, morbid obesity, type two diabetes mellitus with diabetic polyneuropathy, and unspecified protein-calorie malnutrition, did not receive prescribed insulin on multiple occasions. The medical record showed that insulin was not administered on specific dates, and there was no documentation explaining the missed doses. The Director of Nursing confirmed the lack of documentation for the missed insulin doses. Resident #23, diagnosed with type two diabetes mellitus, morbid obesity, and other conditions, also experienced missed insulin doses. The resident did not receive Levemir insulin on two occasions, and there was no documentation explaining these omissions. An interview with the resident revealed that the insulin was not administered due to a lack of stock, as reported by an agency nurse. The Director of Nursing confirmed the absence of documentation for the missed doses, and the facility's policy requires timely medication administration and proper documentation.
Infection Control Deficiencies in Catheter and EBP Management
Penalty
Summary
The facility failed to ensure catheter bags were stored in a sanitary manner, which was observed in the case of a resident with an indwelling catheter. The resident, who had diagnoses including Parkinsonism and neuromuscular dysfunction of the bladder, was observed with his catheter bag laying flat against the floor under his bed. This was confirmed by an LPN, and it was noted that the facility's policy required the catheter to be secured and checked to ensure proper drainage, which was not adhered to in this instance. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a peg tube, despite the need for such precautions due to the presence of an opening. The resident, who had a history of malignant neoplasms and required assistance with ADLs, reported that staff typically wore masks and gloves but not gowns. There was no signage or PPE available near the resident's room, and EBP was only ordered after surveyor intervention. This oversight was confirmed by both an agency RN and the Director of Nursing.
Delayed Family Notification After Resident Fall
Penalty
Summary
The facility failed to notify the family of a resident, identified as Resident #21, in a timely manner following a fall. Resident #21, who was cognitively intact and had a diagnosis of Parkinson's disease, muscle weakness, and vascular dementia, experienced a fall while exiting the restroom. The incident report indicated that the resident's physician was notified shortly after the fall, but the resident's spouse, who was the Power of Attorney (POA) for healthcare, was not informed until approximately 15 hours later. This delay in notification was confirmed through interviews with facility staff, including Registered Nurses and the facility's administration. The facility's policy on Notification of Change requires that the resident's legal representative or an interested family member be informed immediately when an accident occurs that results in injury or has the potential for requiring physician intervention. However, the policy was not followed in this instance, as evidenced by the lack of timely communication with the resident's family. The deficiency was identified during a complaint investigation and was confirmed by staff interviews and a review of the facility's policy and the resident's medical records.
Failure to Execute Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure timely completion of physician-ordered laboratory services for a resident diagnosed with Alzheimer's disease, diabetes mellitus, and dementia. The resident had orders for a hemoglobin A1C (HbA1c) and a basal metabolic panel (BMP) to be conducted every six months due to their diabetes diagnosis. Despite these orders being documented on 07/18/24 and reiterated on 08/09/24, the laboratory tests were not completed from 07/18/24 to 09/11/24. This oversight was confirmed during an interview with the Administrator and Director of Nursing, who acknowledged that the laboratory company was not contacted to perform the necessary tests. The facility's policy, dated 06/09/22, states that the nurse who receives a physician's order is responsible for executing it, including contacting laboratory services. However, this procedure was not followed, resulting in the failure to conduct the required laboratory tests for the resident. This deficiency was identified during a complaint investigation, highlighting a lapse in the facility's adherence to its own policies regarding the execution of physician orders.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during medication administration for residents under enhanced barrier precautions. On the specified date, an LPN was observed preparing and administering medications to two residents without performing hand hygiene before and after the process. The LPN did not wear gloves while preparing medications and failed to clean hands upon entering and exiting the residents' rooms, which were marked with enhanced barrier precaution signs. The deficiency was confirmed during an interview with the LPN, who acknowledged not performing hand hygiene as required. The facility's policy on Infection Control- Isolation/Precautions mandates hand hygiene before and after resident contact and after contact with objects in the resident's room. The signage from the United States Department of Health and Human Services also requires hand cleaning before entering and upon leaving the room. This incident was identified during a complaint investigation.
Failure to Conduct Pre-Employment Background Checks
Penalty
Summary
The facility failed to ensure that background checks for staff were completed prior to employment, affecting three employees: two State Tested Nursing Assistants (STNAs) and one Occupational Therapist (OT). The employee files for STNA #230, STNA #122, and OT #356 lacked documented evidence of completed background checks, and these individuals were not listed on the Bureau of Criminal Investigation (BCI) background check log. This oversight had the potential to affect all 81 residents residing in the facility. Interviews with the Administrator and HR personnel confirmed the absence of background checks in the employee files. HR #366 acknowledged that background checks were supposed to be conducted on the same day as orientation, but this was not done for the mentioned employees. The facility's policy, dated October 2023, mandates checking the Ohio Nurse Aide Registry, applicable licensing and certification authorities, and conducting criminal background checks in accordance with Ohio law and facility policy before hiring new employees. This deficiency was investigated under Complaint Number OH00155375.
Lack of Performance Evaluations for STNAs
Penalty
Summary
The facility failed to ensure that performance evaluations were completed for State tested Nursing Assistants (STNAs), specifically affecting two employees whose files were reviewed. STNA #122, hired on 07/29/22, and STNA #230, hired on 07/28/23, both lacked documented evidence of having undergone performance evaluations since their respective hire dates. This deficiency was confirmed through interviews with the Administrator and Human Resources, who verified the absence of performance evaluations for these STNAs. The issue was identified during an investigation under Complaint Number OH00155375, with the potential to impact all residents in the facility, which had a census of 81.
Deficiency in STNA Training Documentation
Penalty
Summary
The facility failed to ensure that State tested Nursing Assistants (STNAs) received the required minimum of 12 hours of training to maintain their competence. This deficiency was identified through a review of personnel files and staff interviews. Specifically, the personnel files of two STNAs, hired on different dates, lacked documented evidence of the required training. This issue was confirmed during an interview with a Human Resources representative, who verified the absence of documentation for the training. The deficiency was noted to have the potential to affect all residents in the facility, which had a census of 81 at the time of the report. This noncompliance was investigated under Complaint Number OH00155375.
Failure to Follow Prepared Menu
Penalty
Summary
The facility failed to adhere to the prepared lunch menu on 07/30/24, which was intended to include chicken Parmesan, cauliflower, garlic toast, and tiramisu for dessert. During an observation at 11:56 A.M., lunch trays for Unit One were seen leaving the kitchen with a test tray on an open cart. The last lunch tray was delivered to a resident at 12:46 P.M., and the test tray was removed. Upon inspection, it was noted that the resident's tray contained mixed vegetables instead of cauliflower, and there was no garlic bread or substitute provided. An interview with Dietary Manager (DM) #140 at 2:06 P.M. confirmed that there was no cauliflower available, leading to the substitution with mixed vegetables. Additionally, DM #140 acknowledged the omission of garlic toast and the failure to provide a substitute. This deficiency was identified during an investigation under Complaint Number OH00156101.
Failure to Provide Timely Meals and Snacks
Penalty
Summary
The facility failed to ensure that no more than 14 hours elapsed between the evening meal and breakfast, which had the potential to affect all residents receiving food from the kitchen. The evening meal was served at different times across units, with the earliest at 4:50 P.M. and the latest at 5:30 P.M., while breakfast was served starting at 7:50 A.M. and ending at 8:30 A.M., resulting in a 15-hour gap between meals. Interviews with the Dietary Manager confirmed the 15-hour interval and the lack of substantial snacks being offered during this period. Additionally, interviews with three residents revealed dissatisfaction with the long interval between supper and breakfast, as well as insufficient snack distribution. Two residents reported not receiving a snack the previous night, indicating a failure to provide suitable and nourishing alternatives for those who wished to eat outside of scheduled meal times. This deficiency was investigated under Complaint Number OH00156101.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers or baths for two residents, which was identified through record reviews, resident interviews, and staff interviews. Resident #25, who was admitted with diagnoses including diabetes, hyperkalemia, hyperglycemia, pressure ulcer wounds, and obesity, was found to have received only one shower over a two-week period despite being scheduled for at least two showers weekly. The resident confirmed not refusing any bathing care and had requested showers on scheduled days. The Director of Nursing (DON) verified the lack of documentation for showers and confirmed the resident's schedule. Similarly, Resident #68, with diagnoses including atrial fibrillation, diabetes, obesity, and COPD, was documented to have received only one shower in a month. The resident's care plan indicated a need for assistance with activities of daily living (ADLs), yet there was no documentation of showers or refusals except for one noted refusal. The resident confirmed receiving only one shower and not refusing any care. The DON acknowledged the lack of documentation and confirmed the requirement for STNAs to document care provided.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dublin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand The | 2.5 mi | ★★★★★ | 21 | 0 |
| The Sanctuary At Tuttle Crossing | 3 mi | ★★★★★ | 4 | 0 |
| Friendship Village Of Dublin | 3.1 mi | ★★★★★ | 0 | 0 |
| Dublin Post Acute | 3.4 mi | ★★★★★ | 34 | 0 |
| Darby Glenn Nursing And Rehabilitation Center | 4.2 mi | ★★★★★ | 4 | 0 |
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