F 0770
Provide timely, quality laboratory services/tests to meet the needs of residents.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, review of the facility policy, and staff interview, the facility failed to ensure physician
ordered laboratory services for a resident were completed in a timely manner. This affected one (Resident
#10) of three residents reviewed for laboratory services. The facility census was 88.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #10 revealed an admission date of 10/20/22 with diagnoses
including Alzheimer's disease, diabetes Mellitus (DM) and dementia. Review of the Minimum Data Set
(MDS) assessment completed 07/18/24 revealed Resident #10 had a memory problem and had a
diagnosis of DM.
Review of Resident #10's physician orders dated 07/18/24 revealed hemoglobin A1C (HbA1c) (a blood test
that measures average blood sugar levels over the past two to three months) and basal metabolic panel
(BMP) (checks the body's fluid balance and levels of electrolytes) every six months on the second
Wednesday in August and January due to a diagnosis of DM.
Review of the physician notes dated 07/18/24 revealed a new order received from certified nurse
practitioner for BMP and HbA1c every six months starting in August. The physician note completed
08/09/24 revealed the labs were not completed that were ordered on last visit, will re-order today.
Review of the medication administration record (MAR) for Resident #10 revealed a BMP, Complete Blood
Count (CBC), and Thyroid Stimulating Hormone (TSH) were ordered and completed on 08/12/24. However,
review of laboratory results revealed there were were no labs drawn on 08/12/24 and the BMP and HbA1C
was never drawn from 07/18/24 to 09/11/24.
Interview on 09/12/24 at 10:02 AM with the Administrator and Director of Nursing (DON) confirmed
Resident #10's physician orders for BMP and HbA1C to be drawn on 07/18/24 and 08/09/24 but were never
drawn from 07/18/24 to 09/11/24. The Administrator and DON confirmed the CBC and TSH labs were not
completed too. The Administrator and DON stated the laboratory company was not sent out to obtain
Resident #10's labs.
Review of the facilities Physician Orders policy dated 06/09/22 revealed the nurse that takes the physician
order will be responsible for executing the order. The nurse should contact laboratory services to execute
the order.
This was an incidental finding discovered during the course of the complaint investigation.
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
Page 1 of 2
Event ID:
365717
Printed: 05/15/2026
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
365717
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Convalarium of Dublin
6430 Post Rd
Dublin, OH 43016
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, review of the facility policy, and staff interview, the facility failed to complete hand
hygiene during medication administration to residents in enhanced barrier precautions. This affected two
(Resident #24 and #70) of four residents observed for medication administration. The facility census was
88.
Residents Affected - Few
Findings include:
Observation on 09/12/24 at 12:07 P.M. with Licensed Practical Nurse (LPN) #999 revealed prior to
preparing medication for Resident #70, hand hygiene was not performed, and gloves were not worn. LPN
#999 began preparing Resident #70's medication, directly from the medication card into the medication
cup. LPN #999 then returned the medication card to the cart, locked it, and entered Resident #70's room,
which had an enhanced barrier sign posted on the door. Resident #70 needed moderate assistance with
medication administration, including spoon-feeding the medication with applesauce. Resident #70 took
medications without difficulty. Upon exiting, hand hygiene was not performed by LPN #999.
Observation on 09/12/24 at 12:15 P.M. with LPN #999 revealed after administering Resident #70's
medication, hand hygiene was not performed. LPN #999 unlocked the medication cart and started
preparing medications for Resident #24. LPN #999 poured Tylenol from a shared facility bottle into the
medication cup and then retrieved a medication card from the medication cart and popped it into the cup.
LPN #999 returned the medication card to the cart, locked it, and entered Resident #24's room, which had
an enhanced barrier precautions sign posted on the door. LPN #999 gave Resident #24 his medication,
which he took without issues. After completing the task, LPN #999 discarded the medication cup in the
trash, exited the room without performing hand hygiene, and returned to the medication cart.
Interview on 09/12/24 at 12:20 P.M. with LPN #999 confirmed that hand hygiene was not performed as
required before and after preparing Resident #70 and #24's medications.
Review of the Enhanced Barrier Precautions signage from United States Department of Health and Human
Services, undated, revealed everyone must clean their hands, including before entering and when leaving
the room.
Review of the facilities Infection Control- Isolation/Precautions policy dated 08/2024 revealed staff must
perform hand hygiene before and after contact with the resident and after contact with blood, body fluids,
visibly contaminated surfaces or after contact with objects in the resident's room.
This was an incidental finding discovered during the course of the complaint investigation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365717
If continuation sheet
Page 2 of 2
