Health inspection·October 9, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on record review, review of facility policy, and staff interview, the facility failed to notify Resident #21's family of a resident's fall in a timely manner. This affected one (Resident #21) of three residents reviewed for family notification. The facility census was 83. Findings include: Review of the medical record for Resident #21 revealed an admission date of 08/15/23 with diagnoses of Parkinson's disease without dyskinesia, muscle weakness, and vascular dementia. Review of the Minimum Data Set (MDS) 3.0 assessment completed 09/26/24 revealed Resident #21 was cognitively intact. Review of Resident #21's General Durable Power of Attorney (POA) form dated 04/20/23 revealed the resident's wife was the POA for healthcare and listed in the medical record as emergency contact number one. Review of the Resident Preferences Evaluation dated 08/26/24 revealed It is very important for the resident to have their family or a close friend involved in discussions about their care. Review of the incident report dated 09/28/24 revealed Resident #21 was exiting the restroom when he slid down to the floor, landing on his bottom. An assessment completed post-fall revealed he was alert and oriented to person, with no injuries found. The report revealed the physician was notified on 09/28/24 at 1:57 A.M., and the spouse was notified on 09/28/24 at 4:36 P.M. Review of the progress notes dated 09/28/24 revealed Resident #21 slid down to the floor while in the restroom with no injury. The medical record did not have evidence that the POA/family were notified of the fall. The progress note dated 09/28/24 at 5:15 P.M. revealed Resident #2's POA was contacted regarding the resident's fall, which occurred approximately 15 hours after the incident. Interview on 10/09/24 at 11:30 A.M. with Registered Nurse (RN) #900 confirmed Resident #21's family/POA was not notified timely after the fall. RN #900 confirmed this nurse observed the fall however did not notify the family immediately after stabilizing the resident and informing the doctor. Interview on 10/09/24 at 1:32 P.M. with RN #999 confirmed family members should be notified as soon as practicable of a resident's fall. Interview on 10/09/24 at 1:58 P.M. with the Administrator, Director of Nursing, and Regional Director of Clinical Operations #1 confirmed family members should be notified immediately after a resident's fall. (continued on next page) 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 10/09/2024 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)