Inspection visit
Inspection
13 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 13 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
medical record review and staff interview, the facility failed to follow resident code status orders. This
affected one (Resident #90) of one resident reviewed for code status. Also, the facility failed to follow
physician orders regarding resident weight status. This affected one (Resident #44) of five residents
reviewed for nutritional orders. The census was 79.
Residents Affected - Few
Findings include:
1. Resident #90 was admitted to the facility on [DATE]. Her diagnoses were congestive heart failure, muscle
weakness, chronic respiratory failure, acute pulmonary edema, asthma, morbid obesity, atrial fibrillation,
hypertension, anxiety disorder, insomnia, depression, hypothyroidism, osteoarthritis, and obstructive sleep
apnea.
Review of her Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact.
Review of Resident #90's physician orders and code status form found she had a code status of Do Not
Resuscitate (DNR) Comfort Care Arrest (CCA).
Review of Resident #90's progress notes dated [DATE] revealed staff entered her room at approximately
11:10 P.M. and found there was no response from the resident when staff called out. A carotid pulse was
found when checked, but Resident #90 was still unresponsive. At that time, staff started Cardiopulmonary
Resuscitation (CPR), until the paramedics arrived, then it was discovered that the patient had a DNR-CCA
order. CPR was ceased at that point and Resident #90 expired.
Interview with Registered Nurse (RN) #139 and RN #141 on [DATE] at 9:25 A.M. and 9:33 A.M. confirmed
they are to check code status before performing CPR. They can find code status in the electronic record
and they have a hard copy at the nurse's station too.
Interview with the Director of Nursing (DON) on [DATE] at 9:42 A.M. and 9:48 A.M. confirmed CPR was
performed on Resident #90, who had a code status of DNR-CCA.
2. Review of the medical record for Resident #44 revealed an admission date of [DATE] and a re-entry
admission date of [DATE]. Medical diagnoses include chronic obstructive pulmonary disease, morbid
obesity due to excess calories, type two diabetes mellitus with diabetic polyneuropathy, and unspecified
protein-calorie malnutrition. The resident also had a body mass index (BMI) between 45.0-49.9.
Review of Resident #44's Minimum Data Set (MDS) 3.0 assessment revealed a Brief Interview of Mental
Status (BIMS) score of 15 indicating the resident was cognitively intact.
(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 14
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
11/27/2024
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 0684
Review of the physician orders revealed the following orders:
Level of Harm - Minimal harm
or potential for actual harm
Daily weight monitoring for a weight gain of three pounds in two days or five pounds in one week. Notify the
medical director (MD) of gains outside of parameters with a start date of [DATE] and an end date of [DATE].
Residents Affected - Few
Daily weight monitoring for a weight gain of three pounds in two days or five pounds in one week. Notify the
medical director (MD) of gains outside of parameters with a start date of [DATE] and an end date of [DATE].
Daily weight checks starting [DATE] and an end date of [DATE].
Weekly weight checks every Monday for monitoring with a start date of [DATE] and an end date of [DATE].
Weekly weight checks every day shift on Tuesdays with a start date of [DATE].
Review of the weight checks revealed the following dates were outside of the parameters with no
notification to the MD:
- [DATE] 229.8 pounds - [DATE] 233.2 pounds for a weight gain of 3.4 pounds in one day
- [DATE] 236.8 pounds - [DATE] 239.9 pounds for a weight gain of 3.1 pounds in one day
Additionally, review of the weight checks revealed the following dates for weight monitoring were missing:
[DATE]-[DATE], [DATE]-[DATE], [DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE], [DATE],
[DATE]-[DATE], [DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE]-[DATE],
[DATE], [DATE]-[DATE], [DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE], [DATE] (completed on [DATE]
instead), [DATE], [DATE], [DATE], [DATE], [DATE], [DATE].
Review of the progress notes for Resident #44 revealed there were no notes regarding the weight gains
outside of parameters or notification to the MD or notes regarding the resident refusing weights on the
dates that are missing.
Interview on [DATE] at 2:23 P.M. with the Director of Nursing (DON) confirmed daily and weekly weights
were not followed and stated if there were any refusals the staff should be documenting in the progress
notes.
Interview on [DATE] at 3:52 P.M. with the DON confirmed there was no documentation regarding why the
weight checks were not followed according to the physicians orders.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365717
If continuation sheet
Page 2 of 14
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
11/27/2024
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident medical record review, interviews with staff, and review of facility policy, the facility failed to provide
proper wound monitoring for Resident #61. This affected one resident (#61) out of five residents reviewed
for wound care. The facility census was 79 residents.
Residents Affected - Few
Findings include:
Resident #61 was admitted on [DATE] with diagnoses that included chronic respiratory failure, protein
calorie malnutrition, paraplegia, disease of spinal cord, tracheostomy, and person injured in a motor vehicle
accident.
Review of Resident #61's Minimum Data Set (MDS) assessment dated [DATE] revealed that resident had
four stage four pressure ulcers, all of which were present upon admission to the facility.
Review of Resident #61's medical record revealed the resident was seen by the wound care nurse and
wound nurse practitioner on 09/18/24 and measurements of his wounds were recorded. On 09/24/24,
Resident #61 had a brief hospitalization and he was readmitted to the facility on [DATE]. On 09/25/24,
Resident #61's wounds were not measured. The wound nurse attempted to see Resident #61 on 10/02/24,
but he was unable to be seen, as he was out to an appointment. On 10/04/24, Resident #61 had a brief
hospitalization and he was readmitted to the facility on [DATE]. On the clinical nursing assessment dated
[DATE], it was noted the resident had multiple skin issues with treatments completed, but wounds were not
measured. On 10/09/24, Resident #61's weekly wound assessment stated, See the hospital wound care
notes. Measurements and area taken from these notes. On 10/16/24, Resident #61's wounds were
visualized, measured, and recorded by the wound care nurse. The resident did not suffer any adverse
outcome from the lack of wound monitoring, but had the potential to suffer an adverse outcome after not
having a wound specialist visualize his wounds in the facility for twenty-eight days.
An interview with Registered Nurse (RN) #142 on 11/26/24 at 10:31 A.M. confirmed that neither she nor the
wound nurse practioner saw Resident #61's wounds from the time frame between 09/18/24 and 10/16/24.
An interview with the Director of Nursing (DON) on 11/27/24 at 1:31 PM revealed that she would expect a
resident with pressure ulcers to be assessed and monitored by the wound nurse or wound specialist on a
weekly basis. Interview with the DON confirmed that the wounds were not measured upon readmission on
[DATE] and 10/05/24.
Review of a facility policy titled, Pressure Injury Risk Assessment last reviewed on 08/2023 revealed that a
complete head to toe skin check would be completed by a licensed nurse upon admission and readmission.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365717
If continuation sheet
Page 3 of 14
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
11/27/2024
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observations, staff interview, and review of the facility policy, the facility failed to ensure
medications were not left at bedside. This affected one resident (#55) of one resident observed for
medications left at bedside. The census was 79.
Findings include:
Review of medical record for Resident #55 revealed an admission date of 02/14/20. The resident was
admitted with diagnosis of acute and chronic respiratory failure.
Observation on 11/27/24 at 8:50 A.M. upon entering Resident #55's room, revealed the resident was
asleep with bipap upon his face. The nightstand beside the bed had a pill cup with eight tablets of
medications. There was not a nurse in the room at this time. There was a certified nurse aide who came into
the room with his breakfast tray and the resident removed the bipap then grabbed at the pill cup to take
them. The resident stated they were the pills from the night time. This surveyor asked the resident to wait
until the nurse could come to the room to verify the medications.
Interview with Licensed Practical Nurse (LPN) #187 on 11/27/24 verified the medications were left on the
resident's nightstand from the night shift nurse. The medications were from the 6:00 A.M. medication pass.
Review of the undated medication storage policy revealed medication will be stored in a manner the
integrity of the product ensures the safety of the residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365717
If continuation sheet
Page 4 of 14
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
11/27/2024
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff interview, and review of the facility policy, the facility failed to prevent a medication error
rate of less than five percent. There were two medication errors out of 25 opportunities, resulting in an eight
percent error rate. This affected one (Resident #20) of six residents observed for medication administration.
The census was 79.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #20 was admitted on [DATE].
Review of the physician orders dated 07/17/24 for Resident # 20 revealed an order for Tylenol 325
milligrams (mg), give two tablets every six hours for general discomfort and an order dated 09/30/24 for
Morphine Sulfate oral solution 20 mg per 5 milliliters (ml) to give 0.5 mg by mouth four times a day and to
give 0.5 ml by mouth every two hours for pain and short of breath.
Observation of Licensed Practical Nurse (LPN) #119 on 11/26/24 at 2:15 P.M. revealed LPN #119 prepared
medications for Resident # 20 which included Tylenol 500 mg, two tablets and Morphine solution 20 ml per
5 ml, 0.75 mg liquid. The pills were crushed and placed in applesauce. The syringe contained 0.75 mg of
Morphine and Tylenol was given by mouth.
Interview with LPN #119 on 11/26/24 at 2:15 P.M. explained the resident receives 0.5 mg of Morphine as a
routine medications and 0.25 mg which is as needed (PRN) to equal 0.75 ml of Morphine for pain and was
written by hospice.
Interview with LPN #119 on 11/26/24 at 2:35 P.M. verified the medications which were given; Tylenol 500
mg, two tablets, and Morphine solution 20 ml per 5 ml, to equal 0.75 mg liquid were not the correct
medication dose as ordered by the physician. The LPN #119 stated the order must have been changed
from what the resident previously was receiving.
Review of the facility's policy, Medications Dispensing, undated, revealed all medications will be prepared
and administered in a manner consistent with the general requirements outlined in this policy, Including
medication inspection to confirm the medication name and dose are correct.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365717
If continuation sheet
Page 5 of 14
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
11/27/2024
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 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
2. Review of the medical record for Resident #23 revealed an admission date on 06/06/23. Medical
diagnoses included type two diabetes mellitus without complications, morbid obesity, long term use of
insulin, unspecified mood (affective) disorder, and delusional disorders.
Residents Affected - Few
Review of the current physician orders revealed Resident #23 had an order for Levemir insulin with
instructions to inject 29 units subcutaneously at bedtime for diabetes dated 07/25/23.
Review of the care plan revised 06/13/24 revealed Resident #23 had potential for unmanaged blood
glucose levels and for complications related to type two diabetes mellitus, insulin dependency, and morbid
obesity. Interventions included administer medications as ordered.
Review of the Medication Administration Record (MAR) dated September 2024 revealed Resident #23 did
not receive Levemir insulin on 09/01/24. There was a code of 9 (other-see notes) entered.
Review of the Medication Administration Record (MAR) dated November 2024 revealed Resident #54 did
not receive Levemir insulin on 11/11/24. There was a code of 9 (other-see notes) entered.
Review of the progress notes and electronic MAR (e-MAR) notes revealed there were not any notes
entered to explain why Resident #54 did not receive insulin injections on 09/01/24 or 11/11/24.
Interview on 11/25/24 at 10:22 A.M. with Resident #54 revealed she did not always receive insulin at night
as ordered. The resident reported she did not receive Levemir injection approximately one to two weeks
ago because the agency nurse stated there was not any Levemir insulin in stock at the facility. Resident #54
denied having any negative outcomes from the missed dose of insulin.
Interview on 11/27/24 at 9:00 A.M. with the Director of Nursing (DON) confirmed Resident #54 did not
receive ordered doses of Levemir insulin on 09/01/24 or 11/11/24. The DON confirmed there was no
evidence in the medical record to explain why the insulin doses were not received.
Review of the facility policy, Medication Dispensing System, undated, revealed the policy stated,
medications are administered in a timely fashion as specified by policy. After Medication Administration:
document necessary medication administration/treatment information (e.g., when medications are
administered, medication injection site, refused medications and reason, prn medications, etc.) on
appropriate forms.
Based on record review, staff interview, resident interview, and policy review, the facility failed to prevent
significant medication errors. This affected two (Resident's #44 and #23) of five residents reviewed for
medication administration. The facility census was 79.
Findings include:
1. Review of the medical record for Resident #44 revealed an admission date of 05/13/23 and a re-entry
admission date of 09/23/24. Medical diagnoses include chronic obstructive pulmonary disease (COPD),
morbid obesity due to excess calories, type two diabetes mellitus with diabetic polyneuropathy, and
unspecified protein-calorie malnutrition.
Review of Resident #44's Minimum Data Set (MDS) 3.0 assessment revealed a Brief Interview of Mental
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365717
If continuation sheet
Page 6 of 14
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
11/27/2024
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 0760
Status (BIMS) score of 15, indicating the resident was cognitively intact.
Level of Harm - Minimal harm
or potential for actual harm
Review of the physician orders for Resident #44 revealed an order for insulin glargine solostar
subcutaneous solution pen-injector 100 unit, inject 45 units subcutaneously two times a day related to type
two diabetes melluitus with diabetic polyneuropathy with a start date of 09/24/24.
Residents Affected - Few
Review of the medication administration report (MAR) revealed Resident #44's insulin was not provided on
10/02/24, 10/08/24, 10/12/24, 10/22/24, 11/04/24, and 11/10/24.
Review of the vitals tab revealed Resident #44's blood sugars were taken on the dates her insulin was not
provided. The following sugars were noted on the missing dates: 10/02/24 259 at 8:53 A.M., 10/08/24 156
at 7:51 A.M., 10/12/24 212 at 10:15 A.M., 10/22/24 302 at 7:50 A.M., 11/04/24 225 at 8:00 A.M., and
11/10/24 297 at 8:49 A.M.
Review of the progress notes for Resident #44 revealed there were no notes indicating why Resident #44
missed her insulin on those dates.
Interview on 11/26/24 at 2:23 P.M. with the Director of Nursing (DON) verified that any missed doses of
insulin should have been documented in the progress notes including why the does was missed.
Interview on 1126/24 at 3:52 P.M. with the DON verified that there was no documentation of why the insulin
was not administered on the missing dates.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365717
If continuation sheet
Page 7 of 14
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
11/27/2024
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, staff interviews, and review of facility policies and procedures, the facility failed to
maintain sanitary food storage and preparation conditions. This had the potential to affect 55 residents who
ate food prepared from the facility. The facility census was 79.
Findings include:
Observation of the kitchen walk in refrigerator on 11/25/24 at 8:38 A.M. revealed that a container that
appeared to contain de-stemmed grapes, a container that appeared to contain shredded lettuce and a
container that contained a small diced yellow fruit were unlabeled and undated on the refrigerator shelves.
Interview on 11/25/24 at 8:38 A.M. with Dietary Manager #235 confirmed that three containers of food in
the walk in refrigerator were unlabeled and undated. Dietary Manager #235 was unable to verify when the
food items were initially opened.
Observation on 11/25/24 at 8:43 A.M. revealed that there was approximately one inch thick of ice and snow
like frost build up on the bottom left freezer when the walk in freezer door was opened. There were boxes of
food with ice and frost on them. The door frame was observed to have ice build up on the door frame near
the seal.
Interview on 11/25/24 at 8:43 A.M. with Dietary Manager #235 confirmed that there was visible ice and
snow build up on food products in the walk in freezer and ice build up on the freezer door frame.
Observation on 11/26/24 at 11:04 A.M. revealed that two ceiling vents were covered in a brown and black
fuzz. The dirty ceiling vents were over a food preparation area.
Interview on 11/26/24 at 11:04 A.M. with Dietary Manager #235 confirmed the presence of a brown and
black fuzzy substance on the ceiling vents located over the food preparation area.
Review of a 2023 policy titled, Food Storage, revealed that food will be stored in an area that is clean, dry
and free from contaminants. Food will be stored at appropriate temperatures and by methods designed to
prevent contamination or cross contamination. All containers or storage bags must be legible and
accurately labeled and dated. Racks and other storage surfaces should be clean and protected from
splashes, overhead pipes or other contaminations (ceiling sprinklers, sewer/waste disposal pipes, vents,
etc.) All foods should be covered, labeled and routinely monitored to assure that foods will be consumed by
their use by dates.
\
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365717
If continuation sheet
Page 8 of 14
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
11/27/2024
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
the medical record for Resident #86 revealed an admission date on 08/19/24. Medical diagnoses included
malignant neoplasm of larynx, dysphagia-oropharyngeal phase, and malignant neoplasm of head, face,
and neck.
Residents Affected - Few
Review of the MDS assessment dated [DATE] revealed Resident #86 had intact cognition. Resident #86
required assistance from staff to complete Activities of Daily Living (ADLs). Resident #86 had a feeding
tube in place.
Observations and interviews on 11/25/24 at 2:15 P.M., 11/26/24 at 8:38 A.M., and 11/26/24 at 3:30 P.M.
revealed Resident #86 had a peg tube placed in abdominal area. Resident #86 stated staff typically wore a
mask and gloves while caring for him but did not wear gowns. There was no sign on Resident #86's door or
any available Personal Protective Equipment (PPE) placed near Resident #86's room. There was no
evidence Resident #86 had been placed under Enhanced Barrier Precautions (EBP).
Review of the physician orders revealed there was no order for Enhanced Barrier Precautions (EBP) in
place until 11/26/24, following surveyor intervention.
Interview on 11/26/24at 3:35 P.M. with Agency Registered Nurse (ARN) #502 confirmed Resident #86 did
not have a sign placed on his door or any PPE placed by his room for EBP. ARN #502 confirmed EBP
should be utilized for a resident who had any openings, like a peg tube.
Interview on 11/26/24 at 3:38 P.M. with the Director of Nursing (DON) confirmed Resident #86 had not been
placed under EBP due to having a peg tube. The DON confirmed EBP should have been initiated.
Based on observation, interview, medical record reveiw, and policy review, the facility failed to ensure
catheter bags were stored in a sanitary manner to prevent infection. This affected one (Resident #20) of
one resident observed for catheter storage. Additionally, the facility failed to ensure Enhanced Barrier
Precautions (EBP) were in place for Resident #96. This affected one (Resident #96) of one resident
observed for EPB. The facility census was 79.
Findings include:
1. Resident #20 was admitted on [DATE] with diagnoses including Parkinsonism, neuromuscular
dysfunction of bladder, personal history of malignant neoplasm of prostate, and muscle weakness.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that resident had an indwelling
catheter.
Review of Resident #20's orders dated 06/17/24 revealed that Resident #20 had scheduled catheter and
foley care monitoring on every shift daily.
Observation of Resident #20 on 11/26/24 from 6:59 A.M. until 7:16 A.M. revealed that his catheter bag was
laying flat against the floor under his bed.
Interview with Licensed Practical Nurse (LPN) #119 on 11/26/24 at 7:16 A.M. revealed that Resident #20's
catheter bag was laying flat against the floor under his bed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365717
If continuation sheet
Page 9 of 14
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
11/27/2024
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
Level of Harm - Minimal harm
or potential for actual harm
Review of facility policy reviewed in August 2024 titled, Catheter Care, revealed that the catheter should be
secured after catheter care is provided. The drainage tubing and bag should be checked to ensure that the
catheter is draining properly.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365717
If continuation sheet
Page 10 of 14
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
11/27/2024
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, review of immunization records, staff interview, and facility policy review, the facility
failed to educate residents on the risks and benefits and/or offer influenza vaccinations to residents as
required. This affected five (Residents #42, #44, #61, #72, and #89) of five reviewed for immunizations. The
facility census was 79.
Residents Affected - Some
Findings Include:
1. Review of the medical record for Resident #42 revealed an admission date on 10/29/24. Medical
diagnoses included encephalopathy, acute and chronic respiratory failure with hypoxia, type II Diabetes
Mellitus with hyperglycemia, and morbid obesity.
Review of immunization records revealed Resident #42 received the influenza (flu) immunization on
11/23/22. There was no further evidence Resident #42 had been offered the vaccination since admission.
There was no evidence Resident #42 had been educated on the risks and benefits of receiving the flu
vaccination.
2. Review of the medical record for Resident #44 revealed an initial admission date on 05/13/23 and a
readmission date on 09/23/24. Medical diagnoses included idiopathic aseptic necrosis of right hand,
chronic obstructive pulmonary disease, type II Diabetes Mellitus with polyneuropathy, and morbid obesity.
Review of immunization records revealed Resident #44 received the flu vaccination on 11/08/23. There was
no evidence Resident #44 had been offered the flu vaccination in 2024. There was no evidence Resident
#44 had been educated on the risks and benefits of receiving the flu vaccination.
3. Review of the medical record for Resident #61 revealed an initial admission date on 09/16/22 and a
readmission date on 11/19/24. Medical diagnoses included chronic respiratory failure with hypoxia,
resistance to carbapenem, tracheostomy status, paraplegia, disease of spinal cord, colostomy status,
pressure ulcer of right lower back stage IV, pressure ulcer of sacral region stage IV, pressure ulcer of other
site stage IV, pressure ulcer of left lower back stage IV, and anal fistula.
Review of immunization records revealed Resident #61 refused the flu vaccination. However, there was no
date indicated on the Influenza Vaccine Consent Form. Resident #61's signature or a representative's
signature was not present on the form. There was no evidence Resident #61 and/or the resident's
representative had been educated on the risks and benefits of the flu vaccination.
4. Review of the medical record for Resident #72 revealed an initial admission date on 03/16/23 and a
readmission date on 08/09/24. Medical diagnoses included anoxic brain damage, resistance to
carbapenem, protein-calorie malnutrition, epilepsy, tracheostomy status, gastrostomy status, and
dependence on respirator (ventilator) status.
Review of immunization records revealed Resident #72 received the flu vaccination on 11/08/23. There was
no evidence the flu vaccination had been offered to the resident or resident representative in 2024. There
was no evidence Resident #72 and/or the resident representative had been educated on the risks and
benefits of the flu vaccination.
5. Review of the medical record for Resident #89 revealed an admission date on 10/30/24. Medical
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365717
If continuation sheet
Page 11 of 14
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
11/27/2024
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 0883
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
diagnoses included encephalopathy, chronic respiratory failure, morbid obesity, and simple chronic
bronchitis.
Review of the immunization records revealed Resident #89 received the flu vaccination on 12/09/22. There
was no evidence Resident #89 or the resident's representative had been offered the flu vaccination since
admission. There was no evidence Resident #89 and/or the resident's representative had been educated
on the risk and benefits of the flu vaccination.
Interview on 11/27/24 at 11:23 A.M. with the Director of Nursing (DON) confirmed the above findings. The
DON confirmed deficiencies with vaccinations of residents had been identified and she had planned to start
obtaining consents from residents next week. The DON stated, I know we aren't where we are supposed to
be with them.
Review of the facility policy, Influenza and Pneumococcal Disease Prevention, dated 01/31/22, revealed the
policy stated, residents, regardless of stay, should be offered the seasonal influenza vaccine. Influenza
immunizations are offered to all residents and facility personnel according to the time period provided by
the Centers for Disease Control and Prevention (CDC). Before offering the immunization, nursing facility
personnel and each resident or the resident's legal representative receive education regarding the benefits
and potential side effects of the immunization. Documentation that the resident and/or resident's legal
representative was provided education regarding the benefits and potential side effects of the influenza
and/or pneumococcal immunization, documentation of any refusals to be vaccinated, and documentation
that the resident either received the influenza and/or pneumococcal immunization or did not receive it, is
kept in the resident's medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365717
If continuation sheet
Page 12 of 14
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
11/27/2024
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 0887
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and
staff after education, and properly document each resident and staff member's vaccination status.
Based on record review, review of immunization records, staff interview, and facility policy review, the facility
failed to educate on the risks and benefits and/or offer COVID-19 vaccinations to residents as required. This
affected five (Residents #42, #44, #61, #72, and #89) of five reviewed for immunizations. The facility census
was 79.
Findings include:
1. Review of the medical record for Resident #42 revealed an admission date on 10/29/24. Medical
diagnoses included encephalopathy, acute and chronic respiratory failure with hypoxia, type II Diabetes
Mellitus with hyperglycemia, and morbid obesity.
Review of immunization records revealed Resident #42 received COVID-19 vaccinations on 03/04/21,
04/01/21, and 11/10/21. There was no evidence Resident #42 and/or the resident's representative was
educated on the COVID-19 vaccination upon admission. There was no evidence the COVID-19 vaccination
was offered to Resident #42 or the resident's representative upon admission.
2. Review of the medical record for Resident #44 revealed an initial admission date on 05/13/23 and a
readmission date on 09/23/24. Medical diagnoses included idiopathic aseptic necrosis of right hand,
chronic obstructive pulmonary disease, type II Diabetes Mellitus with polyneuropathy, and morbid obesity.
Review of immunization records revealed Resident #44 refused the COVID-19 booster vaccination. There
was no date indicated in the medical record of when the vaccination was refused. There was no evidence in
the medical record Resident #44 and/or the resident's representative received education on the risks and
benefits of the vaccination in 2023 or 2024. There was no evidence Resident #44 was offered the
COVID-19 vaccination in 2023 or 2024.
3. Review of the medical record for Resident #61 revealed an initial admission date on 09/16/22 and a
readmission date on 11/19/24. Medical diagnoses included chronic respiratory failure with hypoxia,
resistance to carbapenem, tracheostomy status, paraplegia, disease of spinal cord, colostomy status,
pressure ulcer of right lower back stage IV, pressure ulcer of sacral region stage IV, pressure ulcer of other
site stage IV, pressure ulcer of left lower back stage IV, and anal fistula.
Review of immunization records revealed Resident #61 revealed there was no evidence the resident had
received any COVID-19 vaccinations. There was no evidence in the medical record Resident #61 and/or the
resident's representative refused the vaccination. There was no evidence Resident #61 and/or the
resident's representative had been educated on the risks and benefits of the COVID-19 vaccination. There
was no evidence the COVID-19 vaccination had been offered to Resident #61 and/or the resident's
representative in 2023 or 2024.
4. Review of the medical record for Resident #72 revealed an initial admission date on 03/16/23 and a
readmission date on 08/09/24. Medical diagnoses included anoxic brain damage, resistance to
carbapenem, protein-calorie malnutrition, epilepsy, tracheostomy status, gastrostomy status, and
dependence on respirator (ventilator) status.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365717
If continuation sheet
Page 13 of 14
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
11/27/2024
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 0887
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of immunization records revealed Resident #72 refused the COVID-19 vaccine booster, however,
there was no date indicated. There was no evidence in the medical record of Resident #72 and/or the
resident's representative refusing the vaccination. There was no evidence in the medical record Resident
#72 and/or the resident's representative was educated on the risks and benefits of the COVID-19
vaccination. There was no evidence the COVID-19 vaccination was offered to Resident #72 and/or the
resident's representative in 2023 or 2024.
5. Review of the medical record for Resident #89 revealed an admission date on 10/30/24. Medical
diagnoses included encephalopathy, chronic respiratory failure, morbid obesity, and simple chronic
bronchitis.
Review of the immunization records revealed Resident #89 received COVID-19 vaccinations on 06/30/21,
12/29/21, and 12/09/22. There was no evidence in the medical record Resident #89 and/or the resident's
representative had been educated on the risks and benefits of the COVID-19 vaccine since admission.
There was no evidence Resident #89 and/or the resident's representative were offered the COVID-19
vaccine since admission.
Interview on 11/27/24 at 11:23 A.M. with the Director of Nursing (DON) confirmed the above findings. The
DON confirmed deficiencies with vaccinations of residents had been identified and she had planned to start
obtaining consents from residents next week. The DON stated, I know we aren't where we are supposed to
be with them.
A facility policy related to COVID-19 vaccination was requested at the time of the survey, however, a policy
was not provided for review.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365717
If continuation sheet
Page 14 of 14
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
13 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
FAQ · About this visit
Common questions about this visit
What happened during the November 27, 2024 survey of THE CONVALARIUM OF DUBLIN?
This was a inspection survey of THE CONVALARIUM OF DUBLIN on November 27, 2024. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE CONVALARIUM OF DUBLIN on November 27, 2024?
Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arra..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.