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Inspection visit

Health inspection

THE CONVALARIUM OF DUBLINCMS #3657171 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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** Based on observation, medical record review, resident and staff interview, review of facility's infection control surveillance log, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure proper personal protective equipment (PPE) was available for staff providing care for a resident (#24) with COVID-19 infection. Additionally, the facility failed to ensure a resident (#25) with known exposure to a COVID-19 resident followed appropriate guidance and physician orders to prevent potential spread of the virus. This had the potential to affect all 83 residents residing in the facility. The census was 83. Residents Affected - Many Findings include: 1. Review of the medical record for Resident #24 revealed an admission date of 12/15/24. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure, type II diabetes mellitus, and pneumonia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was cognitively intact required limited assistance with activities of daily living (ADLs). Review of a nursing progress note dated 02/04/25 revealed Resident #24 was transferred to the hospital due to shortness of breath. While in the hospital on [DATE] she tested positive for COVID-19. Resident #24 returned to the facility on [DATE] and was placed in isolation. The resident had a roommate who was relocated to a private room due to being exposed to Resident #24. Review of a physician order dated 02/05/25 revealed Resident #24 was ordered single room isolation, airborne, droplet, or contact with all services provided in the room through the duration of isolation every shift. 2. Review of the medical record for Resident # 25 revealed an admission date of 03/31/23. Diagnoses included end stage renal disease, hypertension, congestive heart failure, and cirrhosis of liver. Resident #25 was noted to share a room with Resident #24. Review of the MDS assessment dated [DATE] revealed Resident #25 was cognitively intact and required limited assistance with ADLs. Review of Resident #25's active physician orders revealed an order written on 02/05/25 for the resident to be in COVID-19 exposure isolation every shift for COVID positive for 10 days and re-evaluate on the tenth day to determine if the resident met criteria to discontinue isolation on the eleventh day. The order had an end date of 02/15/25. (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 3 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 02/12/2025 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 Residents Affected - Many Review of a nursing progress note revealed Resident #25 agreed to change his room on 02/05/25 at 1:12 P.M. and on 02/06/25 at 12:06 P.M. Resident #25 was unhappy in a private room under isolation and the facility moved him back into the same room as Resident #24. Interview with the Director of Nursing (DON) on 02/11/25 at 11:00 A.M. revealed Resident #25 refused to stay in an isolated private room and demanded he move back into his old room with Resident #24. Resident #25 refused to believe he would contract COVID-19 even after being provided education. Resident #24 agreed to have Resident #25 move back into her room. Observation and interview on 02/11/25 at 12:15 P.M., revealed a bin of personal protective equipment (PPE) was located outside of Resident #24 and Resident #25's room. The bin included gloves, gowns, shoe covers, and N-95 face masks, but contained no PPE to offer eye protection. Interview with Licensed Practical Nurse (LPN) #100 during the observation confirmed the PPE bin contained no eye protection for staff entering the room. Interview and observation at 12:20 P.M. with Resident #24 revealed her roommate (Resident #25) was not currently in the room and explained he was out in the lobby. Observation of the dining room for lunch on 02/11/25 from 12:45 P.M. to 1:25 P.M. revealed Resident #10, Resident #12, Resident #14, Resident #16, Resident #20, Resident #25, Resident #45, Resident #50, and Resident #52 were all in the dining room having lunch together. Further observation revealed Resident #25 was not wearing a mask. Interview with Resident #16 on 02/11/25 at 1:30 P.M. confirmed Resident #25 went to the dining room for each meal and frequently sat in the lobby visiting with staff and residents throughout the day. Resident #16 confirmed Resident #25 does not wear a mask. Interview with LPN #100 on 02/11/25 at 1:30 P.M. confirmed Resident #25 frequently leaves his room and remains in common areas with other residents without wearing a face mask. Interview with the Director of Nursing (DON) on 02/11/25 at 2:00 P.M. confirmed the facility followed the Centers for Disease Control and Prevention (CDC) guidelines when a resident or staff member was positive for COVID-19. The DON confirmed the facility had a sign on the entrance doors of the facility notifying the public they had a COVID-19 positive case in the facility; however, they did not notify the residents and or their representatives that someone in the facility tested positive for COVID-19. The DON stated they do not require the residents to wear masks, however, all employees during outbreak must wear a surgical mask. Interview on 02/11/25 at 2:00 P.M. with Dietary Supervisor #500 stated Resident #25 went to the dining room daily and does not wear a face mask. Review of the infection control surveillance log from 11/01/24 to 02/11/25 revealed Resident #24 was the only resident who tested positive for COVID-19 during that time frame. Review of the CDC website at https://www.cdc.gov/covid/hcp/infection-control/?CDC_AAref_Val=https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection revealed infection control guidance related to SARS-CoV-2 (COVID-19) dated 06/24/24. Review of the guidance revealed healthcare personnel (HCP) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 2 of 3 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 02/12/2025 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 Residents Affected - Many Health (NIOSH) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Ideally, residents with suspected or confirmed SARS-CoV-2 infection should be placed in a single-person room and if limited single rooms are available, or if numerous residents are simultaneously identified to have known SARS-CoV-2 exposures or symptoms concerning for COVID-19, residents should remain in their current location. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Limit transport and movement of the patient outside of the room to medically essential purposes. Source control refers to use of respirators or well-fitting facemasks or cloth masks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. Source control is recommended for individuals in healthcare settings who have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or had close contact (patients and visitors) or a higher-risk exposure (healthcare professionals) with someone with SARS-CoV-2 infection, for 10 days after their exposure. Even when a facility does not require masking for source control, it should allow individuals to use a mask or respirator based on personal preference, informed by their perceived level of risk for infection based on their recent activities (e.g., attending crowded indoor gatherings with poor ventilation) and their potential for developing severe disease if they are exposed. Further review of the CDC website under the section titled, Duration of Empiric Transmission-Based Precautions for Asymptomatic Patients following Close Contact with Someone with SARS-CoV-2 Infection, revealed in general, asymptomatic patients do not require empiric use of Transmission-Based Precautions while being evaluated for SARS-CoV-2 following close contact with someone with SARS-CoV-2 infection. These patients should still wear source control and those who have not recovered from SARS-CoV-2 infection in the prior 30 days should be tested as described in the testing section. Additionally, patients placed in empiric Transmission-Based Precautions based on close contact with someone with SARS-CoV-2 infection should be maintained in Transmission-Based Precautions for the following time periods; patients can be removed from Transmission-Based Precautions after day seven (7) following the exposure (count the day of exposure as day 0) if they do not develop symptoms and all viral testing as described for asymptomatic individuals following close contact is negative. If viral testing is not performed, patients can be removed from Transmission-Based Precautions after day 10 following the exposure (count the day of exposure as day zero) if they do not develop symptoms. This deficiency represents non-compliance investigated under Complaint Number OH00162349. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365717 If continuation sheet Page 3 of 3

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Citations

1 citation 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.

  • 0880GeneralS&S Fpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the February 12, 2025 survey of THE CONVALARIUM OF DUBLIN?

This was a inspection survey of THE CONVALARIUM OF DUBLIN on February 12, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at THE CONVALARIUM OF DUBLIN on February 12, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."

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

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.