Inspection·August 22, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and resident rights, resident and staff interview, and observation, the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable interior. This affected one resident (#75) and had the potential to affect an additional 36 residents (Resident #2, #3, #5, #8, #9, #11, #12, #19, #22, #23, #25, #26, #30, #32, #33, #35, #36, #40, #41, #43, #48, #49, #59, #62, #64, #65, #69, #71, #74, #83, #84, #85, #86, #91, #92, and #94) who resided on the second floor. The facility census was 93. Findings include: Review of Resident #75's medical record revealed an admission date of 12/20/22. Diagnoses included depression, muscle weakness, and peripheral vascular disease. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 was cognitively intact and required maximum assistance from staff with bathing. Observation on 08/19/24 at 12:13 P.M. of the second-floor community shower room revealed an unpleasant foul odor coming from a drain in the bathroom, and the restroom had a brown smeared substance on the wall. One of the two shower curtains had scattered black dots on it. Observation and interview on 08/19/24 at 4:09 P.M. with State Tested Nursing Assistant (STNA) #272 confirmed a foul odor was present, the restroom had a brown substance on the wall, and one of the two shower curtains had scattered black dots on it. STNA #272 stated it was housekeeping's responsibility to clean the restroom and change the dirty shower curtain. STNA #272 stated a remedy for the foul odor was to run water down the drain. Interview on 08/20/24 at 10:19 A.M. with Resident #75 said the facility does not clean the community restroom/shower room routinely and the smell was terrible in the community shower room. Interview on 08/20/24 at 8:32 A.M. with Clinical Service Manager #400 confirmed the second-floor community shower room was to be cleaned when soiled and to run water down the shower drains to prevent gas buildup. Review of the facility Resident Rights and Facility Responsibilities dated 10/24/23 revealed the residents have the right to a safe and clean living environment. Review of the facility policy on routine cleaning dated 11/30/23 revealed cleaning walls and blinds according to the cleaning schedule and whenever dust or soil is visible. (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: 366418 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 366418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Dublin Post Acute 4075 West Dublin-Granville Road Dublin, OH 43017 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)