FRIENDSHIP VILLAGE OF DUBLIN
Non profit - Corporation
50 Beds
Independent
Data: November 2025
Trust Grade
48/100
#680 of 913 in OH
Photo by Friendship Village of Dublin
Photo by Friendship Village of Dublin
Photo by Friendship Village of Dublin
1 / 5 photos
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Friendship Village of Dublin has a Trust Grade of D, indicating below-average performance with some concerns about care quality. It ranks #680 out of 913 nursing homes in Ohio, placing it in the bottom half, and #31 out of 56 in Franklin County, meaning there are only a few local options that rank higher. The facility is worsening, with reported issues increasing from 6 in 2022 to 8 in 2024. Staffing is a weakness here, earning only 1 out of 5 stars, though it has a 0% turnover rate, which is much better than the state average. There are some troubling incidents, such as a resident being injured during a transfer due to insufficient assistance, and failures in food safety practices, which could affect all residents. Overall, while there are strengths such as low staff turnover, the facility's serious concerns and poor rankings suggest that families should carefully consider their options.
- Trust Score
- D
- In Ohio
- #680/913
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- $3,145 in fines. Lower than most Ohio facilities. Relatively clean record.
- Skilled Nurses ○ Average
- RN staffing data not reported for this facility.
- Violations ⚠ Watch
- 20 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Bottom 26%
Needs review
6 → 8 violations
★★☆☆☆
2.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2022: 6 issues
2024: 8 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Ohio average (3.2)
Below average - review inspection findings carefully
Federal Fines: $3,145
Below median ($33,413)
Minor penalties assessed
The Ugly 20 deficiencies on record
1 actual harm
Nov 2024
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a preadmission screening and record review (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a preadmission screening and record review (PASRR) document in a timely manner. This affected one (Resident #29) of one reviewed for PASRR. The census was 40.
Findings Include:
Resident #29 was admitted to the facility on [DATE]. Her current diagnoses were nontraumatic intracranial hemorrhage, osteoporosis, dementia, morbid obesity, polyosteoarthritis, atrial fibrillation, congestive heart failure, anxiety disorder, hyperlipidemia, occlusion and stenosis of carotid artery, acute kidney failure, chronic kidney disease (stage III), post traumatic stress disorder, osteoarthritis, and major depressive disorder. Review of her minimum data set (MDS) assessment, dated 10/10/24, revealed she had a mild cognitive impairment.
Review of Resident #29's progress notes, dated 09/12/24, revealed she was admitted to the facility from the hospital.
Review of Resident #29's hospital documentation found the hospital completed a hospital exemption form for admission to the long term care/skilled care facility. This form allows the resident to remain in the facility for up to 30 days, without the facility having to complete a PASRR document.
Review of Resident #29's PASRR document, dated 11/13/24, revealed this was the only PASRR document completed. The PASRR document should have been completed and submitted to the appropriate state agency by 10/12/24, which it was not.
Interview with Social Worker (SW) #317 on 11/13/24 at 2:30 P.M. confirmed the hospital exemption form was completed on 09/12/24. She also confirmed a hospital exemption form was completed on 10/03/24 and thought that was acceptable for her to remain in the facility. She confirmed the only PASRR completed for Resident #29 was on 11/13/24. SW stated she didn't know she would have to complete a PASRR if they went into the hospital multiple times within the first 30 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and record review the facility failed to ensure medications were administered according to the prescribing physician's orders. This affected two (#4 and #7) of f...
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Based on observation, staff interview, and record review the facility failed to ensure medications were administered according to the prescribing physician's orders. This affected two (#4 and #7) of four residents reviewed for medication administration. The census was 40.
Findings include:
1. Resident #4 had an admission date of 12/29/23 with diagnoses including: falls, depression, overactive bladder, hyperlipidemia, rosacea, abnormal gait/mobility, Parkinson's disease, and anxiety.
Observation on 11/14/24 at 8:56 A.M. revealed Licensed Practical Nurse (LPN) #329 administered Carbidopa-Levodopa (used to treat symptoms of Parkinson's disease), extended release (ER), 25-100 mg, one tablet by mouth to Resident #4.
Review of the electronic medication administration record (eMAR) on 11/14/24 at 8:57 A.M. revealed an order for Carbidopa-Levodopa ER, 25-100 mg, one tablet by mouth, give at 7:00 A.M.
Review of the order summary report for Resident #4 on 11/14/24 at 10:00 A.M. revealed the following orders for Resident #4:
Carbidopa-Levodopa ER, oral tablet 25-100 mg, give one tablet by mouth in the evening for Parkinson's disease, give at 8:00 P.M., dated 01/31/24.
Carbidopa-Levodopa oral tablet, 25-100 mg, give two tablets by mouth three times a day for Parkinson's disease, dated 12/29/23.
Interview with LPN #329 at 10:15 A.M. on 11/14/24 confirmed that the wrong dose of Carbidopa-Levodopa ER, was administered at the wrong time for Resident #4.
2. Resident #7 had an admission date of 02/19/24 with diagnoses including: hypothyroidism, allergic rhinitis, anxiety, depression, dementia, Alzheimer's disease, hypertension, pain, and insomnia.
Observation on 11/14/24 at 9:13 A.M. revealed LPN #329 administered Depakote Sprinkles (mood stabilizer anticonvulsant), Delayed Release (DR)125 mg, one capsule by mouth to Resident #7 at 9:15 A.M.
Review of the eMar on 11/14/24 at 9:15 A.M. revealed an ordered administration time for Depakote Sprinkles DR, one capsule, of 7:30 A.M.
Review of the order summary report for Resident #7 on 11/14/24 at 10:00 A.M. revealed the following orders for Resident #7:
Depakote Sprinkles, oral capsule, DR, 125 mg, give one capsule by mouth two times a day for dementia with agitation.
Depakote Sprinkles, oral capsule, DR, 125 mg, give two capsules by mouth in the evening for agitation with dementia.
Interview with LPN #329 at 10:15 A.M. on 11/14/24 confirmed that the administered dose of Depakote Sprinkles DR was given at the wrong time for Resident #7.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy, the facility failed to ensure pressure injury intervention...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy, the facility failed to ensure pressure injury interventions were implemented in a timely manner for one (Resident's #11) of two resident's reviewed for pressure ulcers. Additionally, the facility failed to complete skin measurements and monitoring in a timely manner for two (Residents #11 and #29) of two residents reviewed for pressure ulcers. The facility census was 40.
Findings include:
1. Review of the medical record for Resident #11 revealed an admission date of 10/04/24 with diagnoses including fracture of left femur, disruption of wound, edema, type II diabetes, chronic diastolic heart failure, osteoarthritis, paroxysmal atrial fibrillation, rosacea, bilateral primary osteoarthritis of knee, anxiety, chronic pain, chronic kidney disease stage III, thrombophilia, gastro esophageal reflux disease, hypertension, hyperlipidemia, and irritable bowel syndrome.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a brief interview of mental status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #11 had impaired mobility, required the use of a walker or wheelchair for ambulation and required moderate to maximal assistance with acclivities of daily living. The resident was coded to have a stage three pressure ulcer present at the time of admission and a nutrition risk.
Review of the skilled nursing assessments for Resident #11, from 10/04/24 to 11/12/24, revealed the facility did not document any measurements for the stage III pressure ulcer until 10/10/24 even though pressure ulcer was documented as present at time of admission.
Review of the physician orders for Resident #11 revealed use of a Prevalon boot with a start date of 10/02/24.
Review of the treatment administration record (TAR) reveaeld the resident had a treatment order for the left heel of change foam dressing to the left heel three times a week and as needed dated 10/07/24 and 10/08/24. No wound treatment intervention was implemented until 10/07/24.
Review of the care plan for Resident #11 revealed the facility will administer treatments as ordered and monitor for effectiveness. Additionally, the facility was to assess, record, and monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the physician.
Review of the progress notes for Resident #11 revealed on 10/11/24 at 4:13 P.M. Assistant Director of Nursing (ADON) placed call to the resident's daughter regarding current wound treatment for pressure injuries present on admission. Medication review complete and orders for labs to be drawn on Monday. All questions answered and verbalized understanding.
Interview on 11/13/24 at 1:44 P.M. with ADON #345 confirmed pressure ulcers should be addressed promptly upon admission and confirmed that the interventions were not initiated until 10/07/24.
Interview on 11/14/24 at 2:16 P.M. with RN #347 verified a head to toe assessment is completed the day of admission and if a pressure ulcer or skin alteration is present they notify the Director of Nursing (DON) and Nurse practitioner (NP). RN #347 stated the Nurse Practitioner will examine the pressure ulcer the same day. RN #347 also stated the staff, including the NP, ADON, or nursing staff, will measure the wound the same day as admission and the wound nurse will measure again on Thursday when they are at the facility.
2. Resident #29 was admitted to the facility on [DATE]. Her current diagnoses were nontraumatic intracranial hemorrhage, osteoporosis, dementia, morbid obesity, polyosteoarthritis, atrial fibrillation, congestive heart failure, anxiety disorder, hyperlipidemia, occlusion and stenosis of carotid artery, acute kidney failure, chronic kidney disease (stage III), post traumatic stress disorder, osteoarthritis, and major depressive disorder. Review of her minimum data set (MDS) assessment, dated 10/10/24, revealed she had a mild cognitive impairment.
Review of Resident #29 progress notes, dated 11/01/24, revealed she was re-admitted back to the facility after an acute hospital stay.
Review of Resident #29 skin observation tool, dated 11/01/24, revealed staff documented that she had Moisture Associated Skin Damage (MASD) on her right and left buttocks. There were no measurements or description documented for this skin alteration.
Review of Resident #29 Skin Provider Consultation report, dated 11/05/24, revealed the nurse practitioner assessed the wound and determined it to be a stage III pressure ulcer to her buttocks with the measurements of 3.0 centimeters (cm) by 3.5 cm by 0.1 cm. The report also documented this wound was present upon admission.
Interview with Assistant Director of Nursing (ADON) #345 on 11/13/24 at 1:44 P.M. and 11/14/24 at 9:05 A.M. confirmed Resident #29 skin injury/pressure ulcer was not officially measured and monitoring was not started until 11/05/24, which was four days after she was re-admitted to the facility from the hospital. She confirmed the skin injury was not present when she left for the hospital, so it was only present upon readmission. She confirmed they have started new procedures of having each new skin injury assessed and measured upon admission, instead of waiting until the wound nurse arrives to the facility once a week.
Review of the Pressure Ulcers/Skin Breakdown - Clinical Protocol revealed, the staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions and the physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. Additionally, the clinical protocol indicated treatments such as pressure-reducing surfaces and appropriate wound care measures should be initiated immediately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews, and review of facility policy, the facility failed to ensure resident weights were o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews, and review of facility policy, the facility failed to ensure resident weights were obtained as per dietician recommendations. This had the potential to affect two (#36 and #37) out of four reviewed for nutrition. The census was 40.
Findings Include:
1. Review of the medical record for Resident #37 revealed an admission date of 08/26/24 diagnoses include severe fracture of the left femur, history of falling, dementia, severe cognitive deficits, and anemia. Resident required one person assist with activities of daily living.
Review of Resident #37's plan of care revealed the resident will maintain adequate nutrition support as evidenced with no significant weight changes.
Review of Resident #37's Nutrition/Dietary Note dated 09/18/24 revealed Resident #37 weighed 140.2 pounds triggering him for significant weight loss of 5.7% weight loss in one month. This was related to his decreased intakes and appetite. Medications to increase appetite have been ordered. Dietician will continue to monitor Resident #37's weight trends via weekly weights to review effectiveness of interventions .
Review of Resident #37's physician orders for 09/22/24 to 11/14/24 did not indicate resident was to be weighed weekly.
Review of Resident #37's documented weights revealed a weight was obtained on 9/22/24 of 141.8 pounds and on 10/23/24 137.6 pounds. No additional weights were obtained.
Interview with Dietician #380 on 11/14/24 at 10:50 A.M. revealed she did see the resident on 9/18/24 and recorded in his progress notes to monitor the resident's weight trends and indicated the resident was to be weighed weekly. She notified Resident #37's doctor to order the weekly weights.
2. Resident #36 was admitted to the facility on [DATE], diagnoses include collapsed vertebra, history of falling , pacemaker, severe cognitive deficits, and unspecified dementia with agitation.
Review of Resident #36's plan of care revealed Resident #36 will maintain adequate nutrition support as evidenced by no significant weight changes. Weigh resident as ordered and in similar manner for accuracy.
Review of Resident #36's Quarterly Nutrition Review note on 10/04/24 at 10:16 A.M. Resident #36 weighed 115.2 pounds indicating she has had a decline in the last three months. Dietician to order weekly weights for close monitoring for four weeks.
Review of Resident #36's physician orders for 10/04/24 to 11/14/24 did not indicate resident was to be weighed weekly.
Review of Resident #36's documented weights revealed on 09/01/24 she weighed 115.2 pounds and on 10/30/24 she weighed 111.4 lbs. Resident #36 had no other documented weights.
Interview with Dietician #380 on 11/14/24 at 11:30 A.M. revealed she did see the resident on 10/04/24 and stated in progress notes to monitor the residents weight trends and indicated the resident was to be weighed weekly. She notified Resident #36's doctor to order the weekly weights.
Review of facility policy titled Interventions for Unintended Weight Loss , dated 03/01/2019, revealed Unintended weight loss or gradual weight loss will be monitored so that appropriate and individualized intervention can be implemented. Residents will be weighed upon admission or readmission , weekly for the first four weeks after admission, and at least monthly thereafter to help identify and document weight trends. Weekly weights may be ordered due to significant change in condition or altered nutritional status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, policy review and review of medication information from Medscape, the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, policy review and review of medication information from Medscape, the facility failed to ensure a resident was free from unnecessary psychotropic medications by ensuring there was an adequate indicate for use for the use of an antipsychotic medication. This affected one (#7) of five residents reviewed for unnecessary medications. Additionally, the facility failed to adequately monitor behaviors for residents that were prescribed psychotropic medications. This affected two (Residents #7 and #29) of five reviewed for unnecessary medications. The facility census was 40.
Findings include:
1. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Her diagnoses were Alzheimer's disease, insomnia, dementia, hypothyroidism, allergic rhinitis, depression, hypertension, intervertebral disc degeneration lumbar region, gastro-esophageal reflux disease without esophagitis, pain, pure hypercholesterolemia, and postnasal drip.
Review of the Minimum Data Set (MDS) assessment, dated 05/08/24, revealed a brief interview of mental status (BIMS) score of 02 indicating significant cognitive impairment. Resident #7 was not coded as having any psychotic disorder.
Review of the physician orders for antipsychotic medications used in Resident #7's care from 10/08/24 to present revealed the following orders:
Seroquel (antipsychotic) oral tablet 25 milligrams (mg) one tablet by mouth every 24 hours as needed for Alzheimer's dementia with psychosis for 14 days with a start date of 11/12/24 and an end date of 11/26/24.
Seroquel oral tablet 25 mg one tablet by mouth two times a day for agitation for seven days with a start date of 11/4/24.
Seroquel oral tablet 25 mg by mouth one time a day for agitation for seven days with a start date of 10/27/24 and an end date of 10/29/24.
Seroquel oral tablet 25 mg by mouth in the evening for agitation for seven days with a start date of 10/18/24 and an end date of 10/25/24.
Seroquel oral tablet 50 mg by mouth one time a day for agitation for seven days with a start date of 10/19/24 and an end date of 10/26/24.
Seroquel oral tablet 50 mg by mouth one time a day for dementia with psychosis and give 50 mg by mouth one time a day and give 50 mg by mouth at bedtime for dementia with psychosis with a start date of 10/8/24 and an end date of 10/18/24.
Seroquel oral tablet 25 mg by mouth one time a day for dementia with psychosis give at noon with a start date of 10/8/24 and an end date of 10/18/24.
Review of the progress notes revealed on 11/06/24 at 11:18 A.M., medication review team which included the Certified Nurse Practitioner (CNP), Medical Director, Pharmacy, Director of Nursing (DON), Assistant Director of Nursing (ADON) but did not indicate clear evidence or outcomes of the review that supported ongoing use of Seroquel for Resident #7. The note does not specify whether behavioral management strategies other than pharmacological interventions were considered and there was insufficient evidence in the record that other non-pharmacologic interventions were attempted or that the family was involved in discussions about the medication changes. There was no clear documentation present in the record of the need for continued use of psychotropic medications and justification for such use. The use of Seroquel was not sufficiently documented as being aligned with the goals of treatment. There was no evidence of specific documentation regarding the resident's response to Seroquel or any assessments regarding the risks and benefits of its use.
Interview on 11/13/24 at 8:51 A.M. with ADON #345 and DON confirmed the diagnoses for ordering Seroquel were not appropriate for the medications use. Documentation provided no clear rationale for the ongoing use of the medication and its effectiveness in managing the Resident's symptoms.
Interview on 11/14/24 at 9:24 A.M. the Nurse Practitioner verified Seroquel was initially prescribed to address agitation related to Alzheimer's disease, but the plan to taper off Seroquel was discussed.
Review of medication information from Medscape at: https://reference.medscape.com/drug/seroquel-xr-quetiapine-342984?_gl=1*5jj9fp*_gcl_au*MTU0MDAzODMxNC4xNzI2NTk1Nzgz revealed Seroquel is an antipsychotic medication used for schizophrenia, bipolar and major depressive disorder. Seroquel is not approved for dementia-related psychosis; elderly patients with dementia-related psychosis who are treated with antipsychotic drugs are at increased risk of death, as shown in short-term controlled trials; deaths in these trials appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (eg, pneumonia) in nature.
2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE]. Her diagnoses were Alzheimer's disease, insomnia, dementia, hypothyroidism, allergic rhinitis, depression, hypertension, intervertebral disc degeneration lumbar region, gastro-esophageal reflux disease without esophagitis, pain, pure hypercholesterolemia, and postnasal drip.
Review of the Minimum Data Set (MDS) assessment, dated 05/08/24, revealed a brief interview of mental status (BIMS) score of 02 indicating significant cognitive impairment. Additionally, Resident #7 was not coded as having a psychotic disorder.
Review of Resident #7's current orders revealed the resident had the current psychotropic medications used in her care: Seroquel (antipsychotic) oral tablet 25 milligrams (mg) one tablet by mouth every 24 hours as needed for Alzheimer's dementia with psychosis for 14 days with a start date of 11/12/24 and an end date of 11/26/24.
Rexulti (Serotonin-Dopamine Activity Modulator used for schizophrenia, depression, and agitation associated with Alzheimer's dementia) oral tablet three mg one tablet by mouth one time a day for Alzheimer's dementia with agitation with a start date of 11/19/24.
Depakote sprinkles (mood stabilizer anticonvulsant) oral capsule delayed release sprinkle 125 mg, two capsules by mouth in the evening for agitation with dementia start date 10/30/24.
Review of the care plan for Resident #7 revealed that the nursing staff was responsible for monitoring and documenting any behavioral symptoms that occur while the resident is receiving psychotropic medications. This includes tracking any changes in behavior (e.g., increased agitation, aggression, confusion) and evaluating whether the antipsychotic medications are effective or if dosage adjustments are necessary. There was no evidence behavioral symptoms (such as agitation, aggression, or confusion) were systematically monitored or documented on a shift-by-shift basis as required by the care plan.
Review of the progress notes revealed no evidence that behavioral symptoms (such as agitation, aggression, or confusion) were systematically monitored or documented on a shift-by-shift basis as documented in the care plan. Despite changes in medication orders there was no clear documentation of the effectiveness of these medications in managing the resident's behavioral symptoms over time.
Interview on 11/13/24 at 12:12 P.M. with the Administrator, verified behavior documentation for the facility would be in the skilled notes.
Interview on 11/14/24 at 9:43 A.M. with the DON confirmed the facility documents by exception and would document behaviors in the progress notes if they occur and then discuss the behaviors at their daily/weekly meetings with the nurse practitioner and staff.
3. Resident #29 was admitted to the facility on [DATE]. Her current diagnoses were nontraumatic intracranial hemorrhage, osteoporosis, dementia, morbid obesity, polyosteoarthritis, atrial fibrillation, congestive heart failure, anxiety disorder, hyperlipidemia, occlusion and stenosis of carotid artery, acute kidney failure, chronic kidney disease (stage III), post traumatic stress disorder, osteoarthritis, and major depressive disorder. Review of her minimum data set (MDS) assessment, dated 10/10/24, revealed she had a mild cognitive impairment.
Review of Resident #29's current physician orders revealed she was ordered Duloxetine (anti-depressant) 40 milligrams (mg) for depression.
Review of Resident #29 current care plan revealed she was prescribed Duloxetine for depression and anxiety. An intervention for this care plan stated the facility was to, monitor/document/report as needed adverse reactions to antidepressant therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in activities of daily living (ADL) ability, continence, no voiding, constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance problems, movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, weight loss, nausea/vomiting, dry mouth, and dry eyes.
Review of Resident #29 progress notes and behavior tracking documentation, dated 09/12/24 to 11/14/24, revealed no behaviors documented. Also, there was no documentation to support behaviors were being tracked in general.
Interview with Administrator on 11/13/24 at 12:12 P.M., via email revealed the behavior documentation for residents are completed in progress notes as each behavior occurs. They do not keep logs for specific behaviors for each resident.
Interview with DON on 11/14/24 at 9:43 A.M. stated they document by exception for behaviors. She confirmed the staff would document behaviors in the progress notes if they occur, and then discuss the behaviors at their daily/weekly meetings with the facility nurse practitioner if changes to their medication regimen needs to occur.
Review of the behavioral assessment, intervention and monitoring policy revealed if the resident is being treated for altered behavior or mood, the interdisciplinary team (IDT) will seek and document any improvements or worsening in the individuals behavior, mood, and functioning. Additionally, the IDT will monitor the progress of individuals with impaired cognition and behavior until stable with new or emergent symptoms being documented and reported. Finally, interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review the facility failed to ensure residents had an appropriate indication...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review the facility failed to ensure residents had an appropriate indication for the use of antibiotics. This affected one resident (#26) of five residents reviewed for antibiotic stewardship. The census was 40.
Findings include:
Review of medical record for Resident #26 revealed the resident was admitted on [DATE], diagnoses included: vitamin D deficiency, myocardial infarction, hypertension, osteoporosis, obstructive sleep apnea, heart disease, and abnormal weight loss with a body mass index (BMI) of 19.9 or less, (normal healthy weight rage is BMI 18.5-24.9).
Review of Resident #26's physician orders for January of 2024 revealed an order for Macrobid (antibiotic) oral capsule, 100 milligrams (mg), give one capsule by mouth, two times a day, for urinary tract infection (UTI), for five days. The order start date was 01/04/24, with a stop date of 01/09/24. The order was listed as completed.
Review of Resident #26's Infection Report Form based on The McGeer Criteria (set of surveillance tools used to identify health care-associated infections), dated 01/04/24 on 11/14/24 at 1:30 P.M. revealed Resident #26 was hallucinating with increased incontinence. Documentation on the form stated Resident #26 was not experiencing fever, pain, hematuria, urgency, frequency, dysuria, or tenderness, and no urinalysis or urine culture was completed. No subcriteria, nor microbiologic criteria were met to support the use of an antibiotic for a urinary tract infection. Resident #26 was prescribed Macrobid, 100 mg, twice a day, for five days, with an ordered start date of 01/04/24 and a stop date of 01/09/24 for a urinary tract infection.
Interview with the Assistant Director of Nursing (ADON) #345 on 11/14/24 at 2:09 P.M. confirmed Resident #26 completed a course of antibiotics for a urinary tract infection that did not meet The McGeer Criteria for a UTI from 01/04/24 - 01/09/24.
Review of the policy titled Antibiotic Stewardship dated 2001 revised 12/2016 revealed: Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program.
The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, staff interviews and policy review the facility failed to prepare, distribute and serve food in a safe, sanitary manner. This had the potential to affect all residents. The cens...
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Based on observations, staff interviews and policy review the facility failed to prepare, distribute and serve food in a safe, sanitary manner. This had the potential to affect all residents. The census was 40.
Findings Include:
Observation on 11/13/24 at 11:30 A.M. of the lunch meal preparation revealed [NAME] #501 and Dietary Aid #502 preparing food for the meal and neither worker were observed to have beard covers on, to cover their cheeks, upper lip, and chin hair while working in the kitchen . This observation was verified by Director of Dietary Quality Assurance #700.
Interview on 11/13/24 at 11:45 A.M. with [NAME] #501 confirmed he should have had a beard cover on while cooking the food.
Review of facility policy titled Employee Sanitary Practices, dated 04/04/19 and 03/01/19, revealed employees will wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on record review, staff interviews, review of the facility's water management program, review of facility policy and review of the Centers for Disease Control and Prevention's (CDC) guidance, th...
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Based on record review, staff interviews, review of the facility's water management program, review of facility policy and review of the Centers for Disease Control and Prevention's (CDC) guidance, the facility failed to ensure adequate monitoring of the water management program to control the spread of waterborne pathogens. This had the potential to affect all 40 residents. The census was 40.
Findings include:
Interview on 11/14/24 at 9:01 A.M. with the Facilities Director #450 confirmed the facility had performed a Legionella (bacteria that can cause a severe type of pneumonia) risk assessment in April of 2024.
Review of the facility's binder titled Water Management, no date, on 11/14/24 at 9:01 A.M. revealed a list of team members and their responsibilities in the water management program, and a map to describe the water filtration system. There was no documented evidence provided to show the facility monitored physical controls, documented water temperatures, monitored disinfectant level controls, completed visual inspections, or environmental testing for waterborne pathogens in the calendar years of 2023 or 2024.
Interview on 11/14/24 at 10:20 A.M. with the Facilities Safety Specialist #455 it was confirmed there was no documented evidence of Legionella monitoring from 2023 to present.
Interview on 11/14/24 at 10:34 A.M. with the Facilities Director #450 he stated he was hired in December of 2023, and had no documented evidence of Legionella monitoring from 2023 to present.
Review of the facility's policy and procedures document on 11/14/24 at 11:30 A.M. titled Water Mitigation Program dated November of 2023, revealed the facility's policy was to contract with a water mitigation system provider to ensure adequate facilitation of the water management program to control the spread of waterborne pathogens. The procedures were listed as follows:. Water will be tested in accordance with the facility's contracted water mitigation and management program. The Facilities Director is the responsible party for overseeing the facility's water mitigation and management program Regular testing of the water mitigation and management program is reported and reviewed through the monthly quality assurance and performance improvement committee, including Legionella surveillance and compliance.
Review of the CDC guidance titled Overview of Water Management Programs, dated 03/15/24, revealed water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Further review revealed the seven key elements of a Legionella water management program included: establish a water management program team, describe the building water systems, identify areas where Legionella could grow and spread, decide where control measures should be applied and how to monitor them, establish ways to intervene when control limits are not met, ensure the program runs as designed and is effective, and document and communicate all the activities.
Jun 2022
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #3 was properl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy and procedure review and interview the facility failed to ensure Resident #3 was properly transferred to prevent a fall. This affected one resident (#3) of three residents reviewed for accidents.
Findings include:
Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance, major depressive disorder, and osteoarthritis.
Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 04/28/22 revealed Resident #3 had cognitive impairment. The MDS revealed the resident required extensive assistance of two staff for transfers.
Review of a nurse's note, dated 05/29/22 at 10:30 A.M. revealed the nurse heard Resident #3 scream out. The nurse found the resident lying on the floor under a sit-to-stand mechanical lift. The note revealed the State Tested Nursing Assistant (STNA) said Resident #3 would not hold on or sit still during the transfer. No visible injuries were noted. The STNA was educated on the use of the sit-to-stand mechanical lift since the resident did not have an order for sit-to-stand transfers at the time of the incident.
Review of the Post Fall Evaluation, dated 05/29/22 revealed contributing factors for Resident #3's fall included the sit-to-stand lift being used by only one staff member.
On 06/02/22 at 10:08 A.M. interview with Licensed Practical Nurse (LPN) #162 revealed the STNA stated she had seen other staff use the sit-to-stand by themselves with Resident #3 and felt she could transfer the resident without assistance.
On 06/02/22 at 12:46 P.M. interview with the Director of Nursing verified Resident #3's medical record revealed the resident required extensive assistance of two staff for transfers and there was only one staff member transferring the resident on 05/29/22 at the time the resident fell.
Review of the Safe Lifting and Movement of Resident Policy and Procedure, revised July 2017 revealed nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident needs for transfer assistance on an ongoing basis. Assessments should include the residents mobility, size, weight-bearing ability, cognitive status and whether the resident was usually cooperative with staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to provide oxygen as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to provide oxygen as ordered for Resident #13 and failed to ensure oxygen/respiratory supplies were dated to maintain proper use. This affected one resident (#13) of one resident reviewed for oxygen.
Findings include:
Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic diastolic heart failure, chronic respiratory failure hypoxia, dependence on supplemental oxygen, chronic kidney disease stage four, iron deficiency anemia and pleural effusion.
Review of the physician's orders revealed an order, dated 03/16/22 for Resident #13 to receive three liters of oxygen continuously for shortness of breath.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 03/23/22 revealed Resident #13 had impaired cognition.
Review of the April 2022 and May 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation related to oxygen use or oxygen tubing.
Review of the plan of care, dated 04/05/22 revealed Resident #13 had oxygen therapy related to terminal prognosis, comfort measures, chronic respiratory failure, chronic pleural effusion and chronic heart failure. Interventions included oxygen through nasal prongs at three liters, monitoring for signs of respiratory distress, providing medications as orders and positioning the resident to facilitate ventilation.
On 05/31/22 at 11:50 A.M. and 12:00 P.M. Resident #13 was observed receiving oxygen via a nasal cannula. The oxygen was set at two liters and there was no date on the tubing.
On 05/31/22 at 12:00 P.M. interview with Licensed Practical Nurse (LPN) #134 confirmed the above observation. LPN #134 confirmed Resident #13's orders were for three liters of oxygen and she was receiving two liters. LPN #134 revealed Resident #13's daughter had been in to visit with her on 05/30/22 and stated the daughter may have adjusted the concentrator. LPN #134 reported oxygen tubing was to be changed weekly and confirmed there was no documentation to indicate the last time Resident #13's tubing had been changed as the tubing was not dated and there was no documentation of such on the administration records.
On 06/01/22 at 1:07 P.M. interview with the Director of Nursing (DON) revealed residents who received oxygen continuously should have their tubing changed weekly. The DON indicated staff should document the tubing changes on the administration record also.
Review of the policy titled Oxygen Administration, dated October 2010 revealed that unless otherwise ordered the flow of oxygen should be started at two to three liters. After completing oxygen setup or adjustment the nurse should document the date and time the procedure was performed, the rate of oxygen flow, route, and rationale, the reason for the administration and all assessment data obtained.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to provide a Fentanyl patch as ordered for pain management and correctly document the administration of the patch for Resident #33. This affect...
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Based on interview and record review the facility failed to provide a Fentanyl patch as ordered for pain management and correctly document the administration of the patch for Resident #33. This affected one resident (#33) of one resident reviewed for pain management.
Findings include:
Record review revealed Resident #33 had a plan of care, dated 07/08/21 related to risk for alteration in comfort related to generalized discomfort, arthritis, limited mobility, respiratory failure, edema, hypertension, macular degeneration, osteoporosis and additional diagnoses. The care plan revealed Resident #33 was noted to scratch and pick at her transdermal pain patch at times. Interventions included applying ice 20 minutes per hour and after activities as needed, attempt non-medication interventions, ensure transdermal pain patch was securely in place, medication as ordered, monitor for pain every shift and notify physician of any new or worsening changes in pain.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/18/22 revealed the Resident #33 had impaired cognition. The MDS revealed she received a scheduled pain medication regimen and had not experienced pain during the assessment reference period.
Review of the physician's order for Resident #33 revealed an order, (from 01/16/22 to 05/10/22) for a Fentanyl (pain) Patch 12 microgram (mcg) per hour to be applied transdermally every 72 hours for pain and covered with tegaderm to secure, an order dated 05/11/22 to 05/13/22 for a Fentanyl Patch 12 microgram (mcg) per hour to be applied transdermally every 72 hours for pain and covered with tegaderm to secure and an order, dated 05/13/22 for a Fentanyl Patch 12 microgram (mcg) per hour to be applied transdermally every 72 hours for pain and covered with tegaderm to secure.
Review of the May 2022 medication administration record (MAR) revealed a Fentanyl patch was documented as being applied on 05/08/22 at 7:25 A.M. and 05/11/22 at 8:46 A.M. by Licensed Practical Nurse (LPN) #149 and on 05/13/22 at 7:30 A.M.
Review of the progress note, dated 05/13/22 at 7:10 A.M. revealed LPN #134 noted during shift to shift change that Resident #33's Fentanyl patch that was in place, was dated 05/08/22. The note indicated orders in the electronic medical record stated to change every 72 hours; the Director of Nursing (DON) and Hospice were notified.
Review of the progress note, dated 05/13/22 at 7:19 A.M. revealed Hospice returned the phone call and gave a verbal order to take off Resident #33's patch, dated 05/08/22 and replace it with a new patch, the start date changed in the MAR for 72 hours from 05/13/22.
On 06/02/22 at 12:45 P.M. interview with the Director of Nursing (DON) revealed following the incident, the Fentanyl patch count (sign out sheet and supply on hand) were never off and she had determined the medication had not been properly administered during this time period as opposed to the medication being misappropriated or misused by staff.
On 06/02/22 at 1:21 P.M. interview with LPN #149 revealed she had not administered the Fentanyl patch on 05/11/22 as ordered. She reported she had been waiting for the oncoming nurse and had been checking off things she had completed on the MAR. LPN #149 reported she was supposed to change the patch with another nurse, however, by the time the nurse arrived she had forgotten.
Review of the controlled drug receipt, record, and disposition form revealed Resident #33 did not receive a Fentanyl patch as ordered on 05/11/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure medications were not administered to Resident #27 when outsid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure medications were not administered to Resident #27 when outside of the parameters set by the physician for medication administration. This affected one resident (#27) of five residents reviewed for unnecessary medication use.
Findings include:
Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE] with diagnoses including hyperlipidemia, unspecified systolic heart failure, Alzheimer's disease, hypertensive heart disease, unspecified severe protein-calorie malnutrition, unspecified atrial fibrillation and cardiomyopathy.
Review of Resident #27's physician's orders revealed an order, dated 04/10/22 to hold beta blockers, ace inhibitors, and diuretics for systolic blood pressure less than 110 millimeters of mercury (mm Hg). Additional review revealed an order for Spironolactone 12.5 milligrams (mg) to be given by mouth one time a day for chronic thromboembolic pulmonary hypertension and Toprol extra-large tablet extended release 12.5 mg by mouth in the evening for chronic thromboembolic pulmonary hypertension.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/11/22 revealed Resident #27 had mildly impaired cognition.
Review of the plan of care, dated 05/15/22 revealed Resident #27 was on diuretic therapy related to chronic heart failure and fluid management. Interventions included administering diuretic medications as ordered by physician, monitor for interactions and adverse consequences. An additional intervention to monitor dose as it may require modification to achieve desired effects while minimizing adverse consequences, especially when multiple antihypertensives were prescribed simultaneously.
Review of the May 2022 Medication Administration Record (MAR) for Resident #27 revealed Spironolactone was administered in the morning on 12 occasions when Resident #27's systolic blood pressure was below 110 mm Hg. This included on 05/02/22, 05/05/22, 05/06/22, 05/09/22, 05/10/22, 05/13/22, 05/14/22, 05/15/22, 05/16/22, 05/24/22, 05/27/22, and 05/29/22.
Review of the May 2022 MAR for Resident #27 revealed Toprol was administered in the evening on eight occasions when Resident #27's systolic blood pressure was below 110 mm Hg. This included on 05/05/22, 05/09/22, 05/10/22, 05/20/22, 05/22/22, 05/23/22, 05/24/22, and 05/30/22. Further review revealed Toprol was administered when an evening blood pressure was not obtained and marked as 'vitals outside of parameters' on three occasions on 05/02/22, 05/27/22, and 05/29/22.
Review of the progress notes from 05/02/22 to 05/29/22 for Resident #27 revealed no notes indicating a physician was contacted about administering medications outside of parameters. Additionally, there were no progress notes to indicate medication was not administered when indicated on the MAR.
On 06/01/22 at 1:07 P.M. and 1:51 P.M. interview with the Director of Nursing (DON) confirmed generally a check mark in the MAR meant the medication was administered unless otherwise stated in the progress notes. She confirmed the medications were held at times due to the vitals being outside of the parameters and were administered at other times when they were outside of the ordered parameters. The DON confirmed blood pressure was obtained at the time of medication administration. When asked if nurses should be documenting if they were calling the physician prior to administering medications outside of parameters she stated she was not sure, but probably.
On 06/01/22 at 1:51 P.M. interview with Physician #165 revealed Resident #27 had beta blockers for her chronic heart failure. He reported a desire to drive her heart rate down. Physician #165 reported when a resident admitted on beta blockers and diuretics the standard order was to hold for a systolic blood pressure below 110 mm Hg. However, the physician revealed this was not always necessary in the case of Resident #27's beta blockers, but he was not able to speak to the diuretic. Physician #165 reported he was unsure about every documented incident of the medication being administered outside of parameters, however, at times the nurses would call him and ask prior to administering it. He reported the hold order probably should have been discontinued but confirmed it was still in place.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, facility policy and procedure review and interview the facility staff failed to ensure the hood and filter system in the main kitchen and serving kitchen food production areas we...
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Based on observation, facility policy and procedure review and interview the facility staff failed to ensure the hood and filter system in the main kitchen and serving kitchen food production areas were maintained in a clean and sanitary manner to prevent the contamination of food. This had the potential to affect all 45 residents residing in the facility who consumed food prepared in the two areas.
Findings include:
On 05/31/22 at 8:45 A.M. observations during the kitchen tour revealed the main kitchen hood and filters above the stove were very dusty. Interview with Executive Chef #101 at the time of the observation verified the dust on the hood and filters and revealed they were last cleaned by a contracted company on 02/01/22.
On 05/31/22 at 8:55 A.M. observation of the serving kitchen area revealed the hood and filters above the stove were very dusty. Interview with Dietary Director #100 at the time of the observation verified the areas were very dusty and indicated the hood and filters were last cleaned by a contracted company on 02/01/22.
Review of the undated policy titled Weekly Cleaning Schedule Legacy revealed the hood filters were removed and cleaned weekly. The hood interior and exterior were to be cleaned with a stainless steel cleaner weekly.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, facility policy and procedure review and interview the facility staff failed to ensure trash was covered in the main kitchen storage and production areas. The had the potential t...
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Based on observation, facility policy and procedure review and interview the facility staff failed to ensure trash was covered in the main kitchen storage and production areas. The had the potential to affect all 45 residents residing in the facility.
Findings include:
On 05/31/22 at 8:45 A.M. observations during the kitchen tour revealed the main kitchen dry stock areas had a trash can full of trash with no lid near the sugar and flour storage bins.
Interview with Executive Chef #101 at the time of the observation verified the trash can was full of trash with no cover and was not being currently used by staff. Continued observation in the main kitchen revealed a trash can half full of trash with no cover near the ovens in the food production area that was not in use by staff. Interview with Dietary Director #100 at the time of this observation verified the trash can was half full of trash with no cover near the ovens in the food production area.
Review of the policy titled Waste Disposal, dated 2019 revealed that prior to disposal, all waste was kept covered in a leak-proof container when not in use.
Oct 2019
6 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record of Resident #32 revealed an initial admission dated of 11/22/16. Diagnoses included pathological...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record of Resident #32 revealed an initial admission dated of 11/22/16. Diagnoses included pathological fracture of hip, anxiety disorder, major depressive disorder, abnormalities of gait and mobility and general weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/24/19, revealed Resident #32 was cognitively intact and required the extensive assistance from one person for transfers. The resident used a walker and wheelchair and was participating in physical therapy.
Review of the nursing progress notes, dated 06/13/19, revealed Resident #32 was being transferred to the wheelchair by a State Tested Nurse Aide (STNA) and hit her left lower leg on the wheelchair. Resident #32 had two small skin tears measure 2.5 centimeters (cm.) in length by 1.5 cm. in width and 1.5 cm. by 1.5 cm. and there was a moderate amount of bleeding. The wounds were cleaned and steri-strips were placed on both wounds. Further review of the nursing note revealed an intervention to add wrapped padding to the upper parts of the wheelchair to prevent any further injury.
Review of the Health Center Wheelchair Check List, dated 06/13/19, revealed the resident was evaluated for a new wheelchair.
Review of the care plan, dated 08/14/19, revealed the resident had an activity of daily living (ADL) self-care performance deficit, impaired mobility and impaired safety with interventions to assist the resident with showers, staff to turn and reposition in bed and the resident required the extensive assistance of staff for transfers.
Review of the nursing progress note, dated 10/13/19, revealed the resident was being transferred into the wheelchair by an STNA and the resident received a skin tear to the left lower leg. The resident stated she was being transferred and something on the wheelchair gave her a skin tear. The note further revealed the wound was cleansed and the physician was notified for an order for a dressing.
Review of a work order, dated 10/13/19, revealed the wheelchair was being placed in an office to check for any sharp surfaces.
Review of the physician's orders, dated 10/14/19, revealed an order to treat the skin tear to the left lower leg and cleanse with normal saline, pat dry, apply Adaptic, dry dressing and wrap with Kerlix daily until healed.
Review of the undated weekly non-pressure ulcer tracking log revealed Resident #32 had two skin tears on 10/13/19. The first skin tear was located on the left shin and documented to be 3.2 cm. x 2.2 cm. and the second tear was located on the distal shin measuring 2.25 cm. x 1.0 cm. and a small amount of serosanguineous discharge was noted.
Interview and observation with Resident #32 on 10/15/19 at 3:30 P.M. revealed there was white gauze wrapped and taped on her left shin area. The resident stated she hit her leg on the wheelchair when getting out of bed. The resident confirmed that the STNA was present and assisting her during the transfer.
Observation of Resident #32 on 10/16/19 at 2:31 P.M. revealed the resident was in her wheelchair being pushed down the hallway with no padding noted to the wheelchair to prevent further skin tears.
Interview with the Director of Nursing (DON) on 10/17/19 at 2:29 P.M. revealed Resident #32's wheelchair was changed out by physical therapy as they felt the new chair was a better fit. The DON verified there was no padding on the new wheelchair as the brake on the new wheelchair was in a higher location than the old chair. The DON confirmed that the resident was in the new wheelchair when the second skin tear incident occurred on 10/13/19 and the wheelchair was not padded to prevent further injury and no new intervention was in place to prevent further injury after the 10/13/19 incident.
Interview with the Administrator on 10/17/19 at 3:32 P.M. revealed Resident #32's old wheelchair was still locked up in an office and verified there was no padding on the wheelchair Resident #32 was using.
Review of the facility's policy titled Event Management Program, dated 10/16/19, revealed there is a summary of each event with root cause and intervention to prevent reoccurrence in the clinical record and new interventions are put in place to prevent reoccurrence.
Based on observation, medical record review, review of facility investigation, review of staff statements, review of a facility policy, family interview and staff interview, the facility failed to ensure residents were provided adequate assistance during transfers. Actual harm occurred on 01/08/19 when Resident #8, who required extensive assistance from two staff using a Hoyer lift was pivot transferred and subsequently repositioned in a Broda (specialized chair) by one staff resulting in a femur fracture requiring surgical repair. In addition, the facility failed to ensure Resident #32 had interventions in place to ensure she can safely transfer to and from her wheelchair, which placed the resident at risk for potential harm. This affected two residents (#8 and #32) of three residents reviewed for accidents.
Findings include:
1. Review of Resident #8's medical record revealed an original admission date of 12/27/16 with the latest readmission of 01/13/19 with re-admitting diagnoses of osteoarthritis, dementia, and displaced comminuted fracture of shaft of right femur. Record review revealed the resident was receiving Hospice services.
Review of the resident's plan of care, dated 01/10/17 revealed the resident had a self-care performance deficit related to impaired mobility and cognition. An intervention, initiated on 01/29/18 revealed the resident was totally dependent on staff for transferring with a Hoyer (mechanical) lift. The care plan did not include any other methods for transferring the resident.
Review of Hospice plan of care documentation, dated 05/01/18 revealed staff were to assist with transfers. The plan did not specify the level of assistance needed or how staff were to assist.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/08/18, revealed the resident was non-ambulatory, required extensive assistance from two staff for bed mobility and transfers and had functional limitation in range of motion to the upper and lower extremities on both sides.
Review of the 01/08/18 discharge MDS 3.0 assessment revealed the resident had severely impaired cognition, was non-ambulatory and required extensive assistance from two staff for bed mobility and transfers.
Review of a progress note, dated 01/08/19 at 5:35 P.M. and authored by Registered Nurse (RN) #13 revealed she was summoned to the resident's room by a State Tested Nursing Assistant (STNA). The STNA stated, she transferred the resident from her bed to her Broda chair and when she was repositioning her she heard a crack sound on her right leg. Upon assessment the resident's right leg was internally rotated and the resident was grimacing and verbalized pain. The resident was given as needed Tylenol for pain. The resident's physician was notified and an order was obtained for an x-ray. The results of the x-ray revealed acute mid shaft fracture. The resident was sent to the local emergency room (ER) and was admitted for treatment. Hospital documentation reflected the resident had sustained a displaced comminuted fracture of shaft of right femur (a displaced fracture occurs when the bone snaps into two or more parts; if the bone is in many pieces it is called a comminuted fracture)
Review of the facility incident report dated 01/08/19 at 5:03 P.M. and revised on 01/09/19 at 9:31 A.M. revealed under the nursing description was the progress note dated 01/08/19 at 5:35 P.M. by RN #13. The report indicated the immediate action taken was the squad was called to transport the resident to the local emergency room for treatment. The incident report indicated no injuries were observed at the time of the incident and the resident had negative vocalizations, facial expressions, body language and consolability indicating pain. However, this was not consistent with the nursing progress note which documented the resident's right leg was internally rotated and the resident was grimacing, verbalized pain and was medicated with Tylenol.
Review of an undated signed hand written statement completed by STNA #5 revealed, I, [STNA #5] was helping the resident with transfers from bed to her broda chair, when I tried to reposition her in the broda, I heard a crack sound and I called the nurse.
Review of the typed statement with a drawing dated 01/08/19 and titled, Statement of Event revealed, STNA #5 was getting Resident #8 up for lunch. It was after 11:00 A.M. She was in bed. The STNA changed her brief and finished dressing her. The statement documented the resident normally stands up and will bear weight on her feet and pivot. The STNA sat the resident up on the side of the bed and the resident put her arms around the STNA's neck. The STNA hugged her and pivoted her into the Broda chair. The STNA documented the resident and herself transferred body to body. This statement revealed the resident did not indicate any pain at that time. After the STNA sat her in the chair she reclined the back of the chair and then positioned the resident's legs. The STNA documented she heard a pop sound and it wasn't the chair. The STNA started looking, and the resident said, Oh my foot. The STNA then went to get RN #13. The statement was signed respectfully submitted STNA #5 and had the STNA's signature.
Review of the acute care hospital documentation dated 01/10/19 revealed the resident was seen for right leg pain and according to her family the resident was being transferred from her bed to her wheelchair when the facility heard a pop and a deformity to the right leg was observed. The resident was seen, evaluated and was diagnosed with a femoral shaft fracture that needed stabilization with a retrograde IM nail (surgical repair). The hospital documentation revealed the resident's baseline was bed bound and non-ambulatory.
Record review revealed a physical therapy evaluation was completed following the incident on 01/17/19. The evaluation reflected the resident sustained a fracture during a stand pivot transfer (SPT) with STNA. The evaluation form revealed At baseline Pt completed SPT with max A (assist) or used Hoyer lift for transfers. The evaluation did not contain any additional information as to how the resident's baseline was determined or provide any additional information as to when staff should be using a Hoyer lift versus a stand pivot transfer.
Review of a Progressive Discipline Form, dated 01/19/19 revealed STNA #5 received a final written warning for substandard performance. The form documented the STNA failed to follow the care guide while delivering resident care resulting in injury to the resident (Resident #8).
Review of the resident's most current MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of five. The assessment revealed the resident required extensive assistance of two staff for transfers.
On 10/15/19 at 11:44 A.M. Resident #8 was observed sitting in a Broda chair with her legs elevated and bilateral heel protectors in place. The resident was observed with bilateral hand contractures. Attempts to interview the resident at this time were unsuccessful as the resident would not communicate with the surveyor.
On 10/15/19 at 2:26 P.M., an interview with Resident #8's family member revealed the resident had limited ability to respond to questions due to her cognition but at times could answer yes/no questions. During the interview a concern regarding a fracture the resident sustained in January 2019 was shared. During the interview, the family member revealed the resident required the use of a Hoyer lift to transfer and staff normally used the Hoyer lift. However, an STNA had transferred her by pivot transfer instead of using the Hoyer lift and the resident ended up with a femur fracture which required surgery resulting in screws and a rod to repair it.
On 10/16/19 at 3:07 P.M., an interview with the Director of Nursing (DON) revealed at 9:30 A.M. on 01/08/19 Resident #5 was being transferred by one STNA, STNA #5 using a pivot type transfer. The DON verified at the time of the incident the resident had a plan of care in place that reflected the use of a Hoyer lift for transfers. The DON indicated during the transfer process while repositioning the resident in the Broda chair, the STNA lifted the resident's legs and felt that something wasn't right with her leg and she notified the nurse immediately. She said she was not the DON at the time of the incident but reviewing the investigation, this is what she felt had occurred.
On 10/17/19 at 10:50 A.M., an interview with the Administrator revealed prior to the incident on 01/08/19 the resident had a plan of care in place which reflected she required a Hoyer lift for transfers. The Administrator revealed the assignment sheet for Resident #5 documented the resident required extensive assistance of one or two staff on the top line and Hoyer lift under it. The sheet failed to provide any guidance as to when staff should use what type of transfer assistance. The Administrator revealed she believed STNA #5 interpreted the sheet as the resident was either a one or two person assist. She said after the incident on 01/08/19 the care guide was update to reflect one or two assist using a Hoyer (mechanical) lift.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to provide ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to provide set-up assistance with breakfast for a resident who required assistance with meals. This affected one (Resident #23) of five residents reviewed for activities of daily living assistance. The facility census was 43.
Findings include:
Review of Resident #23's medical record revealed he admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbance, anxiety disorder, abnormal weight loss, dysphagia, and major depressive disorder.
Review of the Minimum Data Set (MDS) assessment, dated 10/01/19, revealed he had a moderate cognitive impairment and did not exhibit any behaviors. Resident #23 required set-up assistance with eating and was receiving hospice services.
Review of the care plan, dated 10/09/19, revealed he had an activity of daily living deficit and required assistance from staff with meals.
Observation on 10/16/19 at 8:34 A.M. revealed Resident #23 was reclined in his recliner watching television and drinking a nutritional supplement. His breakfast tray was out of reach. Resident #23's breakfast plate was on his portable side table that was perpendicular to his recliner and out of reach for the reclined resident. On 10/16/19 at 8:39 A.M., Resident #23 attempted to grab his oatmeal and in the process, accidentally scooted it further away. He then put his hand on his head and looked at his lap.
Interview on 10/16/19 at 8:41 A.M. with Resident #23 revealed the resident shook his head and stated, no in response to the question if he could reach his oatmeal. During an observation on 10/16/19 at 8:54 A.M., Resident #23 was reclined in his recliner, staring at his lap. His breakfast was untouched. There was no milk in his cereal, no straw was in his milk, and no other covered food containers were opened.
Observation and interview on 10/16/19 at 9:03 A.M. with State Tested Nursing Assistant (STNA) #10 stated while he was not the aid for Resident #23 today, he had cared for him several times in the past. STNA #10 confirmed Resident #23 required set-up assistance from staff for eating. STNA #10 confirmed Resident #23's tray was not set up to his care needs. STNA #10 stated he would have changed Resident #23's position from being reclined, to sitting up right and then move his portable side-table with his breakfast tray on it, in front of him. STNA #10 also stated he would assist opening the covered food items and insert straws. STNA #10 stated the other STNA may not have set up his breakfast tray because normally Resident #10 only drinks his nutritional supplement.
Review of a facility policy titled, Assistance with Meals, last revised February 2014, revealed facility staff would serve resident trays and would help residents who required assistance with eating.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, medical record review, staff interview and facility policy and procedure review, the facility failed to ensure Resident #26, who was dependent on staff for personal hygiene, rece...
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Based on observation, medical record review, staff interview and facility policy and procedure review, the facility failed to ensure Resident #26, who was dependent on staff for personal hygiene, received adequate assistance with nail care. This affected one (#26) of five residents reviewed for activities of daily living.
Findings include:
Review of Resident #26's medical record revealed an admission date of 07/09/15. Diagnoses included Alzheimer's disease and osteoarthritis.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/01/19, revealed the resident had unclear speech, usually understood others, usually made herself understood and had a moderate cognitive deficit. Review of the mood and behavior revealed the resident had indicators of depression and displayed no behaviors. The resident required extensive assistance of two staff for personal hygiene.
Review of the resident's plan of care, dated 10/09/19, revealed the resident had a self-care performance deficit. Interventions included the resident required assistance from staff for personal hygiene and oral care.
On 10/15/19 at 3:41 P.M., an observation of the resident revealed her nails were dirty with a brown substance under them. Subsequent observation on 10/16/19 at 2:50 P.M. revealed her nails remained dirty with a brown substance under them.
On 10/16/19 at 3:50 P.M., an interview with Licensed Practical Nurse (LPN) #18 verified the resident had dirty nails with a brown substance under them.
Review of the facility's policy titled Care of Fingernails/Toenails, dated 10/2010, revealed nail care includes daily cleaning and regular trimming.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, review of the Food and Drug Administration drug label and review of the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, review of the Food and Drug Administration drug label and review of the facility's policy, the facility failed to identify and monitor target behaviors and implement non-pharmacological interventions for psychotropic medication use for the residents. This affected four (#10, #20, #23 and #31) of five residents reviewed for unnecessary medications. The facility identified 11 residents who were prescribed psychotropic medications.
Findings include:
1. Review of Resident #23's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbance, anxiety disorder and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 10/01/19, revealed he had a moderate cognitive impairment and did not exhibit any behaviors.
Review of the physician orders revealed on 09/17/19, he was prescribed 0.6 milligrams (mg.) of Lorazepam (an anxiety-reducing medication) every six hours, as needed (PRN), for restlessness/agitation.
Review of the care plan, dated 10/09/19, revealed Resident #23 was at risk for alteration in comfort related to anxiety. The care plan stated the staff should explore non-pharmacological options such as repositioning, soft music, diversional activities, or one-on-one conversation.
Review of the Medication Administration Record (MAR), for 09/2019, revealed Resident #23 was administered the PRN Lorazepam on 09/29/19. The resident did not receive PRN Lorazepam in 10/2019.
Review of the progress notes, dated from 06/28/19 through 10/16/19, revealed there was no evidence of a target behavior or monitoring for agitation or restlessness. The nursing notes lacked evidence non-pharmacological interventions were attempted. The medical record lacked evidence the prescriber documented the required rationale and determined duration to extend both PRN anti-anxiety orders past the allotted 14 days.
Interview on 10/16/19 at 10:51 A.M. with the Director of Nursing (DON), stated that documentation of non-pharmacological interventions and monitoring of target behaviors would be in the nursing progress notes. She stated nursing staff, document behaviors by exception. Subsequent interview on 10/16/19 at 11:27 A.M., the DON stated Resident #23's hospice company ordered the Lorazepam on 09/17/19 because Resident #23's wife had reported to the hospice staff that he had been restless the last couple days. The DON confirmed there was no facility documentation of identifying or monitoring Resident #23's restlessness and agitation because he did not exhibit that behavior with their staff. On 10/16/19 at 12:42 P.M., the DON confirmed there was no progress note for 09/28/19, the day Resident #23 did receive the Lorazepam, indicating Resident #23 was exhibiting a targeted behavior nor were any non-pharmacological interventions documented as having been implemented. The DON stated she could not provide evidence Resident #23's physician provided a rationale for the continued use of the PRN Lorazepam past the allotted 14 day prescription.
2. Review of Resident #10's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included anxiety, major depressive disorder and insomnia. The MDS assessment, dated 10/01/19, revealed she had a moderate cognitive impairment and did not exhibit any behaviors.
Review of the physician orders revealed on 12/22/18 she was prescribed buspirone (an anxiety reducing medication), two times a day for anxiety.
Review of the care plan, dated 09/09/19, revealed she was at risk for alteration in comfort related to anxiety. The care plan stated the facility staff should explore non-pharmacological options such as repositioning, rest, a warm blanket, soft music, diversional activities or one-on-one conversation.
Review of the nursing progress notes, from 07/02/19 through 10/10/19, revealed it lacked evidence Resident #23's anxiety was being monitored. There were only two nursing notes in that time period that stated Resident #10 had anxiety, on 07/30/19 and 08/16/19.
Interview on 10/16/19 at 10:51 A.M. with the Director of Nursing (DON), stated that documentation with monitoring of target behaviors would be in the nursing progress notes. She stated nursing staff, document behaviors by exception. The DON confirmed there was no behavior monitoring in Resident #10's medical record.
3. Review of the medical record of Resident #31 revealed an admission date of 09/17/19 with diagnoses including insomnia. Review of the admission Minimum Data Set (MDS) assessment, dated 09/17/19, revealed Resident #31 was cognitively intact.
Review of the care plan, dated 09/22/19, revealed a potential for adverse effects related to psychotropic drug use for insomnia and interventions to monitor for adverse effects of antipsychotic drug such as sedation, monitor for adverse affects of hypnotic drug use such as daytime lethargy, and notify the physician of adverse effects.
Review of the physician's order, dated 10/02/19, revealed a medication of Ambien (a medication that induces sleep) 10 milligrams (mg.) at bedtime for hypnotic/sedative.
Review of the nursing progress note, dated 10/06/19, revealed Resident #31 had trouble sleeping and medications given as ordered. There were no further nursing progress notes provided regarding the resident's use of Ambien or behaviors or insomnia and the medical record was absent for any documented evidence of a gradual dose reduction attempt being done related to the use of Ambien.
Review of the medication administration record (MAR), dated 10/2019, revealed Resident #31 received fourteen doses of the Ambien. The record was absent for any documentation of medication monitoring, non-pharmacological interventions, and behavior monitoring.
Interview with the Director of Nursing (DON) on 10/16/19 at 5:59 P.M. revealed that all documentation of non-pharmacology interventions, behaviors, and drug monitoring are documented by exception in the progress notes by the nurse and the DON was aware that nurses have not been documenting properly. The DON further stated that behaviors and non-pharmacological measures should be documented in a resident's charge when giving a psychoactive medication and confirmed there was no documentation of behaviors or non-pharmacological measures in Resident #31's medical record.
Review of the Food and Drug Administration (FDA) drug label, approved on 04/23/08, revealed Ambien is indicated for short-term treatment of insomnia and a need to re-evaluate if insomnia persists after seven to ten days.
4. Review of Resident #20's medical record revealed an admission date of 04/27/17 with diagnoses including major depressive disorder, anxiety and dementia.
Review of the quarterly MDS assessment, dated 07/30/19, revealed the resident had clear speech, understands others, makes herself understood and had a severe cognitive deficit. Review of the mood and behavior revealed the resident displays indicators of depression and displayed no behaviors. The MDS indicated the resident received antidepressant medications.
Review of the plan of care, dated 05/22/17, revealed the resident has a diagnoses of depression and anxiety and the resident was at risk of a mood decline and reported the resident experienced lack of interest/pleasure in doing things. Interventions included to administer medications as ordered, help the resident in conversation to identify interests and what brings her pleasure, monitor mood symptoms and consult physician/psychologist if symptoms worsen, monitor for symptoms of depression and consult physician/psychologist, attempt non-pharmacological interventions, offer activities of interest and offer opportunity to verbalize thoughts and feelings.
Review of the resident's monthly physician's orders for September 2019 indicated an order for Zoloft (a medication to treat depression) 50 milligrams (mg.) by mouth daily for depression.
Review of the progress notes from 05/03/19 to 10/10/19 revealed no identified target behaviors or monitoring of the target behaviors.
On 10/17/19 at 8:34 A.M., an interview with the Administrator revealed the facility charts behaviors by exception in the progress notes. She said they also document behaviors on the 24 hour report sheet and the interdisciplinary team (IDT) summarizes the behaviors with a weekly note. She verified Resident #20's medical record lacked monitoring of the resident's target behaviors.
Review of a facility policy titled, Antipsychotic Medication Use, last revised 02/2014, revealed the residents would only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physcian and other staff would gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risk to the resident and others.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on observation, resident and staff interview and review of facility policy, the facility failed to serve food at an appetizing temperature during the resident's dining. This affected 42 of 43 re...
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Based on observation, resident and staff interview and review of facility policy, the facility failed to serve food at an appetizing temperature during the resident's dining. This affected 42 of 43 residents who receive food from the facilities kitchen as the facility identified one resident who ate nothing by mouth (Resident #31). The facility census was 43.
Findings include:
Interview with the Dietician #102 and Dietary Manager #101 on 10/15/19 at 9:30 A.M. revealed lunch was served in the main dining room and the hallway at 11:30 A.M.
Observation of the resident dining and tray delivery on 10/15/19 at 11:25 A.M. revealed food was brought into the kitchen preparation area and trays were being made up and placed in the hallway serving cart and dining room counter to be delivered to the residents.
Interview with Dietician #102 on 10/15/19 at 12:07 P.M. revealed that a test tray would be placed on the hallway cart and the temperatures taken after the delivery of all residents food.
Observation of the hallway food cart on 10/15/19 revealed the tray was made and placed on the cart at 12:10 P.M. Observation of resident tray delivery in their rooms ran from 12:20 P.M. to 12:33 P.M.
Observation of the test tray's food temperatures with the Dietician #102 on 10/15/19 at 12:38 P.M. revealed milk in a carton was at a temperature of 52 degrees Fahrenheit (F), chicken rice casserole was at a temperature of 103 degrees F and the carrot and pea mixture was at a temperature of 100 degrees F. A taste test of the chicken rice casserole revealed it to be warm and of good flavor and a taste test of the carrot and pea mixture revealed that vegetables were cold. The Dietician stated the vegetables were hard to keep warm.
Subsequent interview with the Dietician #102 on 10/15/19 at 12:46 P.M. verified the test tray was the last tray placed on the cart and other trays sat in the cart for about 45 minutes before they were passed to the residents. The Dietician further stated that the normal kitchen being remodeled was causing a disruption in the flow of food delivery but was expected to be opened next week. The Dietician further stated staff have to run back and forth between the independent living kitchen and the dining room at this time and it was taking longer for them to prepare trays but that tray delivery time was quick once all the trays were prepared.
Interview with Resident #10 on 10/16/19 at 11:23 A.M. revealed the resident ate lunch in her room on 10/15/19 and the food was dry and should have been warmer. Interview with Resident #39 on 10/16/19 at 11:25 A.M. revealed the food was cold a lot of times when it was supposed to be hot and hot when it was supposed to be cold. Resident #39 further stated the milk was warm a lot of times and food items were often too salty. Interview with Resident #35 on 10/16/19 at 11:42 A.M. revealed Resident #35 eats meals in their room each day and the food was sometimes cold when it was supposed to be hot. Resident #35 further stated that sometimes the food was cold when she returns from physical therapy on some days and the facility does not heat it back up for her.
Review of the facility's list of residents who did not receive food from the kitchen revealed Resident #31 was the only resident who didn't receive food from the kitchen.
Review of the facility's undated policy titled Test Trays/Meal Rounds revealed it is the policy of the community to serve food that is palpable, attractive and at the proper temperatures. Tray accuracy, appropriate garnishments, temperatures, and appearance will be checked on each test tray.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, staff interview and review of facility policy, the facility failed to properly date and label food and maintain a clean microwave in the kitchen to prevent contamination and spoi...
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Based on observation, staff interview and review of facility policy, the facility failed to properly date and label food and maintain a clean microwave in the kitchen to prevent contamination and spoilage. This had the potential to affect 42 of 43 residents as the facility identified one resident who did not eat by mouth (Resident #31). The facility census was 43.
Finding include:
Observation and initial kitchen tour of the main with the Dietician #102 and Dietary Manager #101 on 10/15/19 began at 9:24 A.M. Observation of the dry food storage area revealed two packages of elbow macaroni, a package of egg noodles, a package of cornbread stuffing opened and undated. Observation of the kitchen refrigerator revealed open and undated sliced white cheese, two undated and uncovered metal pans of jello and several undated and uncovered pies on cookie sheets.
Interview with the the Dietician #102 on 10/15/19 at 9:35 A.M. confirmed the above items were open and undated and each opened item should contain a date when stored in the dry food storage area, refrigerator and freezer.
Observation of the service kitchen tour on 10/15/19 at 9:50 A.M. with the Dietician #102 and Dietary Manager #101 revealed a freezer with open and undated containers of french toast and pancakes, a container of omelettes and and container of sausage. Observation of the microwave revealed it was dirty with an orange thin liquid spill on the turn plate and inside splatter marks inside the microwave.
Interview with the Dietician #102 on 10/15/19 at 10:00 A.M. verified the items in the service kitchen freezer were open and undated and the microwave was not clean.
Review of the facility's list of residents who did not receive food from the kitchen revealed Resident #31 was the only resident who didn't receive food from the kitchen.
Review of the facility's undated policy titled Food Storage revealed all exposed foods should be stored tightly covered, labeled and dated.
Review of the facility's undated policy titled Equipment and Utensil Cleanliness revealed germs that cause disease are spread by improperly cleaned and sanitized eating and cooking utensils and equipment. All equipment should be cleaned and sanitized on a regularly scheduled basis.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • $3,145 in fines. Lower than most Ohio facilities. Relatively clean record.
Concerns
- • 20 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade D (48/100). Below average facility with significant concerns.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Friendship Village Of Dublin's CMS Rating?
CMS assigns FRIENDSHIP VILLAGE OF DUBLIN an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Ohio, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Friendship Village Of Dublin Staffed?
CMS rates FRIENDSHIP VILLAGE OF DUBLIN's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes.
What Have Inspectors Found at Friendship Village Of Dublin?
State health inspectors documented 20 deficiencies at FRIENDSHIP VILLAGE OF DUBLIN during 2019 to 2024. These included: 1 that caused actual resident harm and 19 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Friendship Village Of Dublin?
FRIENDSHIP VILLAGE OF DUBLIN is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 50 certified beds and approximately 41 residents (about 82% occupancy), it is a smaller facility located in DUBLIN, Ohio.
How Does Friendship Village Of Dublin Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, FRIENDSHIP VILLAGE OF DUBLIN's overall rating (2 stars) is below the state average of 3.2 and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Friendship Village Of Dublin?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Friendship Village Of Dublin Safe?
Based on CMS inspection data, FRIENDSHIP VILLAGE OF DUBLIN has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Friendship Village Of Dublin Stick Around?
FRIENDSHIP VILLAGE OF DUBLIN has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Friendship Village Of Dublin Ever Fined?
FRIENDSHIP VILLAGE OF DUBLIN has been fined $3,145 across 1 penalty action. This is below the Ohio average of $33,110. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Friendship Village Of Dublin on Any Federal Watch List?
FRIENDSHIP VILLAGE OF DUBLIN is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.