Dublin Trails of Journey LLC

Inspectors wroteBased on observations, staff interviews, and a review of the facility's policy titled, Labeling and Dating Inservice, the facility failed to ensure that expired, unlabeled, and undated food items were not stored in the freezer, refrigerator, and dry food storage pantry, and failed to ensure the ice maker was maintained in a sanitary manner. The deficient practices had the potential to place 82 residents who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include: A review of the facility's undated policy titled Labeling and Dating Inservice revealed the Importance of Labeling and Dating section included, Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner. This will minimize waste and ensure that items that have passed their due date are discarded. [...]

Inspectors wroteBased on resident interviews, staff interviews, and review of the facility's policy titled, Resident Personal Funds, the facility failed to provide resident trust fund account quarterly statements for two of three residents (R) (R45 and R51) reviewed. This deficient practice had the potential to place the 62 residents with trust fund accounts managed by the facility at risk of not being provided the quarterly bank statements.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Elopements and Wandering Residents, the facility failed to ensure timely reporting of resident elopement to the State Survey Agency (SSA) for two of 32 sampled residents (R) (R281 and R54).

Inspectors wroteBased on observations, resident interviews, staff interviews, and record review, the facility failed to ensure that activities of daily living (ADL) care was provided for three dependent residents (R) (R45, R46, and R65) related to nail care out of 32 sampled residents. This deficient practice had the potential to place R45, R46, and R65 at risk of feeling self-conscious about their appearance.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled, Oxygen Concentrator, and Oxygen Administration, the facility failed to ensure that three of five residents (R) (R12, R58, and R66) reviewed for oxygen (O2) had respiratory equipment that was properly cleaned and stored. This deficient practice had the potential to place R12, R58, and R66 at risk for respiratory complications and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Hand Hygiene, the facility failed to ensure hand hygiene was performed between residents and failed to ensure shared medical equipment was sanitized between residents. The deficient practices had the potential to place residents at risk of avoidable infections due to cross-contamination. The facility census was 82.

Inspectors wroteBased on observation, staff interview, and Quality Assessment and Performance Improvement Plan (QAPI) the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior by failing to repair peeling wall paint, ceiling light, and torn floor tiles in one of 5 halls. The Facility census was 69 residents. Observations on 11/30/2023 at 1:00 pm 1. All ceiling air vents in the dining room are rusty, and two of them are loose. 2. Hall D - two out of three ceiling lights without covers, and peeling paint on the walls. 3. The light in the middle of the D hall has only one working light tube. 4. Hall D floor linoleum is very decolorated and has torn pieces. 5. The nursing station countertop between halls D and E has chipped paint. A review of the Quality Assessment and Performance Improvement Plan (QAPI)revealed one completed task: [...]

Inspectors wroteBased on record review, staff interviews, and review of facility policy titled Abuse Prevention Program and Reporting, the facility failed to ensure pre-employment screening, specifically fingerprints for three employees and background check for one employee, were obtained for four of 10 staff reviewed.

Inspectors wroteBased on staff interviews, record review, and review of facility document titled admission Screening- Pre-admission Screen for MR/MI the facility failed to conduct a Level II Preadmission Screening and Resident Review (PASARR) screening for one of nine sampled residents (R) (R6) following a new diagnosis of schizophrenia.

Inspectors wroteBased on staff interviews, record reviews, observations, and review of the policies titled, Hand Hygiene, Glucometer Cleaning-Finger Stick Procedure, and Enteral Feeding the facility failed to provide a safe and sanitary environment for one of fifteen Residents receiving fingerstick testing; specifically R63, and one of one Residents receiving enteral feeding, R12. This deficient practice has the potential to cause adverse consequences related to infection control. The census was 69.

Inspectors wroteBased on observations, review of facility policy; resident, resident representative, and staff interviews; and record review, the facility failed to ensure warm water temperatures were maintained in the rooms of two sample residents (Resident (R) 22 and R40) of 25 residents reviewed for water temperatures in the Initial Pool and three supplement residents (R35, R42, and R67). Additionally, the facility failed to ensure the walls were maintained in good condition for two (R17 and R27) of 25 residents in the Initial Pool. These failures had the potential to lead to an unsanitary and uncomfortable environment for these residents.

Inspectors wroteBased on resident and staff interviews and record review, the facility failed to determine and honor waking time/shower schedule preferences for one (Resident (R) 17) of 25 Initial Pool residents reviewed for choices. This failure had the potential to lead to a decline in psychosocial well-being and unnecessary daytime sleepiness for R17.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure one (Resident (R) 27) of 25 Initial Pool residents observed for hygiene and grooming received assistance with activities of daily living (ADLs), including personal hygiene and eating. This failure had the potential to contribute to a lack of good personal hygiene and good nutrition for R27.

Inspectors wroteBased on interviews, record review, and review of facility policy, the facility failed to ensure one (Resident (R) 10) out of 18 sampled residents was administered requested medication (Sodium Bicarbonate-used to treat stomach upset/indigestion) by the nurse. This had the potential to increase R10's indigestion symptoms.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one (Resident (R)19) of one resident's observed catheter bag was below the level of his bladder. Six residents were residing at the facility with indwelling catheters. This had the potential to increase R19's risk of urinary tract infection (UTI).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one (Resident (R) 9) out of one resident sampled for dialysis was provided nutritional services while at dialysis appointments three days a week. This had the potential for R9's nutritional status to decline.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure one (Resident (R) 18) out of two sampled residents for oxygen therapy, was provided oxygen therapy at the correct flow rate and was administered by licensed nursing staff. This had the potential to increase R18's risk for respiratory complications and/or distress.

Inspectors wroteBased on interview, record review and facility document review, the facility failed to ensure one (Resident (R) 9) out of one resident sampled for dialysis, shunt was assessed and documented consistently in the Electronic Medical Record (EMR) as well as ensure he had dialysis communication forms completed. This had the potential to increase R9's risk for complications with dialysis treatment and his dialysis shunt.

Inspectors wroteBased on interview, record review, and the facility policy review, the facility failed to ensure all nursing staff had the competencies and skill set necessary to provide care of a chest tube for one of one (Resident (R) 18) reviewed for chest tubes. This had the potential for the resident to have a decline in health status.