Friendship Village of Dublin

Inspectors wroteBased on interviews, facility record review, review of Centers for Disease Control and Prevention (CDC) guidance, and facility policy review the facility failed to ensure hot water storage tanks were maintained at a safe temperature to prevent legionella growth. This had the potential to affect all residents residing in the facility. The census was 45.

Inspectors wroteBased on staff interviews, record review, and review of facility policy, the facility failed to ensure a resident's advance directive status was addressed accurately in the medical record. This affected one (Resident #8) of three residents reviewed for advanced directives. The facility census was 45 residents.

Inspectors wroteBased on observations, resident and staff interviews, medical record review, and review of the Certified Nursing Assistant (CNA) job description, the facility failed to ensure the residents who were dependent on staff for activities of daily living received the assistance with personal hygiene and facial hair removal. This affected one (#38) of two residents reviewed for activities of daily living (ADL). The facility census was 45 residents.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure post fall follow up notes were completed every shift for 72 hours after fall as ordered by the physician. This affected one (Resident #2) of two residents reviewed for falls. The facility census was 45.

Inspectors wroteBased on interview and record review ,the facility failed to ensure physician ordered laboratory services were collected. This affected one (Resident #3) of one resident reviewed for antibiotics. The facility census was 45.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.