The Convalarium of Dublin

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record reviews, staff interviews, and policy reviews, the facility failed to ensure a resident was safely transported by a trained driver resulting in a resident falling out of a wheelchair on the facility bus. This affected one (#103) of three residents reviewed for transportation. The facility census was 83.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were safely transported to outside medical appointments. This affected one (#66) of three residents reviewed for outside medical transportation. The facility census was 83.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record reviews, staff and resident interviews, hospital record reviews, incident investigation reports, and policy reviews, the facility failed to ensure two staff were present during resident transfers and failed to utilize a mechanical lift for the transfer. This affected one resident (Resident #06) of three residents reviewed for mechanical lift transfers. Actual harm occurred on 04/30/26 when Resident #06, who required the use of a mechanical lift assisted by two staff members for transfers, was picked up by one staff member, Certified Nursing Assistant (CNA) #206, and transferred from the shower chair to the bed. CNA #206 did not utilize the assistance of a mechanical lift and performed the transfer by himself. [...]

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure tracheostomy care procedures were followed as indicated during routine tracheostomy care. This affected one, (Resident #43), of four residents reviewed for respiratory care services. The facility census was 83.

Inspectors wroteBased on record reviews, staff and resident interviews, and policy reviews, the facility failed to ensure accurate medical records. This affected one resident, (Resident #6), of six residents reviewed for medical record accuracy. The facility census was 83.

Inspectors wroteBased on observation, review of a written statement, review of an electronic mail (email) document, staff interview, employee file review, and review of a facility job description, the facility failed to ensure their activities program was directed by a qualified professional. This had the potential to affect all 80 residents who resided in the facility. The census was 80.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure equipment in the kitchen was operating correctly. This had the potential to affect all 70 residents who are served meals from the kitchen. The facility identified 10 (#13, #17, #10, #11, #3, #47, #49, #56, #1, and #68) residents who received nothing by mouth. The census was 80.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and policy review, the facility failed to ensure shared glucometers were appropriately disinfected after use and failed to ensure staff wore required personal protective equipment while providing care for residents on infection control precautions as ordered. This directly affected two (#54 and #21) of two residents observed for infection control practices and had the potential to affect eight (#2, #42, #53, #8, #5, #82, #38, and #34) additional residents residing on the Blarney Stone Hall who utilize the shared glucometer. The facility census was 80.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and policy review, the facility failed to provide resident care following a meal to maintain dignity. This deficient practice affected one (#32) of three residents reviewed for dignity. The facility census was 80. Finding Include:Record review for Resident #32 revealed an admission date of 03/22/23. Diagnoses included of hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, morbid obesity due to excess calories, aphasia following cerebrovascular disease, cerebral infarction due to occlusion or stenosis of the right middle cerebral artery, major depressive disorder, anxiety, bipolar disorder, vascular dementia, hyperlipidemia, chronic kidney disease, and lack of coordination. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure psychotropic medications were not unnecessarily provided. This affected two (#5 and #8) of five residents review for unnecessary medications. The facility census was 80.

Inspectors wroteBased on medical record review, staff interview, and facility policy, the facility failed to ensure a resident's comprehensive care plan was updated to include all interventions implemented by the facility to address nutritional concerns. This affected one (#35) of four residents reviewed for nutrition. The census was 80.

Inspectors wroteBased on observation, medical record review, staff interview, resident interview, and policy review, the facility failed to ensure adequate finger nail care was provided for a dependent resident. This affected one (#21) of one residents reviewed for activities of daily living. The facility census was 80.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to timely assess and implement treatment for non-pressure skin conditions. This affected one (#56) of three residents reviewed for wounds. The facility census was 80.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure pressure ulcer preventative interventions were in place as ordered. This affected one (#35) of five residents reviewed for pressure ulcers. The facility census was 80.

Inspectors wroteBased on medical record review, review of a risk assessment, resident and resident family interviews, staff interview, and review of an incident log, the facility failed to complete a thorough investigation into a resident accident with injury. This affected one (#92) of three residents reviewed for accidents and injuries. The facility census was 80.

Inspectors wroteBased on medical record review, review of a concern form, review of written statements, staff interview, and policy review, the facility failed to ensure adequate transportation was provided to residents for outside appointments. This affected one (#96) of three residents reviewed for transportation to outside appointments. The census was 80.

Inspectors wroteBased on medical record review, review of a concern form, and staff interview, the facility failed to ensure dental services were provided in a timely manner. This affected one (#8) of two residents reviewed for dental services. The facility census was 80.

Inspectors wroteBased on observation, medical record review, resident and staff interview, and policy review, the facility failed to provide recommended eating equipment and utensils during meals as specified. This affected one (#21) of four residents reviewed for nutrition. The census was 80.

Inspectors wroteBased on observation, medical record review, resident and staff interview, review of facility's infection control surveillance log, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to ensure proper personal protective equipment (PPE) was available for staff providing care for a resident (#24) with COVID-19 infection. Additionally, the facility failed to ensure a resident (#25) with known exposure to a COVID-19 resident followed appropriate guidance and physician orders to prevent potential spread of the virus. This had the potential to affect all 83 residents residing in the facility. The census was 83.

Inspectors wroteBased on observations, staff interviews, and review of facility policies and procedures, the facility failed to maintain sanitary food storage and preparation conditions. This had the potential to affect 55 residents who ate food prepared from the facility. The facility census was 79.

Inspectors wroteBased on record review, review of immunization records, staff interview, and facility policy review, the facility failed to educate residents on the risks and benefits and/or offer influenza vaccinations to residents as required. This affected five (Residents #42, #44, #61, #72, and #89) of five reviewed for immunizations. The facility census was 79. Findings Include: 1. Review of the medical record for Resident #42 revealed an admission date on 10/29/24. Medical diagnoses included encephalopathy, acute and chronic respiratory failure with hypoxia, type II Diabetes Mellitus with hyperglycemia, and morbid obesity. Review of immunization records revealed Resident #42 received the influenza (flu) immunization on 11/23/22. There was no further evidence Resident #42 had been offered the vaccination since admission. [...]

Inspectors wroteBased on record review, review of immunization records, staff interview, and facility policy review, the facility failed to educate on the risks and benefits and/or offer COVID-19 vaccinations to residents as required. This affected five (Residents #42, #44, #61, #72, and #89) of five reviewed for immunizations. The facility census was 79.

Inspectors wroteBased on medical record review and staff interview, the facility failed to follow resident code status orders. This affected one (Resident #90) of one resident reviewed for code status. Also, the facility failed to follow physician orders regarding resident weight status. This affected one (Resident #44) of five residents reviewed for nutritional orders. The census was 79.

Inspectors wroteBased on resident medical record review, interviews with staff, and review of facility policy, the facility failed to provide proper wound monitoring for Resident #61. This affected one resident (#61) out of five residents reviewed for wound care. The facility census was 79 residents.

Inspectors wroteBased on observations, staff interview, and review of the facility policy, the facility failed to ensure medications were not left at bedside. This affected one resident (#55) of one resident observed for medications left at bedside. The census was 79.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to prevent a medication error rate of less than five percent. There were two medication errors out of 25 opportunities, resulting in an eight percent error rate. This affected one (Resident #20) of six residents observed for medication administration. The census was 79.

Inspectors wroteBased on record review, staff interview, resident interview, and policy review, the facility failed to prevent significant medication errors. This affected two (Resident's #44 and #23) of five residents reviewed for medication administration. The facility census was 79.

Inspectors wroteBased on observation, interview, medical record reveiw, and policy review, the facility failed to ensure catheter bags were stored in a sanitary manner to prevent infection. This affected one (Resident #20) of one resident observed for catheter storage. Additionally, the facility failed to ensure Enhanced Barrier Precautions (EBP) were in place for Resident #96. This affected one (Resident #96) of one resident observed for EPB. The facility census was 79.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to notify Resident #21's family of a resident's fall in a timely manner. This affected one (Resident #21) of three residents reviewed for family notification. The facility census was 83.

Inspectors wroteBased on record review, review of the facility policy, and staff interview, the facility failed to ensure physician ordered laboratory services for a resident were completed in a timely manner. This affected one (Resident #10) of three residents reviewed for laboratory services. The facility census was 88.

Inspectors wroteBased on observation, review of the facility policy, and staff interview, the facility failed to complete hand hygiene during medication administration to residents in enhanced barrier precautions. This affected two (Resident #24 and #70) of four residents observed for medication administration. The facility census was 88.

Inspectors wroteBased on staff interview, review of employee files, review of Bureau of Criminal Investigation (BCI) log, and policy review the facility failed to ensure background checks for staff were completed prior to employment. This affected three (State Tested Nursing Assistant [STNA] #230 and STNA #122, and Occupational Therapist [OT] #356) of the five employee files reviewed for background checks. This had the potential to affect all residents residing in the facility. The facility census was 81.

Inspectors wroteBased on record review, review of personnel files, and staff interview, the facility failed to ensure performance evaluations were completed for State Tested Nursing Assistants (STNAs). This affected two (STNA #122 and STNA #230) of the four employees' files reviewed but had the potential to affect all residents. The facility census was 81.

Inspectors wroteBased on staff interview, review of employee's personnel files, the facility failed to ensure State Tested Nursing Assistants (STNAs) received at minimum, 12 hours of training to ensure continuing competence. This affected two (State Tested Nursing Assistant [STNA] #230 and STNA #122) of the five employee's files reviewed. This had the potential to affect all residents residing in the facility. The facility census was 81.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to follow the prepared menu. This had the potential to affect all residents who received meals from the kitchen. The facility identified eight (#58, #59, #66, #72, #76, #77, #80, and #83) residents who did not receive meals from the kitchen. The facility census was 81.

Inspectors wroteBased on review of mealtimes, staff and resident interviews, the facility failed to ensure no more than 14 hours elapsed between the evening meal and breakfast. This had the potential to affect all residents who receive food from the kitchen. The facility identified eight residents (#58, #59, #66, #72, #76, #77, #80, and #83) who did not receive meals from the kitchen. The facility census was 81.

Inspectors wroteBased on record review, resident interview, and staff interview, review of facility policy, the facility failed to provide scheduled showers/baths for residents. This affected two (#25 and #68) residents out of the five residents reviewed for showers. The current census is 81.

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of the facility policy, the facility failed to provide a safe environment that was free from accident hazards and failed to complete a thorough investigation into a resident's fall. This resulted in Actual Harm for one resident when on 03/04/24, Resident #04 was attempting to enter the main entrance of the facility with an uneven surface transition causing Resident #04 to fall backwards out of his wheelchair sustaining a subdural hematoma (serious condition where the blood collected between the skull and the surface of the brain), retrolisthesis (backward slippage of one vertebral body with respect to the subjacent vertebra) of cervical vertebrae and a scalp laceration requiring three sutures. [...]

Inspectors wroteBased on observations, resident and staff interviews, the facility failed to provide a safe outside environment for the residents. This affected two (#04 and #50) of two residents reviewed for the physical environment and had the had the potential to affect all 82 residents residing in the facility.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure Resident #15, who was status post brain surgery, received the appropriate care and services to attend to his scheduled neurologist appointments. This affected one (Resident #15) of three residents reviewed for physician appointments. The facility census was 82.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure Resident #15 was provided with dental services. This affected one (Residents #15) of three residents who were reviewed for dental services. The facility census was 82.

Inspectors wroteBased on observations, staff interview, resident interview, and record review, the facility failed to ensure proper Personal Protective Equipment (PPE) was worn when staff entered a COVID-19 positive rooms. This affected two (Residents #34 and #35) of three reviewed for COVID-19. Additionally, the facility failed to complete contact tracing during a COVID-19 outbreak. This had the potential to affect all residents residing in the facility. Facility census was 76.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to complete a thorough investigation related to sexual abuse. This affected one (Resident #100) of three residents reviewed for abuse. This had the potential to affect nine (Residents #35, #52, #80, #6, #7, #51, #2, #63 and #101) Maintenance Man (MM) #150 had contact with. Additionally, the facility failed to investigate an allegation of misappropriation. This affected one (Resident #65) of three residents reviewed for abuse. The facility census was 79.

Inspectors wroteBased on observations, resident interviews, staff interviews, and record review, facility failed to ensure call lights were answered in a timely manner. This affected one (Resident #34) of one resident observed for call lights. Facility census was 76.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure an allegation of sexual abuse was reported to the state agency in a timely manner. This affected one (Resident #100) of three reviewed for abuse. The census was 79.

Inspectors wroteBased on observations, resident interviews and staff interviews, the facility failed to ensure resident's maintained quality of life while in COVID-19 isolation. This affected Residents #34 and #35 of two review for COVID-19 isolation. The facility identified seven residents (#3, #34, #35, #50, #59, #69) with COVID-19 positive diagnosis. Facility census was 76.

Inspectors wroteBased on observations, resident interviews, staff interviews, and record reviews, the facility failed to ensure showers were offered twice weekly according to resident preference. This affected three (Residents #3, #35, and #55) of three reviewed for showers. Facility census was 76.

Inspectors wroteBased on resident representative interview, staff interviews, and record review, facility failed to ensure dietitian recommendations were followed to maintain a resident's nutrition status. This affected one (Resident #55) of three reviewed for nutrition. Resident census was 76.

Inspectors wroteBased on medical record review, hospital record review, laboratory testing result review, and staff interview, this facility failed to implement Foley catheter care and maintenance orders and failed to change the Foley catheter per physician order prior to obtaining a urine sample. This affected one (Resident #2) of the three residents reviewed for Foley catheter care. The facility census was 81.

Inspectors wroteBased on medical record review, staff interview, review of video surveillance, and facility policy review, the facility failed to ensure direct care staff wore the required personal protective equipment while providing incontinent care for a resident in contact isolation. This affected one (Resident #1) of the five residents reviewed for incontinence care. The facility census was 81.

Inspectors wroteBased on medical record review, resident and staff interview, review of a fall investigation, review of hospital documentation, review of facility policy, and review of a MedlinePlus article, the facility failed to ensure Resident #16 received appropriate bed mobility assistance. Actual harm occurred when State Tested Nurse Aide (STNA) #500 was assisting Resident #16 with changing and bed mobility by himself and rolled Resident #16 away from himself which resulted in Resident #16 falling out of bed and sustaining a finger fracture. This affected one (Resident #16) of two residents reviewed for falls. The facility census was 43.

Inspectors wroteBased on observation and staff interview, the facility failed to store and thaw foods in a sanitary manner. This had the potential to affect 41 out of 43 residents who received meals from the kitchen. The facility identified two residents (#8 and #38) who received no food by mouth. The facility census was 43.

Inspectors wroteBased on review of Resident Council meeting minutes, staff interview, resident interview, and facility policy review, the facility failed to timely address and follow up on resident concerns expressed during Resident Council meetings. This affected seven (Residents #4, #14, #19, #20, #24, #30, and #32) of seven residents who regularly attended Resident Council meetings. The facility census was 43. Findings Include: Review of Resident Council meeting minutes dated 04/26/22, 03/25/22, 02/23/22, 01/25/22, 12/28/21, 10/28/21, 09/30/21, 09/08/21, and 07/22/21 revealed the residents had recurrent concerns of staff not wearing nametags, snacks not being passed, staff not checking their floors for dirty laundry, medication administration, requests for ice water to be passed more frequently, and call light response times. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide written notification of transfer to residents and/or resident representatives. This affected seven (Resident #2, #4, #6, #10, #16, #21, and #23) of eight residents reviewed for hospitalization and discharge. Additionally, the facility failed to provide written notification of resident transfer or discharge to the ombudsman. This affected eight (#2, #4, #6, #10, #16, #21, #23, and #42) out of eight residents reviewed for hospitalization and discharge. The facility census was 43.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide notice of bed hold policies to residents and/or their representative upon transfer to the hospital. This affected seven residents (#2, #4, #6, #10, #16, #21, and #23) of seven residents reviewed for hospitalization. The facility census was 43.

Inspectors wroteBased on medical record review, staff interview, and review of the beneficiary notice worksheet, the facility failed to ensure residents received a Notice of Medicare Non-Coverage (NOMNC) prior to being cut from therapy services. This affected two (Resident #295 and #297) of three residents reviewed for beneficiary notices. The facility census was 43. Findings Include: 1. Review of the closed medical record for Resident #295 revealed an admission date on 10/23/21. Resident #295 discharged to home on [DATE]. Medical diagnoses for Resident #295 included COVID-19, Type two diabetes mellitus without complications, acute and chronic respiratory failure with hypoxia (lack of oxygen), muscle weakness, and need for assistance with personal care. Review of the admission Minimum Data Set (MDS) assessment revealed Resident #295 had mildly impaired cognition. [...]

Inspectors wroteBased on medical record review, staff interview, and review of Pre-admission Screenings and Resident Reviews (PASARR), the facility failed to ensure PASARR's were completed accurately. This affected two (Residents #2 and #10) of two residents reviewed for PASARR screenings. The facility census was 43. Findings Include: 1. Review of the medical record for Resident #2 revealed an original admission date on 11/13/21 and a readmission date on 01/04/22. Resident #2 had medical diagnoses with dates of 11/13/21 which included schizophrenia and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had intact cognition and required extensive assistance from one to two staff to complete Activities of Daily Living (ADLs). [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to timely identify and address resident pressure ulcers. This affected one (Resident #22) of three residents reviewed for pressure ulcers. The facility census was 43.

Inspectors wroteBased on observation, staff interview, medical record review, and review of a hospice binder, the facility failed to ensure residents with limited range of motion received appropriate treatment and services. This affected one (Resident #35) of one resident reviewed for range of motion. The facility census was 43.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to ensure resident medications and wound cleansers were acquired from the pharmacy in a timely manner. This affected two (Resident #6, Resident #39) out of five residents reviewed for medications. The facility census was 43. Findings Include: 1. Review of Resident #6's medical record revealed she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, quadriplegia, anemia, severe protein calorie malnutrition, dysphagia, and dementia. Resident #6 was receiving hospice services. Resident #6 passed away on 04/26/22. Review of the Minimal Data Set (MDS) assessment dated [DATE], revealed Resident #6 had severe cognitive impairment. Review of the care plan dated 04/22/22, revealed Resident #6 used anti-anxiety medications related to anxiety. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the physician reviewed/addressed pharmacy recommendations in a timely manner. This affected two (Resident #4 and #22) out of five residents reviewed for unnecessary medications. The facility census was 43.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure medications were stored properly. This affected two (Resident #22 and #242) out of four residents observed during medication administration. The facility census was 43. Findings Include: 1. Review of the medical record for Resident #22 revealed an admission date of 10/26/16. Resident #22's diagnoses included lymphedema, morbid obesity, chronic obstructive pulmonary disease, dysphagia, chronic pulmonary embolism, and anxiety and depressive disorders. Review of the quarterly Minimal Data Set (MDS) dated [DATE] revealed Resident #22 was cognitively intact. Resident #22's functional status was independent to limited one person assist for all activities of daily living. [...]

Inspectors wroteBased on medical record review, observation, resident interview, and staff interview, the facility failed to ensure routine dental appointments were arranged for residents. This affected two (Resident #15 and #21) out of three residents reviewed for dental services. The facility census was 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate foods in order to honor resident preferences for a vegetarian diet. This affected one (Resident #30) out of two residents reviewed for food preferences. The facility census was 43.