Dublin Post Acute

In the surveyor’s words

From the most serious findings on record at Dublin Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Jun 12, 2024

  Based on closed medical record review, hospital record review, pharmacy medication regimen review, interviews with staff, Medical Director #404, Pharmacy Clinical Director #406, and Family Member #500, review of information on the American Heart Association Website www.heart.org, review of the Eliquis online customer information, and consultant pharmacy contract review, the facility failed to prevent a significant medication error for Resident #105. This resulted in Immediate Jeopardy and serious life-threatening harm when Resident #105, who had a history of atrial fibrillation (a condition of rapid heartrate), and cerebral vascular accident (CVA/stroke) did not receive physician ordered anticoagulation therapy (Eliquis) to prevent blood clot formation from [DATE] to [DATE]. […]

• Actual harm, isolatedF686Jan 26, 2026

  Based on observation, record review, interviews, and policy review, the facility failed to implement a comprehensive and individualized pressure ulcer program to timely identify, treat and/or prevent a decline of pressure ulcers. Actual Harm occurred to one resident (#23), who had been identified at risk for pressure ulcer development and required maximum staff assistance for bed mobility, on 12/10/25 when the facility failed to accurately assess, put a treatment and appropriate interventions in place in a timely manner, and complete treatments as ordered to a pressure ulcer wound to the resident's back that was first identified on 12/08/25 (two days after the resident was admitted to the facility). […]

• Actual harm, isolatedF697Oct 31, 2024

  Based on medical record review, review of a fall investigation, resident and staff interviews, and facility policy review, the facility failed to effectively manage one resident's (Resident #43) pain following an unwitnessed fall which resulted in a T12 spinal fracture. Actual harm occurred on 10/07/24 when Resident #43 reported head, neck, and low back pain to Unit Manager (UM) #267. Resident #43 reported an unwitnessed fall occurred in her room on 10/06/24. Resident #43 received scheduled pain medications at 8:04 A.M. Certified Nurse Practitioner (CNP) #700 assessed Resident #43 on 10/07/24 at approximately 9:00 A.M. The resident reported 10 out of 10 pain where 10 is the worst pain possible and was visibly crying while ambulating with her walker. […]

• Actual harm, isolatedF690Jun 12, 2024

  Based on medical record review, resident and staff interviews, review of hospital medical records and policy review, the facility failed to monitor the urinary status of Resident #84 following the removal of an indwelling urinary catheter resulting in urine retention and hospitalization for treatment. This resulted in Actual Harm on 05/10/24 when Resident #84, who was admitted to the facility on [DATE] with an indwelling urinary catheter due to urine retention and failing a voiding trial, was not adequately monitored following the removal of the catheter. On 05/10/24 at 1:12 A.M. the resident complained of lower abdominal pain and distention of the lower abdomen. […]

• Actual harm, isolatedF694Feb 8, 2024

  Based on medical record review, review of hospital records, resident interview, staff interview, observation, resident family interview, and policy review, the facility failed to ensure central venous line (a type of intravenous access that goes directly into central circulation near the heart) dressing changes were completed as ordered. This resulted in actual harm when Resident #43's central venous line dressing changes were not completed as ordered and Resident #43 was admitted to the hospital on 12/25/23 with sepsis from a central line-associated blood stream infection. […]