F 0569
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, personal funds account review, facility policy review, family and staff interview, the facility
failed to promptly notify the resident's representative when the resident's account reached $200 less than
the maximum amount permitted a recipient for Medicaid. This affected one (Resident #32) of four residents
reviewed for personal funds. This had the potential to affect twenty-eight residents with personal funds
accounts. The facility census was 61.
Residents Affected - Few
Findings include:
Review of medical record for Resident #32 revealed the resident was admitted to the facility on [DATE].
Diagnoses included Alzheimer's Disease, malignant neoplasm of the frontal lobe and hemiplegia following
a cerebral vascular infarction. Review of the resident's Minimum Data Set (MDS) assessment, dated
02/06/19, revealed the resident had impaired cognition.
Review of Resident #32's account balances from 04/10/18 through 04/01/19 revealed the following
amounts:
04/23/18 $1,926.47
04/30/18 $1,926.63
05/31/18 $2,248.79
06/15/18 $2,570.79
07/31/18 $2,892.97
08/21/18 $3,214.97
09/30/18 $3,537.39
10/31/18 $3,859.65
11/30/18 $4,181.96
12/31/18 $4,504.27
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
365538
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/04/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Friends Extended Care Center
150 East Herman Street
Yellow Springs, OH 45387
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0569
04/01/19 $5, 083.81
Level of Harm - Minimal harm
or potential for actual harm
Interview on 04/01/19 at 4:30 P.M. with Administrative Accounts Payable staff (AAP) #53 revealed Resident
#32 with an account balance of $5,083.81. AAP #53 confirmed a quarterly statement was sent to the
resident's representative for the time-period of 10/09/18 through 12/31/19. AAP #53 identified a line on the
bottom of the quarterly statement which identified Resident #32's account was over the amount necessary
to remain Medicaid eligible. The statement requested the resident's representative to contact the Licensed
Social Worker.
Residents Affected - Few
Interview on 04/02/19 at 10:10 A.M. with Social Worker (SW) #85 revealed she was not aware of the
statement on the bottom of the quarterly statement. SW #85 additionally stated she has never followed up
on any personal funds accounts for any reason.
Telephone interview on 04/04/19 at 10:57 A.M. with Resident #32's Power of Attorney (POA) did confirm
knowledge Resident #32 being over the maximum amount. Resident #32 confirmed receiving quarterly
statements which had a notice informing that Resident #32 exceeded the amount necessary to remain
Medicaid eligible.
Interview on 04/04/19 at 11:17 A.M. with Administrator confirmed no additional notifications were sent to
Resident #32's other than the quarterly statements. Administrator confirmed resident was within the $200
dollars of exceeding the maximum amount on 04/23/19. Resident #32's representative did not receive a
notice of spend down until 06/30/19 when the quarterly statements were mailed.
Review of the facility policy titled, Management of Resident's Personal Funds dated March of 2017 reveals
if the facility manages the resident's funds, the facility will act as a fiduciary of the resident fund and hold,
safeguard, manage and account for the personal funds of the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365538
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365538
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/04/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Friends Extended Care Center
150 East Herman Street
Yellow Springs, OH 45387
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview, the facility failed to ensure a resident had a valid Ohio Comfort Care Do
Not Resuscitate order. This affected one (Resident #24) of twenty-four residents reviewed during first stage
of the survey. The facility census was 61.
Findings include:
Review of Resident #24's medical record revealed being admitted on [DATE] with diagnoses including
Alzheimer's Disease, depression, anxiety and dementia. Review of the Minimum Data Set (MDS)
assessment, dated 01/17/19, revealed the resident had a severe cognitive deficit.
Review of Resident #24's undated Ohio Do Not Resuscitate (DNR) Comfort Care form revealed resident
was a Do Not Resuscitate Comfort Care -Arrest (DNRCC-A). The form had resident's name, address and
signature of resident's Power of Attorney. However, it did not have the physician's signature. The form did
have a notation at the bottom of having been faxed to the physician on 12/16/18.
Interview on 04/01/19 at 3:50 P.M. with Licensed Practical Nurse (LPN) #58 confirmed Resident #24's Ohio
DNR Comfort Care order did not have a physician's signature. LPN #58 was not able to provide a signed
form for Resident #24.
Interview on 04/02/19 at 3:50 P.M. with Director of Nursing confirmed Resident #24 did not have a signed
Ohio DNR Comfort Care Arrest order.
Review of the facility policy titled, Advanced Directives, dated 10/29/15, revealed the nurse will notify the
attending physician of the advance directives so that the appropriate orders can be documented in the
resident's medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365538
If continuation sheet
Page 3 of 3
