Health inspection·August 27, 2021

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 and interview, the facility failed to convey a resident's funds within 30 days of death. This affected one (Resident #403) of one resident reviewed who had expired. This had the potential to affect twenty-four residents with personal funds accounts. The facility census was 54. Residents Affected - Few Findings include: Review of Resident #403's progress notes revealed the resident expired in the facility on [DATE]. Review of the facility's personal funds documentation revealed an undated letter to the Ohio Attorney General advising of the resident's death on [DATE]. The resident had a balance of $3153.00. The check was issued on [DATE], 16 months after the resident died. Interview on [DATE] with Administrator confirmed the facility had not timely refunded Resident #403's personal funds balance to the State Attorney General's office. 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 2 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 08/27/2021 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)