Health inspection·October 17, 2019

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete with his breakfast tray on it, in front of him. STNA #10 also stated he would assist opening the covered food items and insert straws. STNA #10 stated the other STNA may not have set up his breakfast tray because normally Resident #10 only drinks his nutritional supplement. Review of a facility policy titled, Assistance with Meals, last revised February 2014, revealed facility staff would serve resident trays and would help residents who required assistance with eating. Event ID: Facility ID: 365560 If continuation sheet Page 2 of 13 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 365560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Village of Dublin 6000 Riverside Dr Dublin, OH 43017 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview and facility policy and procedure review, the facility failed to ensure Resident #26, who was dependent on staff for personal hygiene, received adequate assistance with nail care. This affected one (#26) of five residents reviewed for activities of daily living. Residents Affected - Few Findings include: Review of Resident #26's medical record revealed an admission date of 07/09/15. Diagnoses included Alzheimer's disease and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/01/19, revealed the resident had unclear speech, usually understood others, usually made herself understood and had a moderate cognitive deficit. Review of the mood and behavior revealed the resident had indicators of depression and displayed no behaviors. The resident required extensive assistance of two staff for personal hygiene. Review of the resident's plan of care, dated 10/09/19, revealed the resident had a self-care performance deficit. Interventions included the resident required assistance from staff for personal hygiene and oral care. On 10/15/19 at 3:41 P.M., an observation of the resident revealed her nails were dirty with a brown substance under them. Subsequent observation on 10/16/19 at 2:50 P.M. revealed her nails remained dirty with a brown substance under them. On 10/16/19 at 3:50 P.M., an interview with Licensed Practical Nurse (LPN) #18 verified the resident had dirty nails with a brown substance under them. Review of the facility's policy titled Care of Fingernails/Toenails, dated 10/2010, revealed nail care includes daily cleaning and regular trimming. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 3 of 13 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 365560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Village of Dublin 6000 Riverside Dr Dublin, OH 43017 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of facility investigation, review of staff statements, review of a facility policy, family interview and staff interview, the facility failed to ensure residents were provided adequate assistance during transfers. Actual harm occurred on 01/08/19 when Resident #8, who required extensive assistance from two staff using a Hoyer lift was pivot transferred and subsequently repositioned in a Broda (specialized chair) by one staff resulting in a femur fracture requiring surgical repair. In addition, the facility failed to ensure Resident #32 had interventions in place to ensure she can safely transfer to and from her wheelchair, which placed the resident at risk for potential harm. This affected two residents (#8 and #32) of three residents reviewed for accidents. Findings include: 1. Review of Resident #8's medical record revealed an original admission date of 12/27/16 with the latest readmission of 01/13/19 with re-admitting diagnoses of osteoarthritis, dementia, and displaced comminuted fracture of shaft of right femur. Record review revealed the resident was receiving Hospice services. Review of the resident's plan of care, dated 01/10/17 revealed the resident had a self-care performance deficit related to impaired mobility and cognition. An intervention, initiated on 01/29/18 revealed the resident was totally dependent on staff for transferring with a Hoyer (mechanical) lift. The care plan did not include any other methods for transferring the resident. Review of Hospice plan of care documentation, dated 05/01/18 revealed staff were to assist with transfers. The plan did not specify the level of assistance needed or how staff were to assist. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/08/18, revealed the resident was non-ambulatory, required extensive assistance from two staff for bed mobility and transfers and had functional limitation in range of motion to the upper and lower extremities on both sides. Review of the 01/08/18 discharge MDS 3.0 assessment revealed the resident had severely impaired cognition, was non-ambulatory and required extensive assistance from two staff for bed mobility and transfers. Review of a progress note, dated 01/08/19 at 5:35 P.M. and authored by Registered Nurse (RN) #13 revealed she was summoned to the resident's room by a State Tested Nursing Assistant (STNA). The STNA stated, she transferred the resident from her bed to her Broda chair and when she was repositioning her she heard a crack sound on her right leg. Upon assessment the resident's right leg was internally rotated and the resident was grimacing and verbalized pain. The resident was given as needed Tylenol for pain. The resident's physician was notified and an order was obtained for an x-ray. The results of the x-ray revealed acute mid shaft fracture. The resident was sent to the local emergency room (ER) and was admitted for treatment. Hospital documentation reflected the resident had sustained a displaced comminuted fracture of shaft of right femur (a displaced fracture occurs when the bone snaps into two or more parts; if the bone is in many pieces it is called a comminuted fracture) Review of the facility incident report dated 01/08/19 at 5:03 P.M. and revised on 01/09/19 at 9:31 A.M. revealed under the nursing description was the progress note dated 01/08/19 at 5:35 P.M. by RN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 4 of 13 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 365560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Village of Dublin 6000 Riverside Dr Dublin, OH 43017 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 0689 Level of Harm - Actual harm Residents Affected - Few #13. The report indicated the immediate action taken was the squad was called to transport the resident to the local emergency room for treatment. The incident report indicated no injuries were observed at the time of the incident and the resident had negative vocalizations, facial expressions, body language and consolability indicating pain. However, this was not consistent with the nursing progress note which documented the resident's right leg was internally rotated and the resident was grimacing, verbalized pain and was medicated with Tylenol. Review of an undated signed hand written statement completed by STNA #5 revealed, I, [STNA #5] was helping the resident with transfers from bed to her broda chair, when I tried to reposition her in the broda, I heard a crack sound and I called the nurse. Review of the typed statement with a drawing dated 01/08/19 and titled, Statement of Event revealed, STNA #5 was getting Resident #8 up for lunch. It was after 11:00 A.M. She was in bed. The STNA changed her brief and finished dressing her. The statement documented the resident normally stands up and will bear weight on her feet and pivot. The STNA sat the resident up on the side of the bed and the resident put her arms around the STNA's neck. The STNA hugged her and pivoted her into the Broda chair. The STNA documented the resident and herself transferred body to body. This statement revealed the resident did not indicate any pain at that time. After the STNA sat her in the chair she reclined the back of the chair and then positioned the resident's legs. The STNA documented she heard a pop sound and it wasn't the chair. The STNA started looking, and the resident said, Oh my foot. The STNA then went to get RN #13. The statement was signed respectfully submitted STNA #5 and had the STNA's signature. Review of the acute care hospital documentation dated 01/10/19 revealed the resident was seen for right leg pain and according to her family the resident was being transferred from her bed to her wheelchair when the facility heard a pop and a deformity to the right leg was observed. The resident was seen, evaluated and was diagnosed with a femoral shaft fracture that needed stabilization with a retrograde IM nail (surgical repair). The hospital documentation revealed the resident's baseline was bed bound and non-ambulatory. Record review revealed a physical therapy evaluation was completed following the incident on 01/17/19. The evaluation reflected the resident sustained a fracture during a stand pivot transfer (SPT) with STNA. The evaluation form revealed At baseline Pt completed SPT with max A (assist) or used Hoyer lift for transfers. The evaluation did not contain any additional information as to how the resident's baseline was determined or provide any additional information as to when staff should be using a Hoyer lift versus a stand pivot transfer. Review of a Progressive Discipline Form, dated 01/19/19 revealed STNA #5 received a final written warning for substandard performance. The form documented the STNA failed to follow the care guide while delivering resident care resulting in injury to the resident (Resident #8). Review of the resident's most current MDS 3.0 assessment dated [DATE] revealed the resident had clear speech, sometimes understood others, sometimes made herself understood and had a severe cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of five. The assessment revealed the resident required extensive assistance of two staff for transfers. On 10/15/19 at 11:44 A.M. Resident #8 was observed sitting in a Broda chair with her legs elevated and bilateral heel protectors in place. The resident was observed with bilateral hand contractures. Attempts to interview the resident at this time were unsuccessful as the resident would not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 5 of 13 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 365560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Village of Dublin 6000 Riverside Dr Dublin, OH 43017 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 0689 communicate with the surveyor. Level of Harm - Actual harm On 10/15/19 at 2:26 P.M., an interview with Resident #8's family member revealed the resident had limited ability to respond to questions due to her cognition but at times could answer yes/no questions. During the interview a concern regarding a fracture the resident sustained in January 2019 was shared. During the interview, the family member revealed the resident required the use of a Hoyer lift to transfer and staff normally used the Hoyer lift. However, an STNA had transferred her by pivot transfer instead of using the Hoyer lift and the resident ended up with a femur fracture which required surgery resulting in screws and a rod to repair it. Residents Affected - Few On 10/16/19 at 3:07 P.M., an interview with the Director of Nursing (DON) revealed at 9:30 A.M. on 01/08/19 Resident #5 was being transferred by one STNA, STNA #5 using a pivot type transfer. The DON verified at the time of the incident the resident had a plan of care in place that reflected the use of a Hoyer lift for transfers. The DON indicated during the transfer process while repositioning the resident in the Broda chair, the STNA lifted the resident's legs and felt that something wasn't right with her leg and she notified the nurse immediately. She said she was not the DON at the time of the incident but reviewing the investigation, this is what she felt had occurred. On 10/17/19 at 10:50 A.M., an interview with the Administrator revealed prior to the incident on 01/08/19 the resident had a plan of care in place which reflected she required a Hoyer lift for transfers. The Administrator revealed the assignment sheet for Resident #5 documented the resident required extensive assistance of one or two staff on the top line and Hoyer lift under it. The sheet failed to provide any guidance as to when staff should use what type of transfer assistance. The Administrator revealed she believed STNA #5 interpreted the sheet as the resident was either a one or two person assist. She said after the incident on 01/08/19 the care guide was update to reflect one or two assist using a Hoyer (mechanical) lift. 2. Review of the medical record of Resident #32 revealed an initial admission dated of 11/22/16. Diagnoses included pathological fracture of hip, anxiety disorder, major depressive disorder, abnormalities of gait and mobility and general weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/24/19, revealed Resident #32 was cognitively intact and required the extensive assistance from one person for transfers. The resident used a walker and wheelchair and was participating in physical therapy. Review of the nursing progress notes, dated 06/13/19, revealed Resident #32 was being transferred to the wheelchair by a State Tested Nurse Aide (STNA) and hit her left lower leg on the wheelchair. Resident #32 had two small skin tears measure 2.5 centimeters (cm.) in length by 1.5 cm. in width and 1.5 cm. by 1.5 cm. and there was a moderate amount of bleeding. The wounds were cleaned and steri-strips were placed on both wounds. Further review of the nursing note revealed an intervention to add wrapped padding to the upper parts of the wheelchair to prevent any further injury. Review of the Health Center Wheelchair Check List, dated 06/13/19, revealed the resident was evaluated for a new wheelchair. Review of the care plan, dated 08/14/19, revealed the resident had an activity of daily living (ADL) self-care performance deficit, impaired mobility and impaired safety with interventions to assist the resident with showers, staff to turn and reposition in bed and the resident required the extensive assistance of staff for transfers. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 6 of 13 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 365560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Village of Dublin 6000 Riverside Dr Dublin, OH 43017 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 0689 Level of Harm - Actual harm Review of the nursing progress note, dated 10/13/19, revealed the resident was being transferred into the wheelchair by an STNA and the resident received a skin tear to the left lower leg. The resident stated she was being transferred and something on the wheelchair gave her a skin tear. The note further revealed the wound was cleansed and the physician was notified for an order for a dressing. Residents Affected - Few Review of a work order, dated 10/13/19, revealed the wheelchair was being placed in an office to check for any sharp surfaces. Review of the physician's orders, dated 10/14/19, revealed an order to treat the skin tear to the left lower leg and cleanse with normal saline, pat dry, apply Adaptic, dry dressing and wrap with Kerlix daily until healed. Review of the undated weekly non-pressure ulcer tracking log revealed Resident #32 had two skin tears on 10/13/19. The first skin tear was located on the left shin and documented to be 3.2 cm. x 2.2 cm. and the second tear was located on the distal shin measuring 2.25 cm. x 1.0 cm. and a small amount of serosanguineous discharge was noted. Interview and observation with Resident #32 on 10/15/19 at 3:30 P.M. revealed there was white gauze wrapped and taped on her left shin area. The resident stated she hit her leg on the wheelchair when getting out of bed. The resident confirmed that the STNA was present and assisting her during the transfer. Observation of Resident #32 on 10/16/19 at 2:31 P.M. revealed the resident was in her wheelchair being pushed down the hallway with no padding noted to the wheelchair to prevent further skin tears. Interview with the Director of Nursing (DON) on 10/17/19 at 2:29 P.M. revealed Resident #32's wheelchair was changed out by physical therapy as they felt the new chair was a better fit. The DON verified there was no padding on the new wheelchair as the brake on the new wheelchair was in a higher location than the old chair. The DON confirmed that the resident was in the new wheelchair when the second skin tear incident occurred on 10/13/19 and the wheelchair was not padded to prevent further injury and no new intervention was in place to prevent further injury after the 10/13/19 incident. Interview with the Administrator on 10/17/19 at 3:32 P.M. revealed Resident #32's old wheelchair was still locked up in an office and verified there was no padding on the wheelchair Resident #32 was using. Review of the facility's policy titled Event Management Program, dated 10/16/19, revealed there is a summary of each event with root cause and intervention to prevent reoccurrence in the clinical record and new interventions are put in place to prevent reoccurrence. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 7 of 13 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 365560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Village of Dublin 6000 Riverside Dr Dublin, OH 43017 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident #20's medical record revealed an admission date of 04/27/17 with diagnoses including major depressive disorder, anxiety and dementia. Review of the quarterly MDS assessment, dated 07/30/19, revealed the resident had clear speech, understands others, makes herself understood and had a severe cognitive deficit. Review of the mood and behavior revealed the resident displays indicators of depression and displayed no behaviors. The MDS indicated the resident received antidepressant medications. Review of the plan of care, dated 05/22/17, revealed the resident has a diagnoses of depression and anxiety and the resident was at risk of a mood decline and reported the resident experienced lack of interest/pleasure in doing things. Interventions included to administer medications as ordered, help the resident in conversation to identify interests and what brings her pleasure, monitor mood symptoms and consult physician/psychologist if symptoms worsen, monitor for symptoms of depression and consult physician/psychologist, attempt non-pharmacological interventions, offer activities of interest and offer opportunity to verbalize thoughts and feelings. Review of the resident's monthly physician's orders for September 2019 indicated an order for Zoloft (a medication to treat depression) 50 milligrams (mg.) by mouth daily for depression. Review of the progress notes from 05/03/19 to 10/10/19 revealed no identified target behaviors or monitoring of the target behaviors. On 10/17/19 at 8:34 A.M., an interview with the Administrator revealed the facility charts behaviors by exception in the progress notes. She said they also document behaviors on the 24 hour report sheet and the interdisciplinary team (IDT) summarizes the behaviors with a weekly note. She verified Resident #20's medical record lacked monitoring of the resident's target behaviors. Review of a facility policy titled, Antipsychotic Medication Use, last revised 02/2014, revealed the residents would only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physcian and other staff would gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risk to the resident and others. 3. Review of the medical record of Resident #31 revealed an admission date of 09/17/19 with diagnoses including insomnia. Review of the admission Minimum Data Set (MDS) assessment, dated 09/17/19, revealed Resident #31 was cognitively intact. Review of the care plan, dated 09/22/19, revealed a potential for adverse effects related to psychotropic drug use for insomnia and interventions to monitor for adverse effects of antipsychotic drug such as sedation, monitor for adverse affects of hypnotic drug use such as daytime lethargy, and notify the physician of adverse effects. Review of the physician's order, dated 10/02/19, revealed a medication of Ambien (a medication that induces sleep) 10 milligrams (mg.) at bedtime for hypnotic/sedative. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 8 of 13 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 365560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Village of Dublin 6000 Riverside Dr Dublin, OH 43017 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the nursing progress note, dated 10/06/19, revealed Resident #31 had trouble sleeping and medications given as ordered. There were no further nursing progress notes provided regarding the resident's use of Ambien or behaviors or insomnia and the medical record was absent for any documented evidence of a gradual dose reduction attempt being done related to the use of Ambien. Review of the medication administration record (MAR), dated 10/2019, revealed Resident #31 received fourteen doses of the Ambien. The record was absent for any documentation of medication monitoring, non-pharmacological interventions, and behavior monitoring. Interview with the Director of Nursing (DON) on 10/16/19 at 5:59 P.M. revealed that all documentation of non-pharmacology interventions, behaviors, and drug monitoring are documented by exception in the progress notes by the nurse and the DON was aware that nurses have not been documenting properly. The DON further stated that behaviors and non-pharmacological measures should be documented in a resident's charge when giving a psychoactive medication and confirmed there was no documentation of behaviors or non-pharmacological measures in Resident #31's medical record. Review of the Food and Drug Administration (FDA) drug label, approved on 04/23/08, revealed Ambien is indicated for short-term treatment of insomnia and a need to re-evaluate if insomnia persists after seven to ten days. Based on staff interview, medical record review, review of the Food and Drug Administration drug label and review of the facility's policy, the facility failed to identify and monitor target behaviors and implement non-pharmacological interventions for psychotropic medication use for the residents. This affected four (#10, #20, #23 and #31) of five residents reviewed for unnecessary medications. The facility identified 11 residents who were prescribed psychotropic medications. Findings include: 1. Review of Resident #23's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included dementia without behavioral disturbance, anxiety disorder and major depressive disorder. Review of the Minimum Data Set (MDS) assessment, dated 10/01/19, revealed he had a moderate cognitive impairment and did not exhibit any behaviors. Review of the physician orders revealed on 09/17/19, he was prescribed 0.6 milligrams (mg.) of Lorazepam (an anxiety-reducing medication) every six hours, as needed (PRN), for restlessness/agitation. Review of the care plan, dated 10/09/19, revealed Resident #23 was at risk for alteration in comfort related to anxiety. The care plan stated the staff should explore non-pharmacological options such as repositioning, soft music, diversional activities, or one-on-one conversation. Review of the Medication Administration Record (MAR), for 09/2019, revealed Resident #23 was administered the PRN Lorazepam on 09/29/19. The resident did not receive PRN Lorazepam in 10/2019. Review of the progress notes, dated from 06/28/19 through 10/16/19, revealed there was no evidence of a target behavior or monitoring for agitation or restlessness. The nursing notes lacked evidence non-pharmacological interventions were attempted. The medical record lacked evidence the prescriber documented the required rationale and determined duration to extend both PRN anti-anxiety orders past the allotted 14 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 9 of 13 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 365560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Village of Dublin 6000 Riverside Dr Dublin, OH 43017 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 10/16/19 at 10:51 A.M. with the Director of Nursing (DON), stated that documentation of non-pharmacological interventions and monitoring of target behaviors would be in the nursing progress notes. She stated nursing staff, document behaviors by exception. Subsequent interview on 10/16/19 at 11:27 A.M., the DON stated Resident #23's hospice company ordered the Lorazepam on 09/17/19 because Resident #23's wife had reported to the hospice staff that he had been restless the last couple days. The DON confirmed there was no facility documentation of identifying or monitoring Resident #23's restlessness and agitation because he did not exhibit that behavior with their staff. On 10/16/19 at 12:42 P.M., the DON confirmed there was no progress note for 09/28/19, the day Resident #23 did receive the Lorazepam, indicating Resident #23 was exhibiting a targeted behavior nor were any non-pharmacological interventions documented as having been implemented. The DON stated she could not provide evidence Resident #23's physician provided a rationale for the continued use of the PRN Lorazepam past the allotted 14 day prescription. 2. Review of Resident #10's medical record revealed she was admitted to the facility on [DATE]. Diagnoses included anxiety, major depressive disorder and insomnia. The MDS assessment, dated 10/01/19, revealed she had a moderate cognitive impairment and did not exhibit any behaviors. Review of the physician orders revealed on 12/22/18 she was prescribed buspirone (an anxiety reducing medication), two times a day for anxiety. Review of the care plan, dated 09/09/19, revealed she was at risk for alteration in comfort related to anxiety. The care plan stated the facility staff should explore non-pharmacological options such as repositioning, rest, a warm blanket, soft music, diversional activities or one-on-one conversation. Review of the nursing progress notes, from 07/02/19 through 10/10/19, revealed it lacked evidence Resident #23's anxiety was being monitored. There were only two nursing notes in that time period that stated Resident #10 had anxiety, on 07/30/19 and 08/16/19. Interview on 10/16/19 at 10:51 A.M. with the Director of Nursing (DON), stated that documentation with monitoring of target behaviors would be in the nursing progress notes. She stated nursing staff, document behaviors by exception. The DON confirmed there was no behavior monitoring in Resident #10's medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 10 of 13 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 365560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Village of Dublin 6000 Riverside Dr Dublin, OH 43017 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident and staff interview and review of facility policy, the facility failed to serve food at an appetizing temperature during the resident's dining. This affected 42 of 43 residents who receive food from the facilities kitchen as the facility identified one resident who ate nothing by mouth (Resident #31). The facility census was 43. Residents Affected - Many Findings include: Interview with the Dietician #102 and Dietary Manager #101 on 10/15/19 at 9:30 A.M. revealed lunch was served in the main dining room and the hallway at 11:30 A.M. Observation of the resident dining and tray delivery on 10/15/19 at 11:25 A.M. revealed food was brought into the kitchen preparation area and trays were being made up and placed in the hallway serving cart and dining room counter to be delivered to the residents. Interview with Dietician #102 on 10/15/19 at 12:07 P.M. revealed that a test tray would be placed on the hallway cart and the temperatures taken after the delivery of all residents food. Observation of the hallway food cart on 10/15/19 revealed the tray was made and placed on the cart at 12:10 P.M. Observation of resident tray delivery in their rooms ran from 12:20 P.M. to 12:33 P.M. Observation of the test tray's food temperatures with the Dietician #102 on 10/15/19 at 12:38 P.M. revealed milk in a carton was at a temperature of 52 degrees Fahrenheit (F), chicken rice casserole was at a temperature of 103 degrees F and the carrot and pea mixture was at a temperature of 100 degrees F. A taste test of the chicken rice casserole revealed it to be warm and of good flavor and a taste test of the carrot and pea mixture revealed that vegetables were cold. The Dietician stated the vegetables were hard to keep warm. Subsequent interview with the Dietician #102 on 10/15/19 at 12:46 P.M. verified the test tray was the last tray placed on the cart and other trays sat in the cart for about 45 minutes before they were passed to the residents. The Dietician further stated that the normal kitchen being remodeled was causing a disruption in the flow of food delivery but was expected to be opened next week. The Dietician further stated staff have to run back and forth between the independent living kitchen and the dining room at this time and it was taking longer for them to prepare trays but that tray delivery time was quick once all the trays were prepared. Interview with Resident #10 on 10/16/19 at 11:23 A.M. revealed the resident ate lunch in her room on 10/15/19 and the food was dry and should have been warmer. Interview with Resident #39 on 10/16/19 at 11:25 A.M. revealed the food was cold a lot of times when it was supposed to be hot and hot when it was supposed to be cold. Resident #39 further stated the milk was warm a lot of times and food items were often too salty. Interview with Resident #35 on 10/16/19 at 11:42 A.M. revealed Resident #35 eats meals in their room each day and the food was sometimes cold when it was supposed to be hot. Resident #35 further stated that sometimes the food was cold when she returns from physical therapy on some days and the facility does not heat it back up for her. Review of the facility's list of residents who did not receive food from the kitchen revealed Resident #31 was the only resident who didn't receive food from the kitchen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 11 of 13 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 365560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Village of Dublin 6000 Riverside Dr Dublin, OH 43017 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 0804 Level of Harm - Minimal harm or potential for actual harm Review of the facility's undated policy titled Test Trays/Meal Rounds revealed it is the policy of the community to serve food that is palpable, attractive and at the proper temperatures. Tray accuracy, appropriate garnishments, temperatures, and appearance will be checked on each test tray. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 12 of 13 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 365560 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Friendship Village of Dublin 6000 Riverside Dr Dublin, OH 43017 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview and review of facility policy, the facility failed to properly date and label food and maintain a clean microwave in the kitchen to prevent contamination and spoilage. This had the potential to affect 42 of 43 residents as the facility identified one resident who did not eat by mouth (Resident #31). The facility census was 43. Finding include: Observation and initial kitchen tour of the main with the Dietician #102 and Dietary Manager #101 on 10/15/19 began at 9:24 A.M. Observation of the dry food storage area revealed two packages of elbow macaroni, a package of egg noodles, a package of cornbread stuffing opened and undated. Observation of the kitchen refrigerator revealed open and undated sliced white cheese, two undated and uncovered metal pans of jello and several undated and uncovered pies on cookie sheets. Interview with the the Dietician #102 on 10/15/19 at 9:35 A.M. confirmed the above items were open and undated and each opened item should contain a date when stored in the dry food storage area, refrigerator and freezer. Observation of the service kitchen tour on 10/15/19 at 9:50 A.M. with the Dietician #102 and Dietary Manager #101 revealed a freezer with open and undated containers of french toast and pancakes, a container of omelettes and and container of sausage. Observation of the microwave revealed it was dirty with an orange thin liquid spill on the turn plate and inside splatter marks inside the microwave. Interview with the Dietician #102 on 10/15/19 at 10:00 A.M. verified the items in the service kitchen freezer were open and undated and the microwave was not clean. Review of the facility's list of residents who did not receive food from the kitchen revealed Resident #31 was the only resident who didn't receive food from the kitchen. Review of the facility's undated policy titled Food Storage revealed all exposed foods should be stored tightly covered, labeled and dated. Review of the facility's undated policy titled Equipment and Utensil Cleanliness revealed germs that cause disease are spread by improperly cleaned and sanitized eating and cooking utensils and equipment. All equipment should be cleaned and sanitized on a regularly scheduled basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 13 of 13