Health inspection·June 2, 2022

F 0689 staff. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 2 of 9 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 06/02/2022 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview the facility failed to provide oxygen as ordered for Resident #13 and failed to ensure oxygen/respiratory supplies were dated to maintain proper use. This affected one resident (#13) of one resident reviewed for oxygen. Residents Affected - Few Findings include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including chronic diastolic heart failure, chronic respiratory failure hypoxia, dependence on supplemental oxygen, chronic kidney disease stage four, iron deficiency anemia and pleural effusion. Review of the physician's orders revealed an order, dated 03/16/22 for Resident #13 to receive three liters of oxygen continuously for shortness of breath. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 03/23/22 revealed Resident #13 had impaired cognition. Review of the April 2022 and May 2022 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation related to oxygen use or oxygen tubing. Review of the plan of care, dated 04/05/22 revealed Resident #13 had oxygen therapy related to terminal prognosis, comfort measures, chronic respiratory failure, chronic pleural effusion and chronic heart failure. Interventions included oxygen through nasal prongs at three liters, monitoring for signs of respiratory distress, providing medications as orders and positioning the resident to facilitate ventilation. On 05/31/22 at 11:50 A.M. and 12:00 P.M. Resident #13 was observed receiving oxygen via a nasal cannula. The oxygen was set at two liters and there was no date on the tubing. On 05/31/22 at 12:00 P.M. interview with Licensed Practical Nurse (LPN) #134 confirmed the above observation. LPN #134 confirmed Resident #13's orders were for three liters of oxygen and she was receiving two liters. LPN #134 revealed Resident #13's daughter had been in to visit with her on 05/30/22 and stated the daughter may have adjusted the concentrator. LPN #134 reported oxygen tubing was to be changed weekly and confirmed there was no documentation to indicate the last time Resident #13's tubing had been changed as the tubing was not dated and there was no documentation of such on the administration records. On 06/01/22 at 1:07 P.M. interview with the Director of Nursing (DON) revealed residents who received oxygen continuously should have their tubing changed weekly. The DON indicated staff should document the tubing changes on the administration record also. Review of the policy titled Oxygen Administration, dated October 2010 revealed that unless otherwise ordered the flow of oxygen should be started at two to three liters. After completing oxygen setup or adjustment the nurse should document the date and time the procedure was performed, the rate of oxygen flow, route, and rationale, the reason for the administration and all assessment data obtained. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 3 of 9 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 06/02/2022 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to provide a Fentanyl patch as ordered for pain management and correctly document the administration of the patch for Resident #33. This affected one resident (#33) of one resident reviewed for pain management. Residents Affected - Few Findings include: Record review revealed Resident #33 had a plan of care, dated 07/08/21 related to risk for alteration in comfort related to generalized discomfort, arthritis, limited mobility, respiratory failure, edema, hypertension, macular degeneration, osteoporosis and additional diagnoses. The care plan revealed Resident #33 was noted to scratch and pick at her transdermal pain patch at times. Interventions included applying ice 20 minutes per hour and after activities as needed, attempt non-medication interventions, ensure transdermal pain patch was securely in place, medication as ordered, monitor for pain every shift and notify physician of any new or worsening changes in pain. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/18/22 revealed the Resident #33 had impaired cognition. The MDS revealed she received a scheduled pain medication regimen and had not experienced pain during the assessment reference period. Review of the physician's order for Resident #33 revealed an order, (from 01/16/22 to 05/10/22) for a Fentanyl (pain) Patch 12 microgram (mcg) per hour to be applied transdermally every 72 hours for pain and covered with tegaderm to secure, an order dated 05/11/22 to 05/13/22 for a Fentanyl Patch 12 microgram (mcg) per hour to be applied transdermally every 72 hours for pain and covered with tegaderm to secure and an order, dated 05/13/22 for a Fentanyl Patch 12 microgram (mcg) per hour to be applied transdermally every 72 hours for pain and covered with tegaderm to secure. Review of the May 2022 medication administration record (MAR) revealed a Fentanyl patch was documented as being applied on 05/08/22 at 7:25 A.M. and 05/11/22 at 8:46 A.M. by Licensed Practical Nurse (LPN) #149 and on 05/13/22 at 7:30 A.M. Review of the progress note, dated 05/13/22 at 7:10 A.M. revealed LPN #134 noted during shift to shift change that Resident #33's Fentanyl patch that was in place, was dated 05/08/22. The note indicated orders in the electronic medical record stated to change every 72 hours; the Director of Nursing (DON) and Hospice were notified. Review of the progress note, dated 05/13/22 at 7:19 A.M. revealed Hospice returned the phone call and gave a verbal order to take off Resident #33's patch, dated 05/08/22 and replace it with a new patch, the start date changed in the MAR for 72 hours from 05/13/22. On 06/02/22 at 12:45 P.M. interview with the Director of Nursing (DON) revealed following the incident, the Fentanyl patch count (sign out sheet and supply on hand) were never off and she had determined the medication had not been properly administered during this time period as opposed to the medication being misappropriated or misused by staff. On 06/02/22 at 1:21 P.M. interview with LPN #149 revealed she had not administered the Fentanyl patch on 05/11/22 as ordered. She reported she had been waiting for the oncoming nurse and had been checking off things she had completed on the MAR. LPN #149 reported she was supposed to change the patch with another nurse, however, by the time the nurse arrived she had forgotten. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 4 of 9 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 06/02/2022 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 0697 Review of the controlled drug receipt, record, and disposition form revealed Resident #33 did not receive a Fentanyl patch as ordered on 05/11/22. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 5 of 9 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 06/02/2022 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 ensure medications were not administered to Resident #27 when outside of the parameters set by the physician for medication administration. This affected one resident (#27) of five residents reviewed for unnecessary medication use. Residents Affected - Few Findings include: Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE] with diagnoses including hyperlipidemia, unspecified systolic heart failure, Alzheimer's disease, hypertensive heart disease, unspecified severe protein-calorie malnutrition, unspecified atrial fibrillation and cardiomyopathy. Review of Resident #27's physician's orders revealed an order, dated 04/10/22 to hold beta blockers, ace inhibitors, and diuretics for systolic blood pressure less than 110 millimeters of mercury (mm Hg). Additional review revealed an order for Spironolactone 12.5 milligrams (mg) to be given by mouth one time a day for chronic thromboembolic pulmonary hypertension and Toprol extra-large tablet extended release 12.5 mg by mouth in the evening for chronic thromboembolic pulmonary hypertension. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 04/11/22 revealed Resident #27 had mildly impaired cognition. Review of the plan of care, dated 05/15/22 revealed Resident #27 was on diuretic therapy related to chronic heart failure and fluid management. Interventions included administering diuretic medications as ordered by physician, monitor for interactions and adverse consequences. An additional intervention to monitor dose as it may require modification to achieve desired effects while minimizing adverse consequences, especially when multiple antihypertensives were prescribed simultaneously. Review of the May 2022 Medication Administration Record (MAR) for Resident #27 revealed Spironolactone was administered in the morning on 12 occasions when Resident #27's systolic blood pressure was below 110 mm Hg. This included on 05/02/22, 05/05/22, 05/06/22, 05/09/22, 05/10/22, 05/13/22, 05/14/22, 05/15/22, 05/16/22, 05/24/22, 05/27/22, and 05/29/22. Review of the May 2022 MAR for Resident #27 revealed Toprol was administered in the evening on eight occasions when Resident #27's systolic blood pressure was below 110 mm Hg. This included on 05/05/22, 05/09/22, 05/10/22, 05/20/22, 05/22/22, 05/23/22, 05/24/22, and 05/30/22. Further review revealed Toprol was administered when an evening blood pressure was not obtained and marked as 'vitals outside of parameters' on three occasions on 05/02/22, 05/27/22, and 05/29/22. Review of the progress notes from 05/02/22 to 05/29/22 for Resident #27 revealed no notes indicating a physician was contacted about administering medications outside of parameters. Additionally, there were no progress notes to indicate medication was not administered when indicated on the MAR. On 06/01/22 at 1:07 P.M. and 1:51 P.M. interview with the Director of Nursing (DON) confirmed generally a check mark in the MAR meant the medication was administered unless otherwise stated in the progress notes. She confirmed the medications were held at times due to the vitals being outside of the parameters and were administered at other times when they were outside of the ordered parameters. The DON confirmed blood pressure was obtained at the time of medication administration. When asked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 6 of 9 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 06/02/2022 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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete if nurses should be documenting if they were calling the physician prior to administering medications outside of parameters she stated she was not sure, but probably. On 06/01/22 at 1:51 P.M. interview with Physician #165 revealed Resident #27 had beta blockers for her chronic heart failure. He reported a desire to drive her heart rate down. Physician #165 reported when a resident admitted on beta blockers and diuretics the standard order was to hold for a systolic blood pressure below 110 mm Hg. However, the physician revealed this was not always necessary in the case of Resident #27's beta blockers, but he was not able to speak to the diuretic. Physician #165 reported he was unsure about every documented incident of the medication being administered outside of parameters, however, at times the nurses would call him and ask prior to administering it. He reported the hold order probably should have been discontinued but confirmed it was still in place. Event ID: Facility ID: 365560 If continuation sheet Page 7 of 9 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 06/02/2022 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, facility policy and procedure review and interview the facility staff failed to ensure the hood and filter system in the main kitchen and serving kitchen food production areas were maintained in a clean and sanitary manner to prevent the contamination of food. This had the potential to affect all 45 residents residing in the facility who consumed food prepared in the two areas. Findings include: On 05/31/22 at 8:45 A.M. observations during the kitchen tour revealed the main kitchen hood and filters above the stove were very dusty. Interview with Executive Chef #101 at the time of the observation verified the dust on the hood and filters and revealed they were last cleaned by a contracted company on 02/01/22. On 05/31/22 at 8:55 A.M. observation of the serving kitchen area revealed the hood and filters above the stove were very dusty. Interview with Dietary Director #100 at the time of the observation verified the areas were very dusty and indicated the hood and filters were last cleaned by a contracted company on 02/01/22. Review of the undated policy titled Weekly Cleaning Schedule Legacy revealed the hood filters were removed and cleaned weekly. The hood interior and exterior were to be cleaned with a stainless steel cleaner weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 8 of 9 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 06/02/2022 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, facility policy and procedure review and interview the facility staff failed to ensure trash was covered in the main kitchen storage and production areas. The had the potential to affect all 45 residents residing in the facility. Residents Affected - Many Findings include: On 05/31/22 at 8:45 A.M. observations during the kitchen tour revealed the main kitchen dry stock areas had a trash can full of trash with no lid near the sugar and flour storage bins. Interview with Executive Chef #101 at the time of the observation verified the trash can was full of trash with no cover and was not being currently used by staff. Continued observation in the main kitchen revealed a trash can half full of trash with no cover near the ovens in the food production area that was not in use by staff. Interview with Dietary Director #100 at the time of this observation verified the trash can was half full of trash with no cover near the ovens in the food production area. Review of the policy titled Waste Disposal, dated 2019 revealed that prior to disposal, all waste was kept covered in a leak-proof container when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365560 If continuation sheet Page 9 of 9