Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Friendship Village Of Dublin during CMS and state inspections, most recent first.
The facility failed to maintain sanitary food preparation practices, as observed during a lunch meal preparation where a cook and a dietary aide were not wearing beard covers, contrary to the facility's policy. This was confirmed by the Director of Dietary Quality Assurance and acknowledged by the cook.
The facility failed to monitor its water management program to control Legionella, potentially affecting all 40 residents. Despite a risk assessment in April 2024, there was no evidence of monitoring controls, water temperatures, or environmental testing for 2023 and 2024. Interviews confirmed the absence of documented Legionella monitoring, and the facility's policy lacked evidence of regular testing or reporting.
A resident with multiple medical conditions, including dementia, was admitted to the facility with a hospital exemption form, allowing a 30-day stay without a PASRR. The facility failed to complete the PASRR within the required timeframe, as the social worker mistakenly believed the exemption form was sufficient for multiple hospital visits within the first 30 days. The PASRR was completed late, indicating a misunderstanding of the requirements.
Two residents in the facility received medications at incorrect times, contrary to physician orders. An LPN administered Carbidopa-Levodopa ER to a resident with Parkinson's disease at the wrong time, and another resident with dementia received Depakote Sprinkles DR later than scheduled. These errors were confirmed through observation and staff interviews.
The facility failed to provide timely pressure ulcer care for two residents. One resident with a stage III pressure ulcer did not receive wound treatment until five days after admission, and measurements were delayed. Another resident, readmitted with Moisture Associated Skin Damage, had her condition assessed and documented four days later as a stage III pressure ulcer. Staff interviews confirmed the delay in interventions, contrary to facility protocols requiring immediate treatment and monitoring.
The facility failed to obtain weights for two residents as recommended by the dietician, despite significant weight loss and the need for close monitoring. The physician orders did not include weekly weights, and only two weights were documented over a two-month period, contrary to facility policy on unintended weight loss.
A facility failed to justify the use of Seroquel for a resident with Alzheimer's and did not adequately monitor behaviors for residents on psychotropic medications. Despite the resident's cognitive impairment and lack of a psychotic disorder, Seroquel was prescribed without clear documentation of its necessity or effectiveness. Additionally, the facility did not systematically monitor or document behavioral symptoms for two residents, contrary to care plan requirements.
A resident was prescribed Macrobid for a UTI without meeting The McGeer Criteria, as they showed no symptoms like fever or pain, and no urinalysis was done. The ADON confirmed the antibiotics were given despite not meeting criteria, contrary to the facility's antibiotic stewardship policy.
Failure to Maintain Sanitary Food Preparation Practices
Penalty
Summary
The facility failed to prepare, distribute, and serve food in a safe and sanitary manner, which had the potential to affect all residents. During an observation of the lunch meal preparation, two staff members, identified as a cook and a dietary aide, were seen preparing food without wearing beard covers to cover their cheeks, upper lip, and chin hair while working in the kitchen. This observation was confirmed by the Director of Dietary Quality Assurance. An interview with the cook confirmed that he should have been wearing a beard cover while cooking. The facility's policy on Employee Sanitary Practices, dated April 4, 2019, and March 1, 2019, requires employees to wear hair restraints, including beard restraints, to prevent hair from contacting exposed food.
Inadequate Monitoring of Water Management Program
Penalty
Summary
The facility failed to adequately monitor its water management program to control the spread of waterborne pathogens, specifically Legionella, which could potentially affect all 40 residents. The deficiency was identified through a series of interviews and record reviews. The Facilities Director confirmed that a Legionella risk assessment was performed in April 2024, but there was no documented evidence of monitoring physical controls, water temperatures, disinfectant levels, visual inspections, or environmental testing for waterborne pathogens for the years 2023 and 2024. The facility's water management binder lacked documentation of these critical monitoring activities. Interviews with the Facilities Director and the Facilities Safety Specialist confirmed the absence of documented Legionella monitoring from 2023 to the present. The facility's policy, dated November 2023, stated that a contracted water mitigation system provider would ensure the water management program's facilitation, with the Facilities Director responsible for oversight. However, there was no evidence of regular testing or reporting through the monthly quality assurance and performance improvement committee. The CDC guidance outlines the necessity of a comprehensive water management program, including continuous review and documentation, which the facility failed to implement effectively.
Failure to Timely Complete PASRR Document
Penalty
Summary
The facility failed to complete a preadmission screening and resident review (PASRR) document in a timely manner for a resident who was admitted with multiple complex medical conditions, including dementia and major depressive disorder. The resident was initially admitted from the hospital with a hospital exemption form, which allowed her to remain in the facility for up to 30 days without a PASRR. However, the facility did not complete the required PASRR document by the deadline of 30 days post-admission. The social worker confirmed that the hospital exemption form was completed on the date of admission and again during a subsequent hospital visit within the first 30 days. The social worker mistakenly believed that the exemption form was sufficient for the resident to remain in the facility without completing a PASRR. The only PASRR document was completed well after the required timeframe, indicating a lack of understanding of the PASRR requirements when a resident is readmitted to the hospital within the initial exemption period.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications according to the prescribing physician's orders, affecting two residents. Resident #4, who has a history of Parkinson's disease, was observed receiving Carbidopa-Levodopa ER at 8:56 A.M., despite the medication being ordered for administration at 7:00 A.M. and again in the evening at 8:00 P.M. The LPN confirmed that the wrong dose was administered at the incorrect time, deviating from the prescribed schedule. Similarly, Resident #7, diagnosed with dementia and agitation, was given Depakote Sprinkles DR at 9:15 A.M., although the medication was scheduled for 7:30 A.M. The LPN acknowledged the error in timing. These discrepancies in medication administration were identified through observation, staff interviews, and record reviews, highlighting a failure to adhere to the prescribed medication schedules for these residents.
Failure to Implement Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to implement timely pressure injury interventions for a resident with a stage III pressure ulcer. The resident, who was admitted with multiple diagnoses including type II diabetes and chronic kidney disease, had a pressure ulcer documented at the time of admission. However, the facility did not document any measurements for the ulcer until several days later, and no wound treatment intervention was implemented until five days after admission. The care plan required weekly assessment and documentation of wound healing, but these actions were not initiated promptly. Another resident, who was readmitted to the facility after a hospital stay, was found to have Moisture Associated Skin Damage (MASD) on her buttocks upon readmission. The facility did not document measurements or descriptions of this skin alteration until four days later, when it was assessed as a stage III pressure ulcer. The facility's protocol required immediate examination and treatment of pressure ulcers upon admission, but this was not followed. Interviews with facility staff confirmed that pressure ulcers should be addressed promptly upon admission, and that the facility's procedures were not followed in these cases. The Assistant Director of Nursing acknowledged that the interventions for the first resident were delayed, and that the second resident's skin injury was not measured or monitored in a timely manner. The facility's clinical protocol emphasized the need for immediate treatment and monitoring of pressure ulcers, which was not adhered to in these instances.
Failure to Monitor Resident Weights as Recommended
Penalty
Summary
The facility failed to ensure that resident weights were obtained as per dietician recommendations, affecting two residents out of four reviewed for nutrition. Resident #37, who had a history of severe fracture, dementia, and anemia, was identified with a significant weight loss of 5.7% in one month. The dietician recommended weekly weight monitoring to assess the effectiveness of interventions, but the physician orders did not reflect this, and only two weights were documented over a two-month period. Similarly, Resident #36, with diagnoses including collapsed vertebra and dementia, experienced a weight decline over three months. The dietician ordered weekly weights for close monitoring, but the physician orders did not include this, and only two weights were documented. The facility's policy on unintended weight loss requires weekly weights for residents with significant changes in condition, which was not adhered to in these cases.
Failure to Justify and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, as there was no adequate indication for the use of an antipsychotic medication, Seroquel, for Resident #7. Despite the resident's significant cognitive impairment and lack of a psychotic disorder, Seroquel was prescribed multiple times for agitation and dementia with psychosis without clear documentation of its necessity or effectiveness. The medication review team, including the CNP, Medical Director, Pharmacy, DON, and ADON, did not provide clear evidence or outcomes supporting the ongoing use of Seroquel, nor was there documentation of non-pharmacological interventions being considered or attempted. Additionally, the facility did not adequately monitor behaviors for residents prescribed psychotropic medications, affecting both Resident #7 and Resident #29. For Resident #7, there was no systematic monitoring or documentation of behavioral symptoms such as agitation, aggression, or confusion, as required by the care plan. Despite changes in medication orders, there was no clear documentation of the effectiveness of these medications in managing the resident's behavioral symptoms over time. For Resident #29, who was prescribed Duloxetine for depression and anxiety, the facility failed to document behaviors or track them systematically. The care plan required monitoring and documentation of adverse reactions to antidepressant therapy, but there was no evidence of such documentation in the progress notes or behavior tracking documentation. Interviews with the Administrator and DON confirmed that behavior documentation was done by exception and discussed in meetings, but this did not align with the facility's policy for behavioral assessment, intervention, and monitoring.
Inappropriate Antibiotic Use for UTI
Penalty
Summary
The facility failed to ensure that antibiotics were prescribed with an appropriate indication, affecting one resident out of five reviewed for antibiotic stewardship. Resident #26 was admitted with multiple diagnoses, including vitamin D deficiency, myocardial infarction, hypertension, osteoporosis, obstructive sleep apnea, heart disease, and abnormal weight loss. The resident was prescribed Macrobid, an antibiotic, for a urinary tract infection (UTI) from January 4 to January 9, 2024. However, the medical record review revealed that the resident did not exhibit symptoms consistent with a UTI, such as fever, pain, hematuria, urgency, frequency, dysuria, or tenderness, and no urinalysis or urine culture was conducted to confirm the infection. The Assistant Director of Nursing confirmed that the course of antibiotics was completed despite not meeting The McGeer Criteria for a UTI. The facility's policy on antibiotic stewardship, last revised in December 2016, states that antibiotics should be prescribed and administered under the guidance of the facility's antibiotic stewardship program. This incident indicates a failure to adhere to the policy, as the resident was given antibiotics without meeting the necessary criteria for a UTI diagnosis.
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Illustrative
What surveyors actually found near you
We read the 839 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dublin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand The | 0.9 mi | ★★★★★ | 21 | 0 |
| The Sanctuary At Tuttle Crossing | 1 mi | ★★★★★ | 4 | 0 |
| Dublin Post Acute | 1 mi | ★★★★★ | 34 | 0 |
| Mayfair Village Nursing Care Center | 1.7 mi | ★★★★★ | 19 | 0 |
| Crown Pointe Care Center | 2.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.