Dublin, OH

Friendship Village Of Dublin

3-star overall rating with 3-star inspections with $3,145 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

6000 Riverside Dr, Dublin, OH

(614) 764-1600

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

50

Certified beds

Average residents

40

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1981-07-15

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.14

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.97

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

3.04

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

5.15

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

2.11

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

4.53

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.56

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.32

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

1.34

CMS adjusted RN staffing hours

Adjusted total hours

6.09

CMS adjusted total nurse staffing hours

Case-mix index

1.16

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

0%

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

3,278

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

45.09

Composite VBP score used to determine payment impact.

Payment multiplier

0.9983

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.94

Baseline 17.53% · Performance 19.61% · Measure score 3.94 · Achievement 3.94 · Improvement 0

Healthcare-associated infections

1.86

Baseline 5.34% · Performance 7.28% · Measure score 1.86 · Achievement 1.86 · Improvement 0

Total nurse turnover

5.15

Performance 42.62% · Measure score 5.15 · Achievement 5.15 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

7.09

Baseline 4.80 hours · Performance 5.09 hours · Measure score 7.09 · Achievement 7.09 · Improvement 2.52

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	7.86%	10.72% 2.9 pts better	No Different than the National Rate · Eligible stays 211 · Observed rate 2.37% · Lower 95% interval 5.34%
Discharge to community	70.72%	50.57% 20.1 pts better	Better than the National Rate · Eligible stays 200 · Observed rate 75% · Lower 95% interval 64.75%
Medicare spending per beneficiary	1.02	1.02 About the same
Drug regimen review with follow-up	92.03%	95.27% 3.2 pts worse	Numerator 127 · Denominator 138
Falls with major injury	1.45%	0.77% 0.7 pts worse	Numerator 2 · Denominator 138
Discharge self-care score	42.86%	53.69% 10.8 pts worse	Numerator 42 · Denominator 98
Discharge mobility score	46.94%	50.94% 4 pts worse	Numerator 46 · Denominator 98
Pressure ulcers or injuries, new or worsened	1.45%	2.29% 0.8 pts better	Numerator 2 · Denominator 138 · Adjusted rate 1.62%
Healthcare-associated infections requiring hospitalization	7.28%	7.12% 0.2 pts worse	No Different than the National Rate · Eligible stays 136 · Observed rate 5.15% · Lower 95% interval 4.13%
Staff COVID-19 vaccination coverage	6.49%	8.2% 1.7 pts worse	Numerator 5 · Denominator 77
Staff flu vaccination coverage	43.75%	42% 1.8 pts better	Numerator 42 · Denominator 96
Discharge function score	51.02%	56.45% 5.4 pts worse	Numerator 50 · Denominator 98
Transfer of health information to provider	82.93%	95.95% 13 pts worse	Numerator 68 · Denominator 82
Transfer of health information to patient	97.5%	96.28% 1.2 pts better	Numerator 39 · Denominator 40
Resident COVID-19 vaccinations up to date	46.84%	25.2% 21.6 pts better	Numerator 37 · Denominator 79

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.5	1.8 0.3 pts better	1.9 0.4 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.5	1.8 1.3 pts better	1.8 1.3 pts better	Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.2 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	92.4% 7.6 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	94.5% 5.5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	9.3%	3.3% 6 pts worse	3.3% 6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 4.3% · Q3 16.0% · Q4 9.1% · 4Q avg 9.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	6.1%	26.1% 20 pts better	11.4% 5.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.5% · Q3 10.0% · 4Q avg 6.1%
Percentage of long-stay residents who lose too much weight	3.8%	6.2% 2.4 pts better	5.4% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 3.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	9.1%	25.4% 16.3 pts better	19.6% 10.5 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1%
Percentage of long-stay residents who received an antipsychotic medication	2.8%	11.5% 8.7 pts better	16.7% 13.9 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	26.2%	7.7% 18.5 pts worse	16.3% 9.9 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 26.2% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	16.4%	6.2% 10.2 pts worse	14.9% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 16.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.2% 0.2 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.1%	0.5% 0.6 pts worse	1.7% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.7%	21.7% 3 pts worse	19.8% 4.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q3 24.2% · 4Q avg 24.7%
Percentage of long-stay residents with pressure ulcers	2.9%	3.7% 0.8 pts better	5.1% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 4.0% · Q4 4.1% · 4Q avg 2.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.3%	78.1% 19.2 pts better	81.7% 15.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 96.6% · Q3 99.0% · Q4 96.7% · 4Q avg 97.3%
Percentage of short-stay residents who had an outpatient emergency department visit	12.7%	12.5% 0.2 pts worse	12.0% 0.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 10.9% · Expected 9.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.3%	1.2% 0.9 pts better	1.6% 1.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	95.8%	75.6% 20.2 pts better	79.7% 16.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	34.4%	25.1% 9.3 pts worse	23.9% 10.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 34.4% · Observed 24.8% · Expected 17.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-14 · Fire 2024-11-14

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2022-06-02 · Fire 2022-06-02

6 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2019-10-17 · Fire 2019-10-17

6 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-11-14

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-11-14

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-12-27

F · Potential for more than minimal harm 2024-11-14

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2024-12-27

E · Potential for more than minimal harm 2024-11-14

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-12-27

F · Potential for more than minimal harm 2022-06-02

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-06-20

E · Potential for more than minimal harm 2019-10-17

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-11-08

E · Potential for more than minimal harm 2019-10-17

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2019-11-08

E · Potential for more than minimal harm 2019-10-17

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-11-08

E · Potential for more than minimal harm 2019-10-17

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-11-08

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-11-14

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-12-13

F · Potential for more than minimal harm 2024-11-14

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-14

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-14

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-14

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-14

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-14

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-14

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2024-12-13

F · Potential for more than minimal harm 2022-06-02

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-06-20

F · Potential for more than minimal harm 2022-06-02

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-06-02

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-06-02

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-06-02

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2022-06-20

D · Potential for more than minimal harm 2022-06-02

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2022-06-20

G · Actual harm 2019-10-17

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2019-11-08

F · Potential for more than minimal harm 2019-10-17

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2019-11-08

F · Potential for more than minimal harm 2019-10-17

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2019-11-08

E · Potential for more than minimal harm 2019-10-17

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2019-11-08

D · Potential for more than minimal harm 2019-10-17

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2019-11-08

D · Potential for more than minimal harm 2019-10-17

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2019-11-08

Penalties and ownership

What sits behind the stars

$3,145 2023-06-12

Fine

Fine · fine $3,145

Fine

Ownership

Friendship Village Of Dublin Ohio, Inc.

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 1978-04-04

Bachman, Ronald