Mayfair Village Nursing Care C

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interviews, the facility failed to provide assistance with bathing and shaving. This affected (Residents #42 and #44) of three residents reviewed for showers. The facility census was 80. Review of the medical record revealed Resident #42 was admitted on [DATE REDACTED] with diagnoses that included acute embolism and thrombosis of left iliac vein, pulmonary embolism, severe protein-calorie deficiency, schizoaffective disorder, dementia, depression, and bipolar. The annual Minimum Data Set (MDS) dated [DATE REDACTED] revealed it was very important for Resident #42 to choose the type of bathing. A care plan for activities of daily living dated 01/26/24 revealed Resident #42 required supervision with bathing/showering.

Review of the electronic record, therapy notes, and paper documentation revealed in the last 30-days Resident #42 received a bed bath on 09/08/25 and 09/11/25, refused bathing with occupational therapy on 09/18/25, and received a sponge bath on 09/21/25. An observation and interview on 09/22/25 at 12:31 P.M. revealed Resident #42 was sitting in a chair in his room. Resident #42 had a short beard. Resident #42 stated he did not like having a beard and would like to be shaved. Resident #42 also verified he preferred receiving a shower over a bed bath. Interview on 09/22/25 at 2:05 P.M. a family of Resident #42 verified Resident #42 did not like having a beard. The family member also stated Resident #42 was only bathed once a week and preferred a shower. The family member stated they had taken Resident #42 home on a leave of absence so Resident #42 could shower at her house. An interview on 09/22/25 at 4:23 P.M.

Director of Nursing (DON) verified Resident #42 was not being bathed and shaved per his preference. The DON verified there was a concerns with bathing being completed as scheduled. 2. Review of the medical

record revealed Resident #44 was admitted on [DATE REDACTED] with diagnoses that included dementia and atrial fibrillation. Review of the annual MDS dated [DATE REDACTED] revealed Resident #44 had severe cognitive impairment and was dependent on staff for bathing. Review of the electronic record and paper documentation revealed

in the last 30 days Resident #44 received a sponge bath on 08/28/25 and a shower on 09/01/25. Interview

on 09/22/25 at 4:23 P.M. Director of Nursing (DON) verified there was a concern with bathing being completed as scheduled. This deficiency represents non-compliance investigated under Complaint Number

1. 2584976. Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mayfair Village Nursing Care C

3000 Bethel Rd Columbus, OH 43230

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 - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to thoroughly assess a resident after a fall and timely notify

the physician. This affected one resident (#3) of three residents reviewed for falls. The facility census was 80.Findings include: Review of Resident #3's medical record revealed an admission date of 07/10/25 with diagnoses including cognitive communication deficit, dementia, depression, anxiety and fracture of left femur on 08/21/25.Review of Resident #3's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] revealed he had severely impaired cognition. Since the previous assessment Resident #3 had two falls or more without injury, two falls or more with injury, and one fall with major injury.Review of Resident #3's plan of care dated 07/11/25 revealed the resident was at risk for falls related to impaired balance and lack of safety awareness due to cognitive deficit related to dementia. Interventions included assisting out of bed before meals, assisting with toileting before bedtime, dycem to wheelchair, clearing a pathway in his room, fall mat, low bed, medication review, offering snacks when restless, offering toileting in advance of needs, toileting before laying down after meals, and visual reminder to call before you falls.Review of Resident #3's progress note dated 08/16/25 at 3:00 A.M. revealed staff heard yelling coming from the residents room. The residents roommate was calling for help after the resident fell. Resident #3 was found on the floor lying on his back next to his bed. He was unable to voice what happened. A head-to-toe assessment was completed and no visible injuries were noted. However, the resident was unable to stand and complained of left hip pain. Staff assisted the resident back in bed, groomed him and put him in his wheelchair. He was given as needed pain medication at that time.Review of Resident #3's fall investigation dated 08/16/25 revealed no evidence his range of motion was not assessed and the physician was not notified until 8:00 A.M.Interview on 09/22/25 at 11:10 A.M. with the Director of Nursing (DON) verified that range of motion was not assessed after his fall and should have been.Interview on 09/22/25 at 1:04 P.M. with Certified Nurse Practitioner (CNP) #270 verified they were not timely notified of the fall. The physician was notified of the fall at 7:45 A.M. and they should have been notified at the time of the fall so

they could address any concerns at that time.This deficiency represents noncompliance investigated under Complaint Numbers 2593023 and 2584976

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mayfair Village Nursing Care C

3000 Bethel Rd Columbus, OH 43230

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

hurt to move. Resident #3 had a fall on 08/16/25 and was sent to the emergency room for left hip pain with

a negative x-ray. She recommended the facility continue fall precautions, nursing interventions, and neurochecks. His medications were reviewed, his current medications had no concern for polypharmacy to cause sedation or side effects leading to falls. In an addendum on 08/19/25 CNP #270 indicated the hospital notes had a CT scan which revealed a nondisplaced greater trochanter fracture. Orthopedics recommended nonsurgical management, weight bearing as tolerated with walker until pain free, limited abduction, and follow up in three weeks.Review of Resident #3's progress note dated 08/19/25 revealed the resident had pain with turning and completing activities of daily living. CNP #270 was notified and gave a verbal order for new pain medications.Review of Resident #3's physician order dated 08/19/25 to 09/08/25 revealed an order for oxycodone five mg one tablet by mouth every six hours as needed for pain.Review of Resident #3's Medication Administration Record from 08/16/25 to revealed Acetaminophen 325 mg was given on 08/16/25 for no fever, Acetaminophen 650 mg was given on 08/28/25 for an unknown pain. There was no pain medication given from 08/17/25 through 08/19/25. Oxycodone was given on 08/20/25 for a pain of four, five, four, and six. It was given on 08/23/25, 08/24/25, 08/25/25, and 08/30/25 for a pain of six, and on 08/26/25 and 08/27/25 for a pain of five. On 08/17/25 the resident had a pain of three and two, and

on 08/19/25 the resident had a pain of three.Review of Resident #3's progress note dated 08/20/25 at 1:00 A.M. revealed the resident received oxycodone for pain in his left hip.Review of Resident #3's CNP #270 note dated 08/20/25 revealed the resident appeared uncomfortable and was unable to complete activities of daily living. She recommended they use the oxycodone sparingly and only as needed due to concerns for falls. Per nursing the resident had reported significant left hip pain and did not want to move too much.Interview on 09/22/25 at 12:22 P.M. with Certified Nursing Assistant (CNA) #207 revealed she could not recall the details but believed the resident may have reported pain once a little over a month ago.Interview on 09/22/25 at 1:04 P.M. with CNP #270 verified the facility had initially not noted the resident's fracture until MedOne employees (physician services) reviewed the hospital notes on 08/19/25 and noted the CT scan. She reported she had been concerned about using opioids due to his falls. She verified she had noted he was in pain on 08/18/25 and had expected the facility staff to use the Acetaminophen that had been ordered to control his pain. When the facility reported ongoing pain on 08/19/25 she went ahead and ordered the oxycodone, she was unaware the acetaminophen had not been used.Interview on 09/22/25 at 4:20 P.M. with the Director of Nursing (DON) verified that from 08/17/25 to 08/19/25 nursing did not attempt to give Resident #3 Acetaminophen despite his reports of pain. This included not providing pain medication on 08/19/25 after requesting stronger pain medication due to the residents pain.Review of the policy, ‘Pain Assessment and Management,' revised 04/22/25 revealed acute pain included pain that is usually sudden in onset and time limited with a duration of less than a month. It is often caused by injury, trauma, or medical treatments. It was the policy of the facility to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The facility was to identify and use specific strategies for preventing or minimizing different levels of sources of pain or pain-related symptoms based

on the resident specific assessment, preferences and choices, pertinent clinical rationale, and the residents goals.

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