Health inspection·April 9, 2024

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy, and physician and staff interview, the facility failed to monitor the effectiveness of the pain interventions for a resident per the resident's plan of care and professional standards of practice. This affected one (Resident #35) of three residents reviewed for pain management. The facility census was 33. Residents Affected - Few Findings include: Review of the medical record for Resident #35 revealed an admission date of 11/07/23 and discharge date [DATE]. Diagnoses included spinal cerebrospinal fluid leak, spinal fusion, and spondylolisthesis lumbosacral region. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was cognitively intact. Review of the hospital records prior to admission revealed the resident was admitted to the hospital on [DATE] and had spinal surgery 11/01/23. Review of the hospital after visit summary (AVS) dated 11/07/23 revealed the discharge recommendation was to start taking Oxycodone (narcotic pain medication) one tablet by mouth every six hours as needed (PRN) for pain for up to three days and take acetaminophen 325 milligram (mg) tablet to take two tablets by mouth every six hours for mild pain. The AVS instructed to use muscle relaxants to help with muscle spasms and pain. Review of the physician orders dated 11/07/23 revealed an order for acetaminophen tablet 325 mg with instructions to give two tablets by mouth every six hours PRN for mild pain (pain level of one to four on a pain scale from zero (no pain) to 10 (most severe pain). An order dated 11/07/23 to 11/08/23 for Oxycodone HCL oral tablet five mg with instructions to provide one tablet by mouth every six hours as needed for moderate pain (pain level from five to seven). An order dated 11/08/23 to 11/14/23 was for Oxycodone HCL oral tablet five mg with instructions to give one tablet by mouth every six hours for pain. The order dated 11/14/23 to 11/21/23 revealed an order for Oxycodone five mg with instructions to give one tablet by mouth every four hours for pain. Review of the plan of care dated 11/08/23 revealed Resident #35 had acute pain related to a postoperative discomfort with interventions to administer analgesia as per orders, anticipate residents need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of the pain including dosing schedules and resident satisfaction with results, monitor and record side effects of pain medication and notify the physician if interventions were unsuccessful or if current complaint was significant change from past reports of pain, provide the resident and family with information about pain and options available for pain management. Review of the Nurse Practitioner (NP) note dated 11/08/23 revealed Resident #35 was on Oxycodone (continued on next page) 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 Page 1 of 4 Event ID: 365047 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 365047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE First Community Village Healthcare Ctr 1800 Riverside Drive Columbus, OH 43212 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)