Inspection·October 25, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few exterior wall in Resident #47 and Resident #48's room. Additionally, cobwebs were observed in the corner of the windowsills in Resident #47 and Resident #48's room. Interview with Resident #48 at the time of the observation revealed the wall was like that when he moved in a year ago. Observation and interview on 10/25/23 at 5:00 P.M. with the Administrator confirmed Resident #11's room had missing plaster and paint along the window and base of the wall near the heating unit along the outside wall and the privacy curtain has dark brown spots on it. The Administrator indicated the privacy curtain needed washed. The Administrator further verified Resident #47 and Resident #48's room had spots on the outside wall where the paint and plaster were missing and had cobwebs in the corners of the windowsill. This deficiency represents non-compliance investigated under Complaint Number OH00146291. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365410 If continuation sheet Page 2 of 4 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 365410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to accommodate residents cultural preferences for meals. This affected one (Resident #11) out of three residents reviewed for meals. The facility census was 76. Findings include: Review of the medical record for Resident #11 revealed Resident #11 was admitted on [DATE] with diagnoses which included arthritis, type two diabetes mellitus, dysphagia, and major depressive disorder. Review of the quarterly Minimum Data Set assessment, dated 09/05/23, revealed Resident #11 was cognitively intact and required supervision and set-up assistance with eating. Review of Resident #11's physician order, dated 03/29/21, revealed Resident #11 had a physician order for a consistent carbohydrate diet. Review of Resident #11's comprehensive care plan revealed it did not address Resident #11's cultural preferences and requests related to meals. Review of Resident #11's medical record revealed no evidence the facility had asked Resident #11 what spices/seasonings would assist with making the food provided by the facility more closely resemble the Ghanian flavors he preferred. Interview on 10/25/23 at 9:40 A.M. with Resident #11 revealed Resident #11 had concerns about the food. Resident #11 had talked to the dietitian and requested the facility provide him foods that more closely resembled foods/flavors from his Ghanian culture. Resident #11 stated the dietitian told him he had to eat what they gave him in order to follow his diet. Resident #11 stated he was diabetic and the foods the facility provided were very bland and gave him diarrhea. Resident #11 indicated a woman (unnamed) with a similar cultural background would occasionally bring in food for him and put the leftovers in the fridge for staff to heat up later however the facility often threw them away and told him there was nothing available to heat up. Interview on 10/25/23 at 10:45 A.M. with Dietitian #500 revealed the facility had a default planned meal and alternative selections available at each meal. The facility also had a list of always available items. When asked how cultural preferences were addressed, Dietitian #500 indicated the most common request was to have no pork. When Dietitian #500 was asked about how they accommodate African cultures, Dietitian #500 stated they sit down with the resident and try to find food items on the menu that will meet their needs. The interview revealed Dietitian #500 had not asked Resident #11 what spices/seasonings would assist with making the food provided by the facility more closely resemble the Ghanian flavors he preferred. Interview on 10/25/23 at 12:40 P.M. with Kitchen Manager #520 revealed the facility had a default planned meal and alternative selections were available at each meal. The facility also had a list of always available items. When asked about meeting resident's cultural needs, she stated Resident #11 had some cultural requests because he was used to spicier foods from [NAME], so she offered to get (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365410 If continuation sheet Page 3 of 4 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 365410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/25/2023 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 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few him hot sauce. The interview revealed Kitchen Manager #520 had not asked Resident #11 what spices/seasonings would assist with making the food more closely resemble the Ghanian flavors he preferred. Interview on 10/25/23 at 2:15 P.M. with Resident #11 revealed he preferred foods that resembled the unique spices and flavors associated with Ghanian culture. Interview on 10/25/23 at 4:30 P.M. with the Director of Nursing (DON) revealed Resident #11's dietary requests and cultural needs related to the food provided by the facility were missed and not addressed appropriately. The DON revealed Resident #11's request for spicier foods was not a request for hot sauce but rather was a request for food options that more closely resembled his native cuisine. This deficiency represents non-compliance investigated under Complaint Number OH00146291. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365410 If continuation sheet Page 4 of 4