Health inspection·October 25, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and resident interview, the facility failed to ensure resident rooms were maintained in a safe, clean, and homelike manner. This affected three residents (#11, #47, and #48) out of five residents reviewed for the environment. The facility census was 76. Findings include: 1. Review of Resident #11's medical record 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 (MDS) assessment, dated 09/05/23, revealed Resident #11 was cognitively intact. Observation on 10/25/23 at 9:40 A.M. revealed there was cracked and chipped paint along with chunks of plaster missing along the baseboard heating unit in Resident #11's room. Additionally, the privacy curtain in Resident #11's room had brown specks splashed on it. Interview with State Tested Nurse Aide (STNA) #400 on 10/25/23 at 9:45 A.M. verified there was cracked and chipped paint along with chunks of plaster missing along the baseboard heating unit in Resident #11's room. Additionally, STNA #400 verified there were brown spots on Resident #11's privacy curtain. STNA #400 stated the brown spots may be coffee stains and the privacy curtain needed washed. 2. Review of Resident #47's medical record revealed Resident #47 was admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, alcoholic polyneuropathy, suicidal ideation, and schizoaffective disorder. Review of Resident #47's quarterly MDS assessment, dated 09/01/23, revealed Resident #47 was cognitively intact. 3. Review of Resident #48's medical record revealed Resident #48 was admitted on [DATE] with diagnoses which included type one diabetes mellitus, absence of right and left legs below the knee, acute kidney failure, and major depressive disorder. Review of Resident #48's quarterly MDS assessment, dated 08/31/23, revealed Resident #48 was cognitively intact. Observations on 10/25/23 at 10:20 A.M. revealed chunks of plaster and paint were missing from the Page 1 of 4 365410 365410 10/25/2023 Mayfair Village Nursing Care C 3000 Bethel Rd Columbus, OH 43230

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. 365410 Page 2 of 4 365410 10/25/2023 Mayfair Village Nursing Care C 3000 Bethel Rd Columbus, OH 43230

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 365410 Page 3 of 4 365410 10/25/2023 Mayfair Village Nursing Care C 3000 Bethel Rd Columbus, OH 43230

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. 365410 Page 4 of 4