Health inspection·January 31, 2024

F 0624 Prepare residents for a safe transfer or discharge from the nursing home. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, family interviews, staff interviews, and review of facility policies, the facility failed to assist with discharge planning. This affected one (Resident #82) of three residents reviewed for discharge planning. Additionally, the facility failed to document discharge planning efforts and include the residents in discharge planning. This affected three (Residents #82, #31, and #50) of three residents reviewed for discharge planning. The facility census was 77. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #82 revealed an admission date of 10/20/23 and discharge date of 11/08/23. Diagnoses included metabolic encephalopathy, respiratory failure with hypoxia, muscle weakness, unsteadiness on feet, dependence on oxygen, diabetes, chronic obstructive pulmonary disease, pulmonary hypertension, and altered mental status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 was cognitively intact and required substantial and maximum assistance for activities of daily living including toileting and bathing. Progress note dated 11/01/23 revealed Residents #82's insurance cut him from skilled services and offered an appeal process scheduled with medical team for 11/02/23. Progress note dated 11/02/23 revealed the appeal was denied and the resident's last covered day was 11/04/23 with financial liability beginning 11/05/23. On 11/02/23, the facility had a care conference that included Resident #82's guardian, who wanted to await the appeal and go from there. The resident's guardian was encouraged to have a plan. Progress note dated 11/03/23 revealed guardian was planning to discharge the resident on 11/05/23. No information was documented regarding location for discharge or any services at discharge. Progress note dated 11/03/23 revealed the resident's guardian had not set up any discharge placement for Resident #82. Progress note dated 11/08/23 from bedside nurse revealed the resident was discharged to an assisted living and was picked up by family. No progress notes were present related to planning and discussions about assisted livings, providing choices, sending referrals, being accepted and coordination efforts from facility staff to provide a safe discharge plan. Interview on 01/29/24 at 5:41 P.M. with Resident #82's guardian revealed she received no help in planning the discharge and finding a facility for Resident #82 once he was cut from therapy. The resident's guardian revealed the facility informed her of the resident being cut but did not provide information to look into options for discharge and she had to do all work and research herself. She revealed the resident was discharged on 11/08/2, several days after insurance had ended and revealed the delay was due to lack of assistance. Page 1 of 5 365410 365410 01/31/2024 Mayfair Village Nursing Care C 3000 Bethel Rd Columbus, OH 43230

F 0624 Level of Harm - Minimal harm or potential for actual harm Interview on 01/29/24 at 3:54 P.M. with Social Services Director (SSD) #250 revealed she spoke with Resident #82's guardian about discharge planning and revealed he was discharged to an assisted living. SSD confirmed she had no notes documented of any conversations of discharge planning or steps of the referral process related to the assisted living referral and confirmed she was unable to find in the resident record what assisted living facility the resident had discharged to. Residents Affected - Few 2. Review of the medical record for Resident #31 revealed an admission date of 01/22/24 and discharge date of 01/29/24. Diagnoses included traumatic subdural hemorrhage, diabetes, respiratory failure, malnutrition, atrial fibrillation, and dysphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 was cognitively intact and required substantial assistance for toilet and bathing. Review of progress note dated 01/29/24 at 9:36 A.M. revealed Resident #31's insurance appeal was denied with a last covered date of 01/29/24. The social services designee was working on a discharge plan. On 01/29/24 at 11:56 A.M. progress note stated the resident can discharge home with no oxygen per the Certified Nurse Practioner (CNP) and he could go home with the CPAP he brought to facility. Progress note dated 01/29/24 at 2:27 P.M. stated the resident was set up with home health care and durable medical equipment (walker) and follow up appointments were arranged. Further review of progress notes found no evidence of discharge planning that was started prior to 01/29/23 and no mention of discussion with resident related to needed services, choice, referrals and follow up. Interview on 01/29/24 at 11:32 A.M. with Resident #31 revealed he should be discharged later this day (01/29/24). Resident #31 revealed he had not spoken to anyone about discharge planning and denied any services were being set up at home. The resident revealed he did not think he needed any services or equipment. Interview on 01/29/24 at 3:54 P.M. with SSD #250 revealed she spoke with Resident #31's friend/family about discharge planning and revealed he was going home with home health services. SSD confirmed she had no notes documented of any conversations of discharge planning or steps of the referral process until the day of discharge and no conversations including the resident. 3. Review of the medical record for Resident #50 revealed an admission date of 12/11/23 and discharge date [DATE]. Diagnoses included COVD-19, respiratory failure, asthma, atrial fibrillation and dysphasia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was cognitively impaired and was dependent for bed mobility and activities of daily living. Review progress notes dated 01/10/24 revealed Resident #50's family wanted the resident to return home once therapy had ended. Progress note dated 01/29/24 revealed the resident would be discharged home with daughter using transportation. Further review of progress notes found no evidence of the resident being ready for discharge, being cut from therapy, discharge services needed for home, and discussions with resident and family. Interview on 01/29/24 at 11:25 A.M. with Resident #50's daughter verified the resident would be discharged this day (01/29/24) home with daughter. Resident #50's daugther revealed services were arranged at the home and several pieces of medical equipment had already been delivered. 365410 Page 2 of 5 365410 01/31/2024 Mayfair Village Nursing Care C 3000 Bethel Rd Columbus, OH 43230

F 0624 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 01/29/24 at 3:54 P.M. with Social Services Director (SSD) #250 revealed she spoke with Resident #50's family about discharge planning and revealed she was going home with family. SSD confirmed she had no notes documented of any conversations of discharge planning or steps of the referral process. Interview on 01/29/24 at 3:54 P.M. with Unit Manager #260, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #275 while reviewing medical records for Residents #82, #31, and #50 confirmed the documentation was not thorough and revealed Resident #31 had some discharge planning documented in the record, but not until the day of discharge and Residents #82 and #50 had no documentation related to the coordination of discharge. Review of facility policy titled, Transfers and Discharges, dated 08/09/23, revealed the facility must ensure the transfer or discharge was documented in the residents medical record. Information that should be provided to receiving providers include contact information, resident representative, special precautions, comprehensive care plan, medications, labs ect. Review of facility policy titled, Discharge plan, dated 08/09/23, revealed the facility shall identify the needs and goals regarding discharge. Document that resident had been asked about interest and document any referrals to local agencies or entities made based on resident choice. For resident transferred to other facilities or agencies, staff should assist residents and representatives in selecting post-acute providers. Involve the resident and representative in any modification in the discharge plan and document the date and any updated information in the discharge plan. This deficiency represents non-compliance investigated under Complaint Number OH00149804. 365410 Page 3 of 5 365410 01/31/2024 Mayfair Village Nursing Care C 3000 Bethel Rd Columbus, OH 43230

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interviews, the facility failed to ensure a resident was provided with oxygen as ordered at discharge. This affected one (Resident #82) of three reviewed for oxygen. Facility census was 77. Residents Affected - Few Findings include: Review of the medical record for Resident #82 revealed an admission date of 10/20/23 and discharge date of 11/08/23. Diagnoses included metabolic encephalopathy, respiratory failure with hypoxia, muscle weakness, unsteadiness on feet, dependence on oxygen, diabetes, chronic obstructive pulmonary disease, pulmonary hypertension, and altered mental status. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #82 was cognitively intact and required substantial and maximum assistance for activities of daily living including toileting and bathing. Review of the plan of care dated 10/20/23 revealed Resident #82 was at risk for respiratory illness with interventions for oxygen settings via nasal cannula to be administered as ordered. Review of physician orders dated 10/20/23 revealed an order for oxygen at two liter nasal cannula as needed. Review of the progress notes dated 10/30/23 from the Certified Nurse Practitioner (CNP) revealed Resident #82 was on 2 liters of oxygen. CNP note dated 11/01/23, revealed recommendation for oxygen wean trial as able. CNP discussed weaning oxygen with resident as he was off of it prior to the hospitalizations. Progress note dated 11/08/23 from CNP revealed no wean trails had been documented/completed by this date. Progress note dated 11/08/23 from Licensed Practical Nurse (LPN) #240 revealed the resident was discharged to assisted living this date and was picked up and transported by family at 6:30 P.M. with personal belongings. Further review of progress notes revealed no discussions with Resident #82's guardian about discharge planning and equipment needed for discharge and transportation. Interview on 01/29/24 at 5:41 P.M. with Resident #82's guardian revealed the facility discharged the resident to the assisted living facility without any oxygen for transport. Resident #82's guardian revealed the resident had been on two liters of oxygen consistently when at the facility and then upon discharge, had oxygen delivered to the new facility. Resident's #82's guardian provided transport to the new facility and during transport resident was left with no oxygen and no portable tank was provided to ensure safe transport. Interview on 01/29/24 at 3:54 P.M. with Social Services Director (SSD) #250 revealed she was aware Resident #82 had oxygen, as she ordered it at discharge to be delivered to the new facility. SSD #250 revealed she was unaware whether the facility had successfully completed a trial to see if the resident could be off the oxygen at rest and during ambulation. SSD #250 revealed they typically just have the oxygen delivered to the location the resident would discharge to but was unable to explain the reasoning of taking resident off oxygen during transport. Interview on 01/29/24 at 3:54 P.M. with Unit Manager #260, the Director of Nursing (DON), and 365410 Page 4 of 5 365410 01/31/2024 Mayfair Village Nursing Care C 3000 Bethel Rd Columbus, OH 43230

F 0695 Level of Harm - Minimal harm or potential for actual harm Assistant Director of Nursing (ADON) #275 confirmed Resident #82 was consistently on two liters of oxygen with a few entries on the medication administration report for 10/2023 and 11/2023 that resident was on room air. The DON confirmed if a resident was on oxygen in the facility, he should have been on oxygen at discharge including during transport. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00149804. 365410 Page 5 of 5