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. (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 5 Event ID: 365410 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 01/31/2024 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)