Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation, and interview, the facility failed to protect the privacy of Resident #18 and
Resident #12's medical records. This affected two of twenty-two medical records reviewed for the annual
survey. The facility census was 90.
Residents Affected - Few
Findings include:
1. Resident #18 was admitted on [DATE] with diagnoses that included senile degeneration of brain, muscle
weakness, encephalopathy, bipolar disorder and schizophrenia.
Observation on 08/05/24 from 4:04 P.M. through 4:14 P.M. revealed Resident #18's electronic medical
record was open on the medication cart, which was unattended by the nurse on duty. The screen was
visible to passersby's and revealed Resident #18's medication schedule.
Interview with Registered Nurse (RN) Unit Care Coordinator #131 on 08/05/24 at 4:14 P.M. confirmed
Resident #18's electronic health record was unattended, open and easily viewable to any person who
passed by.
Interview with Licensed Practical Nurse (LPN) Unit Nurse #154 on 08/05/24 at 4:15 P.M. confirmed LPN
Unit Nurse #154 did not hide the electronic health record of Resident #18 for ten minutes when she left the
electronic health record unattended, in view of anyone who passed by.
2. Resident #12 was admitted on [DATE] with diagnoses that included cerebrovascular disease, dysphagia,
dysphasia, chronic obstructive pulmonary disease, adult failure to thrive and pressure ulcer.
Observation on 08/07/24 from 1:25 P.M. until 1:29 P.M. revealed Resident #12's electronic medical
treatment record was open to view on an unattended treatment cart. During that time period, four residents,
Maintenance Director #188, Floor Tech #191, and two visitors passed by the open electronic health record,
which was in plain view and unattended. On 08/07/24 at 1:29 P.M., the medical record, which was viewable
on a computer monitor, defaulted to a screen saver. On 08/07/24 at 1:32 P.M., Executive Director #219
lowered the screen of the computer monitor so that it was no longer easily viewable. On 08/07/24 at 1:32
P.M., the RN Assistant Director of Nursing #100 locked the electronic medical record.
Interview with LPN Unit Nurse #154 on 08/07/24 at 1:33 P.M. confirmed she had left the open, viewable
electronic medical treatment record for Resident #12 unattended while she performed his treatments.
(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 11
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
08/12/2024
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)
F 0583
Level of Harm - Minimal harm
or potential for actual harm
Review of policy titled, Safeguarding Electronic Health Information, revised 05/06/22 revealed all users
should be trained to log off their workstation every evening before leaving and when walking away from
their workstation. Laptop computers and electronic devices containing protected health information (PHI)
should not be left unattended.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365410
If continuation sheet
Page 2 of 11
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
08/12/2024
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)
F 0645
PASARR screening for Mental disorders or Intellectual Disabilities
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 and staff interview, the facility failed to ensure all resident Pre-admission Screening
and Resident Review (PASRR) documents were completed as required. This affected one (Resident #78) of
three residents reviewed for PASRR documents. The census was 90.
Residents Affected - Few
Findings Include:
Resident #78 was admitted to the facility on [DATE]. His diagnoses were moderate protein-calorie
malnutrition, hypotension, muscle weakness, mood disorder, dysphagia, catatonic disorder due to known
physiological condition, cognitive communication deficit, major depressive disorder, hyperlipidemia, altered
mental status, post traumatic stress disorder. anxiety disorder, hypertension, suicidal ideations, acute
kidney failure, hypothyroidism, and encephalopathy. Review of his Minimum Data Set (MDS) assessment
dated [DATE] revealed he was cognitively intact.
Review of Resident #78's PASRR document dated 03/28/24, revealed this was the first PASRR document
that was completed for him. He was admitted to the facility on [DATE], and he was not discharged from the
facility at any point. Also, the PASRR document that was completed on 03/28/24 was documented as being
for an expiring respite stay; which was not accurate.
Interview with Director of Nursing (DON) on 08/08/24 at 8:55 A.M. and 9:16 A.M. confirmed the PASRR
document provided was the only PASRR document for Resident #78. She confirmed Resident #78 had not
discharged from the facility or was in the facility for respite services at any point since admission.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365410
If continuation sheet
Page 3 of 11
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
08/12/2024
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident interview, medical record review and facility policy review, the facility failed to create a care plan
related to Post Traumatic Stress Disorder (PTSD) for residents. This affected one (Resident #7) of two
residents reviewed for care plans. The facility census was 90.
Findings include:
Resident #7 was admitted on [DATE] with diagnoses that included absence right below knee amputation,
cerebral palsy, muscle weakness, bipolar disorder, post-traumatic stress disorder, and homelessness.
Review of the Minimum Data Set (MDS) 3.0 assessment on 07/17/24 revealed the resident had a Brief
Interview for Mental Status (BIMS) score of 15, indicating intact cognitive status. She was assessed as
having a PTSD diagnosis.
Review of the medical record for Resident #7 revealed that she was assessed for trauma informed care on
03/13/24 and no events were listed or checked as being experienced by the resident. The events included
sexual assault, which was listed as not being experienced by Resident #7. Further review of the medical
record revealed that a trauma informed care plan was absent for identifying PTSD triggers for Resident #7,
and how to monitor for behaviors regarding Resident #7's past medical history of PTSD.
Review of the medical record progress notes from the Certified Nurse Practitioner on 03/14/24 and
07/11/24 listed an additional diagnosis of sexual assault.
Interview with Resident #7 on 08/08/24 at 11:19 A.M. revealed that she feels safe in the facility; however,
people entering her room is a trigger for her, and this is upsetting to her.
Interview with Licensed Practical Nurse (LPN) MDS Nurse #129 on 08/07/24 at 1:53 P.M. confirmed that
the social services assessment for trauma informed care on 03/13/24 does not include Resident #7's
history of sexual assault.
Interview with LPN MDS Nurse #129 on 08/07/24 at 3:27 P.M. confirmed there is no PTSD care plan that
identifies triggers, nor is there a trauma informed care plan for Resident #7.
Review of the facility policy for trauma informed care reviewed 08/22/23 revealed the facility will use a
multi-pronged approach to identifying a resident with PTSD or history of trauma. This approach would
include assessing the residents for indicators of trauma upon admission and with change in condition. This
assessment will include asking the resident about triggers that may be stressors or may prompt recall of a
previous traumatic event. The facility should collaborate with resident trauma survivors and as appropriate
the resident's family, friends, and any other health care professionals such as psychologists, mental health
professionals to develop and implement an individualized plan of care with interventions. In situations
where a trauma survivor is reluctant to share his or her history, the facility should still attempt to identify
triggers which may retraumatize the resident and develop care plan interventions which minimize or
eliminate the trigger on the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365410
If continuation sheet
Page 4 of 11
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
08/12/2024
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)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
Based on staff interview, record review, policy review, and resident interview, the facility failed to conduct
quarterly care conferences. This affected three (Residents #4, #40 and #65) of three residents reviewed for
care conferences. The facility census was 90.
Findings include:
1. Record review of Resident #4 revealed an admission date of 07/10/22 with pertinent diagnoses of:
Parkinson's disease, cognitive communication deficit, and hypertension.
Review of the 07/03/24 annual Minimum Data Set (MDS) assessment revealed the resident was cognitively
intact and used a wheelchair to aid in mobility and was always incontinent of bladder and frequently
incontinent of bowel.
Interview with Resident #4 on 08/05/24 at 2:50 P.M. revealed she is not invited to attend quarterly care
conferences to discuss her care in the facility.
Review of the medical record on 08/08/24 revealed within the last year an interdisciplinary care conference
was held on 03/05/24 where the resident and staff attended. There was no evidence that a care conference
was attended by an interdisciplinary team any other time during the year.
Interview with the Director of Nursing (DON) on 08/08/24 at 1:57 P.M. verified they only have evidence of
one quarterly interdisciplinary care conference for Resident #4 within the last year.
2. Record review of Resident #65 revealed an admission date of 08/26/22 with pertinent diagnoses of: type
one diabetes mellitus with ketoacidosis without coma, acquired absence of left leg below knee, difficulty in
walking, acute kidney failure, type one diabetes mellitus, acute respiratory failure, and opioid abuse.
Review of the 05/10/24 quarterly MDS revealed Resident #65 was cognitively intact. He used a limb
prosthesis and a cane. The resident required set up or clean up assistance for shower/bathing and was
independent for transfer and most ADLs.
Interview with Resident #65 on 08/05/24 at 9:53 A.M. revealed he is not invited to attend quarterly care
conferences to discuss his care in the facility.
Review of the medical record on 08/08/24 revealed within the last year an interdisciplinary care conference
was held on 05/07/24 where the resident and staff attended. There was no evidence that a care conference
was attended by an interdisciplinary team any other time during the year.
Interview with the Director of Nursing (DON) on 08/08/24 at 1:57 P.M. verified they only have evidence of
one quarterly interdisciplinary care conferences for Resident #65 within the last year.
3. Record review of Resident #40 revealed an admission date of 02/24/23 with pertinent diagnoses of:
acute and chronic respiratory failure, muscle weakness, dysphagia, history of falling, encephalopathy,
moderate protein calorie malnutrition, chronic obstructive pulmonary disease, urinary tract infection, and
hypertensive emergency.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365410
If continuation sheet
Page 5 of 11
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
08/12/2024
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)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the 05/03/24 quarterly MDS assessment revealed the resident is cognitively intact and uses a
wheelchair to aid in mobility and requires partial or moderate assistance for personal hygiene,
shower/bathe self, and putting on taking off footwear. The resident is always continent of bowel and bladder.
Interview with Resident #40 on 08/05/24 at 10:24 A.M. revealed he is not invited to attend quarterly care
conferences to discuss his care in the facility.
Review of the medical record on 08/08/24 revealed within the last year an interdisciplinary care conference
was held on 09/15/23 where the resident and staff attended. There was no evidence that a care conference
was attended by an interdisciplinary team any other time during the year.
Interview with the Director of Nursing (DON) on 08/08/24 at 1:57 P.M. verified they only have evidence of
one quarterly interdisciplinary care conferences for Resident #40 within the last year.
Review of the 08/22/23 facility policy titled, Comprehensive Care Plans and Conferences, revealed the
facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to
ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of
individuals who have knowledge of the resident and his/her needs, and that each resident and resident
representative, if applicable, is involved in developing the care plan and making decisions about his or her
care. A comprehensive care plan must be developed within seven days after completion of the
comprehensive assessment. Prepared by an interdisciplinary team, that includes but is not limited to: The
attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility
for the resident, a member of food and nutrition services staff. To the extent practicable, the participation of
the resident and the resident's representative. An explanation must be included in a resident's medical
record if the participation of the resident and their resident representative is determined not practicable for
the development of the resident's care plan. Other appropriate staff or professionals in disciplines as
determined by the resident's needs or as requested by the resident. Reviewed and revised by the
interdisciplinary team after each assessment, including both the comprehensive und quarterly review
assessments.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365410
If continuation sheet
Page 6 of 11
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
08/12/2024
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)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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, interviews, and observations, the facility failed to properly monitor and accurately
document skin abnormalities. This affected one (Resident #56) out of the one reviewed for skin conditions.
The facility census was 90.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #56 revealed he was admitted on [DATE] with diagnoses
including cirrhosis of the liver, chronic venous insufficiency, atrial fibrillation, and skin vasculitis.
Review of the Minimum Data Set (MDS) 3.0 assessment for Resident #56, completed on 07/22/24,
indicated that he was cognitively intact, at risk for developing pressure ulcers, and had been ordered a
pressure-relieving bed.
Review of the care plan for Resident #56 dated 06/22/24 revealed he is on anticoagulant therapy for atrial
fibrillation and is at risk for abnormal bleeding. Interventions included monitoring for and reporting adverse
reactions to anticoagulant therapy, such as blood-tinged urine, nausea, muscle or joint pain, and bruising.
Review of physician orders for Resident #56 dated 07/20/24 revealed instructions to monitor for signs and
symptoms of bleeding, including black tarry stools, bleeding gums, bruising, and nosebleeds related to
anticoagulant use.
Review of the Medication Administration Record (MAR) for Resident #56 between 08/01/24 and 08/07/24
showed that nursing staff had documented Resident #56 as having no signs or symptoms of adverse
reactions due to anticoagulant use specifically bruising. The MAR indicated that Resident #56 receives
Rivaroxaban Oral Tablet 20 milligrams once daily for atrial fibrillation.
Review of the Bedside [NAME] Report for Resident #56 dated 08/08/24 revealed instructions to observe for
and report PRN (as needed) adverse reactions to anticoagulant therapy, including blood-tinged or red
urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting,
diarrhea, muscle or joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite,
sudden changes in mental status, and significant changes in vital signs. The [NAME] required direct nursing
staff to observe for redness, open areas, scratches, cuts, and bruises and to report any changes to the
nurse.
Review of the admission collection tool dated 07/20/24 revealed Resident #56 had scattered bruising on his
bilateral arms, left leg, and a skin tear on his right upper arm.
Review of the Weekly Skin Integrity Data Collection dated 07/26/24 showed that the only skin concern for
Resident #56 was a skin tear on his right arm.
Review of the Weekly Skin Integrity Data Collection dated 08/02/24 revealed that Resident #56 had faded
bruises on his left arm and no open areas.
Review of daily skilled nursing notes from 08/04/24 to 08/07/24 revealed no concerns regarding
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365410
If continuation sheet
Page 7 of 11
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
08/12/2024
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)
F 0684
bruising or open skin areas.
Level of Harm - Minimal harm
or potential for actual harm
Observation on 08/05/24 at 11:09 A.M., Resident #56 had dark, scattered bilateral bruising of various sizes
on his anterior upper arms, and a large scratch approximately 5 inches long was found on his left elbow.
The bruises observed were all dark purple and not in various stages of healing. Resident #56 denied any
concerns about abuse and was unsure if he was on anticoagulant therapy.
Residents Affected - Few
Observation on 08/07/24 at 11:36 A.M., bruising on Resident #56's upper arms and the scratch on his
elbow remained.
Observation and interview on 08/08/24 at 11:27 A.M., Licensed Practical Nurse (LPN) #135 confirmed the
presence of dark, scattered bilateral upper arm bruising and scratch on his elbow remained.
An interview on 08/08/24 at 11:32 A.M. with LPN #135 confirmed Resident #56 had bilateral bruising. LPN
#135 stated the MAR indicated the resident did not have scattered bilateral bruising and denied seeing
documentation or routine monitoring of the bruising in the medical record.
Review of the Anticoagulant Management Policy dated 11/28/23 indicated that residents receiving
anticoagulants are at increased risk of bleeding and require additional monitoring to ensure medication
dosage and efficacy are managed for safe, resident-centered care. Staff are required to complete
anticoagulation management daily and document it on the Anticoagulation Meeting Form.
Review of the Basic Skin Management Policy dated 11/29/23 revealed that if any new skin alteration or
wound is identified, it is the nurse's responsibility to perform and document an assessment/observation,
obtain treatment orders, and notify the medical doctor and responsible party. Wound assessments are
required to be completed weekly.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365410
If continuation sheet
Page 8 of 11
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
08/12/2024
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)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, resident interview, staff interview, medical record review, and facility policy review, the facility
failed to maintain smoking products. This affected one (Resident #20) of one reviewed for smoking. The
facility census was 90.
Findings include:
Resident #20 was admitted on [DATE] with diagnoses that included quadriplegia, chronic obstructive
pulmonary disease, abnormal posture, neuromuscular dysfunction, panic disorder, chronic fatigue and
chronic pain disorder.
Review of the Minimum Data Set 3.0 (MDS 3.0) assessment on 05/24/24 revealed Resident #20 had a
Brief Interview for Mental Status (BIMS) of 15, revealing intact cognition, and confirmed that Resident #20
received oxygen therapy.
Review of current physician's orders revealed Resident #20 received oxygen at two liters per minute every
night shift.
Observation on 08/08/24 at 8:51 A.M. revealed Resident #20 had a lighter and a package of cigarettes
containing three cigarettes at his bedside. His oxygen was running at two liters per minute.
Interview with Registered Nurse (RN) Unit Nurse #119 on 08/08/24 at 8:51 A.M. confirmed Resident #20
had a lighter and a package of cigarettes containing three cigarettes at his bedside and that his oxygen was
running.
Observation on 08/08/24 at 8:55 A.M. revealed RN Unit Nurse #119 confiscated Resident #20's cigarettes
and lighter and gave them to Executive Director #219.
Interview with Executive Director #219 on 08/08/24 at 8:55 A.M. confirmed Resident #20 is not permitted to
store his lighter and cigarettes at his bedside.
Review of Oxygen Administration policy issued 12/03/18 and revised 02/27/24 revealed that oxygen must
be kept away from combustible materials, soaps, greases and flammable liquids.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365410
If continuation sheet
Page 9 of 11
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
08/12/2024
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)
F 0699
Provide care or services that was trauma informed and/or culturally competent.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident interview, medical record review and facility policy review, the facility did not effectively assess
residents for Post Traumatic Stress Disorder (PTSD). This affected one (Resident #7) of five residents
reviewed for trauma informed care. The facility census was 90.
Residents Affected - Few
Findings include:
Resident #7 was admitted on [DATE] with diagnoses that included absence right below knee amputation,
cerebral palsy, muscle weakness, bipolar disorder, post-traumatic stress disorder, and homelessness.
Review of the Minimum Data Set (MDS) 3.0 assessment on 07/17/24 revealed the resident had a Brief
Interview for Mental Status (BIMS) score of 15, indicating intact cognitive status. She was assessed as
having a PTSD diagnosis.
Review of the medical record for Resident #7 revealed that she was assessed for trauma informed care on
03/13/24 and no events were listed or checked as being experienced by the resident. The events included
sexual assault, which was listed as not being experienced by Resident #7. Further review of the medical
record revealed that a trauma informed care plan was absent for identifying PTSD triggers for Resident #7,
and how to monitor for behaviors regarding Resident #7's past medical history of PTSD.
Review of the medical record progress notes from the Certified Nurse Practitioner on 03/14/24 and
07/11/24 listed an additional diagnosis of sexual assault.
Interview with Resident #7 on 08/08/24 at 11:19 A.M. revealed that she feels safe in the facility; however,
people entering her room is a trigger for her, and this is upsetting to her.
Interview with Licensed Practical Nurse (LPN) MDS Nurse #129 on 08/07/24 at 1:53 P.M. confirmed the
social services assessment for trauma informed care on 03/13/24 does not include Resident #7's history of
sexual assault.
Review of the facility policy for trauma informed care issued reviewed 08/22/23 revealed the facility will use
a multi-pronged approach to identifying a resident with PTSD or history of trauma. This approach would
include assessing the residents for indicators of trauma upon admission and with change in condition. This
assessment will include asking the resident about triggers that may be stressors or may prompt recall of a
previous traumatic event. The facility should collaborate with resident trauma survivors and as appropriate
the resident's family, friends, and any other health care professionals such as psychologists, mental health
professionals to develop and implement an individualized plan of care with interventions. In situations
where a trauma survivor is reluctant to share his or her history, the facility should still attempt to identify
triggers which may retraumatize the resident and develop care plan interventions which minimize or
eliminate the trigger on the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365410
If continuation sheet
Page 10 of 11
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
08/12/2024
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)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation and staff interview, the facility failed to have a carbon monoxide detector in the
kitchen with a gas stove present. This had the potential to affect all 90 residents residing in the facility.
Residents Affected - Many
Findings Include:
Observation on 08/05/24 at 9:30 A.M. revealed in the facility main kitchen, there was a gas stove within the
kitchen area. There was no carbon monoxide detector in this area.
Interview with Food Service Director #195 on 08/05/24 at 9:32 A.M. confirmed they did not have a carbon
monoxide detector in the kitchen with a permanently installed fuel burning appliance (stove). She confirmed
there is a designated spot in place to have a carbon monoxide detector, but it was not in place. She
confirmed she did not know how long it had not been in place.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365410
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F699 - Trauma-informed care
Provide care or services that was trauma informed and/or culturally competent.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the August 12, 2024 survey of MAYFAIR VILLAGE NURSING CARE C?
This was a inspection survey of MAYFAIR VILLAGE NURSING CARE C on August 12, 2024. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at MAYFAIR VILLAGE NURSING CARE C on August 12, 2024?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Keep residents' personal and medical records private and confidential."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.