Inspection·September 23, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 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 interview and record review, the facility failed to thoroughly assess a resident after a fall and timely notify the physician. This affected one resident (#3) of three residents reviewed for falls. The facility census was 80.Findings include: Review of Resident #3's medical record revealed an admission date of 07/10/25 with diagnoses including cognitive communication deficit, dementia, depression, anxiety and fracture of left femur on 08/21/25.Review of Resident #3's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had severely impaired cognition. Since the previous assessment Resident #3 had two falls or more without injury, two falls or more with injury, and one fall with major injury.Review of Resident #3's plan of care dated 07/11/25 revealed the resident was at risk for falls related to impaired balance and lack of safety awareness due to cognitive deficit related to dementia. Interventions included assisting out of bed before meals, assisting with toileting before bedtime, dycem to wheelchair, clearing a pathway in his room, fall mat, low bed, medication review, offering snacks when restless, offering toileting in advance of needs, toileting before laying down after meals, and visual reminder to call before you falls.Review of Resident #3's progress note dated 08/16/25 at 3:00 A.M. revealed staff heard yelling coming from the residents room. The residents roommate was calling for help after the resident fell. Resident #3 was found on the floor lying on his back next to his bed. He was unable to voice what happened. A head-to-toe assessment was completed and no visible injuries were noted. However, the resident was unable to stand and complained of left hip pain. Staff assisted the resident back in bed, groomed him and put him in his wheelchair. He was given as needed pain medication at that time.Review of Resident #3's fall investigation dated 08/16/25 revealed no evidence his range of motion was not assessed and the physician was not notified until 8:00 A.M.Interview on 09/22/25 at 11:10 A.M. with the Director of Nursing (DON) verified that range of motion was not assessed after his fall and should have been.Interview on 09/22/25 at 1:04 P.M. with Certified Nurse Practitioner (CNP) #270 verified they were not timely notified of the fall. The physician was notified of the fall at 7:45 A.M. and they should have been notified at the time of the fall so they could address any concerns at that time.This deficiency represents noncompliance investigated under Complaint Numbers 2593023 and 2584976 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 09/23/2025 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and policy review, the facility failed to ensure Resident #3's pain was timely and appropriately addressed. This affected one resident (#3) of four residents reviewed for falls. The facility census was 80.Findings include: Review of Resident #3's medical record revealed an admission date of 07/10/25 with diagnoses including cognitive communication deficit, dementia, depression, anxiety and fracture of left femur on 08/21/25.Review of Resident #3's comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he had severely impaired cognition. Since the previous assessment Resident #3 had two falls or more without injury, two falls or more with injury, and one fall with major injury.Review of Resident #3's physician order dated 07/10/25 revealed an order for Acetaminophen Tablet 325 milligrams (mg) two tablets by mouth every four hours as needed for a fever above 101 degrees Fahrenheit.Review of Resident #3's physician order dated 07/10/25 revealed an order for Acetaminophen Suppository 650 mg, one suppository insert rectally every four hours as needed for pain. Review of Resident #3's plan of care dated 07/11/25 revealed the resident was at risk for pain and discomfort related to cancer and history of fractures. Interventions included educating the resident and family regarding pain management, notifying the physician if interventions are unsuccessful, observing and reporting to the nurse resident complaints of pain or requests for pain treatment, observing for probable cause of pain, pain medications as ordered, and reporting to the nurse any changes in usual activity.Review of Resident #3's plan of care dated 07/11/25 revealed the resident was at risk for falls related to impaired balance and lack of safety awareness due to cognitive deficit related to dementia. Interventions included assisting out of bed before meals, assisting with toileting before bedtime, dycem to wheelchair, clearing a pathway in his room, fall mat, low bed, medication review, offering snacks when restless, offering toileting in advance of needs, toileting before laying down after meals, and visual reminder to call before you fall.Review of Resident #3's progress note dated 08/16/25 at 3:00 A.M. revealed staff heard yelling coming from the resident's room. The residents roommate was calling for help after the resident fell. Resident #3 was found on the floor lying on his back next to his bed. He was unable to voice what happened. A head-to-toe assessment was completed and no visible injuries were noted. However, the resident was unable to stand and complained of left hip pain. Staff assisted the resident back in bed, groomed him and put him in his wheelchair. He was given as needed pain medication at that time.Review of Resident #3's progress note dated 08/16/25 at 3:10 A.M. revealed the resident was given acetaminophen 325 mg for left hip pain.Review of Resident #3's progress note dated 08/16/25 at 8:06 A.M. revealed the certified nurse practitioner (CNP) was notified of the residents' left hip pain after a fall, and an x-ray was ordered.Review of Resident #3's progress note dated 08/16/25 at 5:24 P.M. revealed the nurse was aware of Resident #3's unwitnessed fall where he landed on his left thigh. The resident had been noted moaning and groaning during their shift. The nurse notified the physician and was given an order to transfer them to the hospital.Review of Resident #3's progress note dated 08/17/25 at 3:53 A.M. revealed the resident returned from the hospital and his x-ray results were negative for fracture.Review of Resident #3's hospital after visit summary dated 08/16/25 revealed his diagnosis was closed fracture of the left hip. Handwritten on this after visit summary was ‘no fx (fracture)'. In the hospital the resident had been given Fentanyl for pain.Review of Resident #3's CT exam of his pelvis revealed there was a previous fracture present, however, there was a new mildly displaced comminuted fracture along the lateral base of the left trochanter which extended to the anchoring stem of the unit.Review of Resident #3's CNP #270 note dated 08/18/25 revealed the resident reported left hip pain, he was sore, and it Residents Affected - Few (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 09/23/2025 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete hurt to move. Resident #3 had a fall on 08/16/25 and was sent to the emergency room for left hip pain with a negative x-ray. She recommended the facility continue fall precautions, nursing interventions, and neurochecks. His medications were reviewed, his current medications had no concern for polypharmacy to cause sedation or side effects leading to falls. In an addendum on 08/19/25 CNP #270 indicated the hospital notes had a CT scan which revealed a nondisplaced greater trochanter fracture. Orthopedics recommended nonsurgical management, weight bearing as tolerated with walker until pain free, limited abduction, and follow up in three weeks.Review of Resident #3's progress note dated 08/19/25 revealed the resident had pain with turning and completing activities of daily living. CNP #270 was notified and gave a verbal order for new pain medications.Review of Resident #3's physician order dated 08/19/25 to 09/08/25 revealed an order for oxycodone five mg one tablet by mouth every six hours as needed for pain.Review of Resident #3's Medication Administration Record from 08/16/25 to revealed Acetaminophen 325 mg was given on 08/16/25 for no fever, Acetaminophen 650 mg was given on 08/28/25 for an unknown pain. There was no pain medication given from 08/17/25 through 08/19/25. Oxycodone was given on 08/20/25 for a pain of four, five, four, and six. It was given on 08/23/25, 08/24/25, 08/25/25, and 08/30/25 for a pain of six, and on 08/26/25 and 08/27/25 for a pain of five. On 08/17/25 the resident had a pain of three and two, and on 08/19/25 the resident had a pain of three.Review of Resident #3's progress note dated 08/20/25 at 1:00 A.M. revealed the resident received oxycodone for pain in his left hip.Review of Resident #3's CNP #270 note dated 08/20/25 revealed the resident appeared uncomfortable and was unable to complete activities of daily living. She recommended they use the oxycodone sparingly and only as needed due to concerns for falls. Per nursing the resident had reported significant left hip pain and did not want to move too much.Interview on 09/22/25 at 12:22 P.M. with Certified Nursing Assistant (CNA) #207 revealed she could not recall the details but believed the resident may have reported pain once a little over a month ago.Interview on 09/22/25 at 1:04 P.M. with CNP #270 verified the facility had initially not noted the resident's fracture until MedOne employees (physician services) reviewed the hospital notes on 08/19/25 and noted the CT scan. She reported she had been concerned about using opioids due to his falls. She verified she had noted he was in pain on 08/18/25 and had expected the facility staff to use the Acetaminophen that had been ordered to control his pain. When the facility reported ongoing pain on 08/19/25 she went ahead and ordered the oxycodone, she was unaware the acetaminophen had not been used.Interview on 09/22/25 at 4:20 P.M. with the Director of Nursing (DON) verified that from 08/17/25 to 08/19/25 nursing did not attempt to give Resident #3 Acetaminophen despite his reports of pain. This included not providing pain medication on 08/19/25 after requesting stronger pain medication due to the residents pain.Review of the policy, ‘Pain Assessment and Management,' revised 04/22/25 revealed acute pain included pain that is usually sudden in onset and time limited with a duration of less than a month. It is often caused by injury, trauma, or medical treatments. It was the policy of the facility to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The facility was to identify and use specific strategies for preventing or minimizing different levels of sources of pain or pain-related symptoms based on the resident specific assessment, preferences and choices, pertinent clinical rationale, and the residents goals. Event ID: Facility ID: 365410 If continuation sheet Page 4 of 4