Health inspection·February 22, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on medical record review, review of Controlled Drug Administration Records, staff interview, and facility policy review, the facility failed to ensure the administration of controlled substances was accurately documented in the medical record. This affected two (Residents #36 and #80) out of six residents reviewed for unnecessary medications. The facility census was 81. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 08/30/17 with diagnoses including schizoaffective disorder, diabetes mellitus, bipolar disease, Chronic Obstructive Pulmonary Disease (COPD), mild cognitive impairment, generalized anxiety disorder, and chronic systolic heart failure. Review of Resident #36's physician order, dated 06/01/23, for Oxycodone (narcotic pain medication used to treat moderate to severe pain) five milligrams (mg) one capsule by mouth every eight hours as needed for pain. The order had no parameters for administration. Review of Resident #36's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/08/24, revealed Resident #36 had intact cognition. Review of Resident #36's plan of care, dated 02/19/24, revealed Resident #36 was at risk for pain due to diagnoses. Resident #36 had chronic pain to the left shoulder and back, and wore a daily pain patch. Interventions included administering medications as ordered, notifying the physician of unrelieved or worsening pain, observing and reporting changes in usual routine, observing for side effects of pain medication, offering non-pharmacological interventions, and reporting to the nurse any changes in usual activity. Review of Resident #36's Medication Administration Record (MAR) for February 2024 revealed Resident #36 received Oxycodone five mg one time on 02/02/24, 02/03/24, 02/04/24, 02/05/24, 02/08/24, 02/09/24, 02/12/24, 02/13/24, 02/16/24, 02/17/24, 02/18/24, and 02/19/24. Review of Resident #36's Controlled Drug Administration Record for February 2024 revealed the record did not match Resident #36's MAR. The record revealed one dose of Oxycodone was administered on 02/10/24, two doses on 02/13/24, and two doses on 02/17/24. Interview on 02/20/24 at 2:10 P.M. and 3:03 P.M. with Regional Nurse #260 verified Resident #36's narcotic sheets did not match the MAR and they should match. She indicated she believed it was a documentation error on Resident #36's MAR. Page 1 of 2 365754 365754 02/22/2024 Majestic Care of Columbus LLC 44 S Souder Ave Columbus, OH 43222

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record for Resident #80 revealed an admission date of 07/11/23 with diagnoses including chronic heart failure, end stage renal disease, type two diabetes mellitus, severe protein-calorie malnutrition, depression, fibromyalgia, COPD, and Barrett's esophagus. Review of Resident #80's physician order, dated 07/14/23, revealed an order for Tramadol (narcotic pain medication used to treat moderate to severe pain) 50 mg one tablet by mouth every eight hours as needed for pain. Review of Resident #80's quarterly MDS assessment, dated 01/10/24, revealed Resident #80 had intact cognition. Review of Resident #80's care plan, dated 02/14/24, revealed Resident #80 had occasional acute pain in the left ribs, back, and left arm. Interventions included administering medications as ordered, notifying the physician of unrelieved or worsening pain, observing and reporting changes in usual routine, observing for side effects of pain medications, and offering non-pharmacological interventions. Review of Resident #80's MAR for February 2024 revealed Resident #80 received Tramadol once on 02/01/24, 02/02/24, 02/03/24, 02/04/24, 02/05/24, 02/06/24, 02/08/24, 02/09/24, 02/11/24, 02/12/24, 02/13/24, 02/14/24, 02/15/24, and 02/17/24. Resident #80 received Tramadol twice on 02/10/24, 02/18/24, and 02/19/24. Review of Resident #80's Controlled Drug Administration Record for February 2024 revealed the record did not match Resident #80's MAR. The record revealed two doses of Tramadol were administered on 02/09/24, 02/11/24, 02/12/24, 02/13/24, and 02/14/24. Interview on 02/20/24 at 2:10 P.M. and 3:03 P.M. with Regional Nurse #260 verified Resident #80's Controlled Drug Administration Record did not match Resident #80's MAR. She indicated she believed it was a documentation error on Resident #80's MAR. Review of the policy titled Pain Management, dated October 2018, revealed documentation of administration of ordered as needed pain medication was to be initialed on the MAR. This deficiency represents non-compliance investigated under Master Complaint Number OH00151047. 365754 Page 2 of 2