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. (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 2 Event ID: 365754 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 365754 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Columbus LLC 44 S Souder Ave Columbus, OH 43222 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)