Health inspection·March 27, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observations, resident and staff interviews, review of the facility census, review of a facility list and policy review, the facility failed to ensure air temperatures were maintained at a comfortable and safe range in the first-floor common area and first-floor dining room. Additionally, the facility failed to ensure the third-floor shower room and shower chair were maintained in a clean manner. This affected six residents (#19, #44, #45, #64, #69, and #76) who were utilizing the first-floor common area and dining area and had the potential to affect 34 residents (#46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78 and #79) who used the third-floor shower room out of 79 residents who resided in the facility. The facility census was 79. Findings include: 1. Observation of the first-floor common area on 04/18/24 at 8:50 A.M. revealed Administrative Assistant (AA) #50 was sitting at the front desk wrapped in a blanket and the area felt cold. Residents #19, #44, #64, #69, and #76 were observed in the first-floor common area that was located across from the front desk. Observation of Resident #69 on 04/18/24 at 8:50 A.M. revealed Resident #69 was walking around the first-floor common area. Resident #69 was wearing a coat and pants. Interview with Resident #69 on 04/18/24 at 8:50 A.M. revealed Resident #69 felt the air temperature was cold in the first-floor common area and dining area. Observation of Resident #76 on 04/18/24 at 8:50 A.M. revealed Resident #76 was walking around the first-floor common area. Resident #76 was wearing a coat and pants. Interview with Resident #76 on 04/18/24 at 8:50 A.M. revealed Resident #76 felt the air temperature was cold in the first-floor common area and dining area. Observation of Resident #64 on 04/18/24 at 8:54 A.M. revealed Resident #64 was sitting in his wheelchair in the first-floor common area. Resident #64 was wearing an orange and white stripped t-shirt with short sleeves and pants. Attempted to interview Resident #64 on 04/18/24 at 8:54 A.M. but Resident #64 was not interviewable due to cognition. Page 1 of 5 365754 365754 03/27/2024 Majestic Care of Columbus LLC 44 S Souder Ave Columbus, OH 43222

F 0584 Level of Harm - Minimal harm or potential for actual harm Observation of Resident #19 on 04/18/24 at 8:55 A.M. revealed Resident #19 was sitting in his wheelchair in the common area wearing a jacket and pants. Interview with Resident #19 on 04/18/24 at 8:55 A.M. revealed Resident #19 felt the air temperature was cold in the first-floor common area. Residents Affected - Some Observation of Resident #44 on 04/18/24 at 8:56 A.M. revealed Resident #44 was sitting a chair in the first-floor common area with her walker in front of her. Resident #44 was covered with a fleece blanket and had on a jacket, pants and a black head band that covered her ears. Interview with Resident #44 on 04/18/24 at 8:56 A.M. revealed it was cold in the first-floor common area. Interview with AA #50 on 04/18/24 at 8:57 A.M. revealed the staff was wearing a blanket at the front desk because it was cold on the first-floor of the facility including the first-floor common area and dining area. AA #50 confirmed Residents #19, #44, #64, #69, and #76 were utilizing the first-floor common area and that residents enjoyed sitting in that area. AA #50 stated the temperature on the first-floor thermostat was 59 degrees Fahrenheit (F) and she had messaged maintenance about the temperature, but the temperature remained cold. AA #50 stated she was not sure when the temperature was changed to 59 degrees F. Observation of Resident #45 on 04/18/24 at 8:50 A.M. revealed Resident #45 was sitting in his wheelchair in the first-floor dining room and was talking to a staff member in the kitchen. Resident #45 was wearing a short sleeve dress shirt and pants. Interview with Resident #45 on 04/18/24 at 8:58 A.M. revealed Resident #45 felt it was cold in the dining room. Interview with the Director of Nursing (DON) on 04/18/24 at 9:03 A.M. revealed she did not have a thermometer to check the air temperature in the facility and maintenance was not in the facility. Observation of Maintenance Staff #800 taking the air temperature of the first-floor common area and first-floor dining area on 04/18/24 at 10:00 A.M. revealed the air temperature was 49.8 degrees F in the common area on the first-floor and 59.8 degrees F in the first-floor dining room. Interview with Maintenance Staff #800 on 04/18/24 at 10:00 A.M. verified the air temperature was 49.8 degrees F in the common area on the first floor and 59.8 degrees F in the first-floor dining room. Maintenance Staff #800 stated he did not work at the facility but was called to assist with the air temperature from a sister facility. Interview with Maintenance Staff #800 on 04/18/24 at 10:00 A.M. revealed someone had turned the thermostat down low causing the low temperatures in the first-floor common area and first floor dining room. Maintenance Staff #800 stated he was not sure when the air temperatures started to lower in those areas. Interview with the DON on 04/18/24 at 11:09 A.M. revealed the facility could not find the maintenance logs due to the maintenance staff that worked at the facility not being present at the facility. Review of the facility policy titled Safe and Homelike Environment, dated February 2023 revealed 365754 Page 2 of 5 365754 03/27/2024 Majestic Care of Columbus LLC 44 S Souder Ave Columbus, OH 43222

F 0584 Level of Harm - Minimal harm or potential for actual harm the facility will maintain comfortable and safe temperature levels. The facility should strive to keep the temperature in common resident areas between 71- and 81-degrees F. 2. Interview with Resident #50 on 04/18/24 at 9:09 A.M. revealed the third-floor shower room and white shower bench chair were dirty. Residents Affected - Some Observation of the third-floor shower room on 04/18/24 at 9:36 A.M. with State Tested Nurse Aide (STNA) #44 revealed there was brown and black build up around the shower walls where the floor tile met the wall and there was an orange colored build up in the corners of the shower chair. Interview with STNA #44 on 04/18/24 at 9:36 A.M. verified there was brown and black build up around the shower walls where the floor tile met the wall and there was an orange colored build up in the corners of the shower chair. Review of the facility's census dated 04/18/24 revealed 34 (#46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, #77, #78 and #79) residents resided on the third-floor and used the third-floor shower room. Review of the facility's undated list of residents that used the facility's third-floor shower chair revealed Resident #50, #72, #75 and #79 used the third-floor shower chair. Review of the facility policy titled Safe and Homelike Environment, dated February 2023 revealed the facility will provide a safe, clean, comfortable, and homelike environment in accordance with resident rights. 365754 Page 3 of 5 365754 03/27/2024 Majestic Care of Columbus LLC 44 S Souder Ave Columbus, OH 43222

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure resident medications were held appropriately and were not administered. This affected one (Resident #10) out of three residents reviewed for medication administration. The facility census was 79. Findings include: Review of Resident #10's medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses which included absence epileptic syndrome not intractable without status epilepticus, mild cognitive impairment, heart failure, depression, hypertension, and long-term use of anticoagulants. Review of Resident #10's most recent Discharge Return Anticipated Minimum Data Set 3.0 assessment, dated 01/31/24, revealed Resident #10 received anticoagulant, antibiotic, antidepressant and diuretic medications. Review of Resident #10's Pre-Operative Instructions, dated 03/13/14, revealed the resident was having a urological procedure on 03/22/24 and should not eat or drink anything after midnight the night before surgery. Resident #10 should stop all aspirin products or anti inflammatory medications seven days prior to surgery and should not have Coumadin (anticoagulant medication) or Vitamin E seven days prior to surgery. Review of Resident #10's progress note, dated 03/19/24 at 6:05 P.M., revealed the surgery center provided pre-operative instructions to hold all medications and supplements for two days beginning on 03/20/24, with the exception of Lansoprazole (proton pump inhibitor), Sertraline (antidepressant), Melatonin (supplement) and Phenytoin (anticonvulsant). Additionally, Resident #10 was to bath with antibacterial soap on the morning of surgery. All pertinent parties were made aware. Review of Resident #10's Medication Administration Record for March 2024 revealed Resident #10 was administered the following medications which were supposed to be held prior to her urological procedure: Vitamin E (supplement) 800 milligram (mg) on 03/16/24, 03/17/24, 03/18/24 and 03/19/24 at 6:00 A.M., Amoxicillin (antibiotic) 500 mg on 03/21/24 at 9:00 A.M., Centrum (vitamin) adult tablet on 03/20/24 at 9:00 A.M., Lasix (diuretic) 40 mg on 03/20/24 at 9:00 A.M., Famotidine (H-2 blocker) 20 mg on 03/20/24 at 9:00 A.M., Miralax powder (laxative) 17 grams on 03/20/24 at 9:00 A.M., Saccharomycas Boulardil (probiotic) capsule 250 mg on 03/20/24 at 9:00 A.M., Senokot (laxative) extra strength 17.2 grams on 03/20/24 at 9:00 A.M., Zofran (anitiemetic) four mg on 03/21/22 at 10:00 A.M., Tylenol (analgesic) extra strength 500 mg, give 1000 mg on 03/20/24 at 9:00 A.M. and on 03/21/24 at 9:00 P.M., and Hydroxine Hcl (antihistamine) 10 mg on 03/21/22 at 9:00 A.M., 3:00 P.M. and 9:00 P.M. Interview with the Director of Nursing on 03/27/24 at 2:30 P.M. confirmed Resident #10's medications were not held according to the instructions provided to the facility prior to her bladder stimulator removal on 03/22/24. Review of the facility policy titled Administering Medications, last revised April 2019, revealed medications are administered in a safe and timely manner and as prescribed. Medications are administered in accordance with prescribers orders, including any required time frames. 365754 Page 4 of 5 365754 03/27/2024 Majestic Care of Columbus LLC 44 S Souder Ave Columbus, OH 43222

F 0755 This deficiency represents non-compliance investigated under Complaint Number OH00152246. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 365754 Page 5 of 5