Health inspection·August 5, 2024

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and resident and staff interview, facility failed to ensure resident rooms were kept in a clean and sanitary manner for two (Residents #29 and #55) and the facility failed to ensure it maintained resident rooms in safe, homelike and well maintained condition for nine (Residents #5, #17, #20, #22, #29, #30, #41, #65, and #69) of 11 reviewed for environment. The total facility census was 75. Findings include 1. Review of the medical record for Resident #29 revealed an admission date of 07/16/20. Diagnoses included schizoaffective disorder bipolar type, anxiety, personality disorder, tremor, and anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #29 was cognitively intact with a BIMS of 15 and required set up and clean up assistance with toileting. Care plan dated 07/16/23 revealed resident had exhibited behavior symptoms of refusals of care including refusing to have room cleaned and became verbally aggressive when staff entered his room with interventions to explain to resident what your doing, before doing it, and give resident choices, maintain a safe environment for resident. Observation on 07/29/24 at 10:53 A.M. of Resident #29's room revealed a heavy stench of urine was present, the toilet had urine and toilet paper that had not been flushed, and the bathroom floor was sticky. Resident light in the toilet room did not work. Observation on 07/30/24 8:34 A.M. revealed Resident's room continued to have a strong stench of urine. The toilet had been flushed, and the toilet room floor remained sticky. Resident's bathroom light still did not work. Observation and interview on 07/31/24 at 4:20 P.M. with Resident #29 revealed he had told staff previously about the light being out and they had not fixed it. Observation and interview on 07/31/24 at 5:00 P.M. with Housekeeping Manager #305 confirmed Resident #29's bathroom light was out and also confirmed the bathroom floor was sticky from resident urinating on the floor. She revealed at times resident refused housekeeping services and when that happened the housekeeping staff would document refusals and also have the nurse sign acknowledging the refusals. Housekeeping Manager revealed staff should be sweeping and mopping the floors each day and they also do deep cleaning where the floors get waxed weekly. She revealed they had been told not to Page 1 of 4 365754 365754 08/05/2024 Majestic Care of Columbus LLC 44 S Souder Ave Columbus, OH 43222

F 0921 wax the bathroom floors as they should have been replaced over six months ago. Level of Harm - Minimal harm or potential for actual harm Review of housekeeping documentation revealed Resident #29 declined housekeeping on 07/02/24, 07/03/24, 07/18/24 and 07/25/24. The forms also mentioned the broken light on 07/05/24, 07/12/24 and 07/27/24 with no repairs being completed. Residents Affected - Some 2. Review of the medical record for Resident #55 revealed an admission date of 12/21/19. Diagnoses included neoplasm, hemiplegia and hemiparesis, peripheral vascular disease, chronic obstructive pulmonary disease, psychotic disorder with delusions and polyneuropathy, aortic aneurysm, vascular dementia, and delusion disorder. Revealed of wound assessments dated 07/29/24 revealed resident had right lower extremity wound with macerated tissue and a second wound of a skin tear. Review of progress notes dated 07/08/24 to 07/31/24 revealed no mention of resident having bleeding, bloody sheets or bloody flooring. Observation on 07/29/24 at 8:50 A.M. of Resident #55's room revealed a quarter size dried blood stain was on residents linens in an easily seen area. Resident also had an accumulation of blood drips in the size of about a hockey puck on the floor with a nickel size blood smear about six inches away from the larger drip. Observation and interview on 07/30/24 at 8:37 A.M. revealed Resident's room continued to have dried blood on the linens and on the floor by resident bed. These spots were easily visible if staff were to enter Resident's room. Resident revealed he did not know where the blood had come from or when it started but stated it had been there for at least a week on the linens and the floor. Resident revealed he would like his linens changed and floor cleaned up. Observation and interview on 07/31/24 at 4:29 P.M. with State Tested Nursing Aide #224 revealed she was unaware of blood on residents linens and floor. She observed the blood in plain site and asked resident if he was okay with staff cleaning it up which resident agreed to. Observation and interview on 07/31/24 at 5:00 P.M. with Housekeeping Manager #305 confirmed Resident #55 bloody floor and linens were just cleaned up. She revealed staff had not informed her of the blood and facility used a special chemical on bloody fluids. She revealed at times resident refused housekeeping services and when that happened the housekeeping staff would document refusals and also have the nurse sign acknowledging the refusals. Review of housekeeping documentation revealed Resident #55 did not decline housekeeping from 07/01/24 to 07/31/24. Resident declined a deep clean but was okay with the standard clean which included sweeping and mopping. 3. Review of the medical record for Resident #5 revealed an admission date of 08/13/16. Diagnoses included Alzheimer's disease, diabetes, bipolar disease, hemiplegia and hemiparesis, malnutrition, unspecified convulsions and contractions of the left hand and knee. Review of the medical record for Resident #20 revealed an admission date of 11/15/21. Diagnoses included schizoaffective disorder, chronic obstructive pulmonary disorder, traumatic brain injury, vascular dementia, Parkinson's and edema. Review of the medical record for Resident #22 revealed an admission date of 05/26/21. Diagnoses 365754 Page 2 of 4 365754 08/05/2024 Majestic Care of Columbus LLC 44 S Souder Ave Columbus, OH 43222

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some included schizoaffective disorder, chronic obstructive pulmonary disorder, Alzheimer's disease, diabetes, dementia, anxiety, and unspecified psychosis. Review of the medical record for Resident #41 revealed an admission date of 07/18/23. Diagnoses included cerebrovascular disease, heart disease, hypertension, ataxia, vascular dementia, epilepsy and toxic encephalopathy. Observation on 07/30/24 at 10:40 A.M. revealed Resident #5, #20, #22 and #41 shared a room and shared a sink in the common area of the room. The sink had a vanity/cabinet that was missing the drawer under the sink leaving an empty space in the vanity from the drawer missing and the wall between the sink and the room door had areas of missing drywall. Observation on 07/31/24 at 12:30 P.M. revealed the vanity drawer remained off and the wall continued to have missing areas of drywall. Observation and interview on 07/31/24 at 5:00 P.M. with Housekeeping Manager #305 confirmed the drawer was missing from the sink vanity and several areas of drywall were missing from the wall between the sink and the resident room door. She took photographs and revealed she would inform the Maintenance Director for repairs to be completed. 4. Review of the medical record for Resident #17 revealed an admission date of 04/22/21. Diagnoses included diabetes, epilepsy, schizophrenia, chronic obstructive pulmonary disease, vascular dementia, anxiety, hemiplegia and hemiparesis, and Alzheimer's disease. Review of the medical record for Resident #30 revealed an admission date of 08/16/22. Diagnoses included epilepsy, malnutrition, cirrhosis, heart failure, anxiety, hemiplegia, depression, chronic obstructive pulmonary disease, dementia, psychotic disorder, cerebral infarct and mild cognitive impairment. Review of the medical record for Resident #65 revealed an admission date of 09/09/21. Diagnoses included cerebral infarct, chronic obstructive pulmonary disease, depression, anxiety, psychotic disorder, epilepsy, vascular dementia and dysphasia. Review of the medical record for Resident #69 revealed an admission date of 08/03/22. Diagnoses included paranoid schizophrenia, hepatitis, Alzheimer's disease, dementia, and chronic obstructive pulmonary disease. Observation on 07/30/24 at 10:40 A.M. revealed Resident #17, #30, #65 and #69 shared a room and shared a sink in the common area of the room. Around the left side of the sink, the drywall was damaged where the sink connected to the wall. The sink was bracketed to the wall and did not have a base and the sink would move slightly if it was pressed on. The drywall was noted to be discolored. Observation on 07/31/24 at 12:30 P.M. revealed the drywall remained missing/damaged. Observation and interview on 07/31/24 at 5:00 P.M. with Housekeeping Manager #305 revealed housekeeping manager confirmed the drywall was damaged on the left side of the sink and also confirmed the sink moved slightly when pressed on. She took photographs to show the Maintenance team the damage. Review of facility policy titled, Safe and Homelike Environment, dated 01/02/24 revealed the 365754 Page 3 of 4 365754 08/05/2024 Majestic Care of Columbus LLC 44 S Souder Ave Columbus, OH 43222

F 0921 Level of Harm - Minimal harm or potential for actual harm facility would provide a safe, clean, comfortable and homelike environment, which included resident receiving care and services safely. This included adequate lighting and Maintenance Director would complete periodic rounds checking lights. The policy revealed housekeeping and maintenance services would be provided as necessary to maintain sanitation and a comfortable environment. Facility shall maintain bed linens that were clean and in good condition. Residents Affected - Some This deficiency represents non-compliance investigated under Complaint Number OH00155526. 365754 Page 4 of 4