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 (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 4 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 08/05/2024 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)