Health inspection·September 11, 2025

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/10/25 at 9:50 A.M. with Manager of Clinical Services (MCS) #300 confirmed Resident #28 had two different wound treatment orders at the same time, for the right buttocks and the treatment order for Santyl should have been discontinued in July 2025 (when the Triad order was received). Interview on 09/10/25 at 1:25 P.M. with the Director of Nursing (DON) revealed that the current treatment order for Resident # 28's right buttocks was to cleanse with normal saline, pat dry, apply triad paste and cover with ABD pad every shift and every twenty-four hours as needed for soilage/dislodgement. The DON stated that the facility had not received any Santyl for Resident #28 for administration since July 2025. The order for Santyl was discontinued at time of discovery on 09/10/25. Interview on 09/11/25 at 1:36 P.M. with Licensed Practical Nurse (LPN) #139 confirmed she completed Resident # 28's right buttocks treatment on 08/18/25 as ordered to apply Santyl to the right buttocks one time a day on her shift. She stated that she checked the physicians' orders and treatment order in Point Click Care (PCC) prior to completing the treatment. LPN #139 also revealed that she found Santyl for Resident #28 in the wound treatment cart. Review of the Skin Assessment Policy dated 12/02/15, revealed residents with pressure injuries shall receive necessary treatment and services to promote healing, prevent infection and prevent new injuries from developing consistent with professional standards of practice, and licensed nurses collaborate with other members of the healthcare team to ensure necessary treatment and services are provided related to data collected for completion of skin assessments and documented per facility policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365195 If continuation sheet Page 2 of 6 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 365195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McNaughten Pointe Nursing and Rehab 1425 Yorkland Road Columbus, OH 43232 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of facility policy, the facility failed to complete a thorough investigation and root cause analysis regarding falls for Resident #59 and failed to ensure adequate supervision, a thorough investigation and root cause analysis were completed for Resident #92 who fell while on an unknown (to facility staff) leave of absence by himself. This affected two residents (#59 and #92) out of three residents reviewed for accidents. The facility census was 112.Findings include: 1. Review of the medical record revealed Resident #59 was admitted on [DATE] and re-entered on 03/18/25 with diagnoses including right heart failure, obstructive sleep apnea, dysphagia, gastrostomy status, personal history of sudden cardiac arrest, anemia, Down syndrome, restlessness and agitation, constipation, insomnia, hyperlipidemia, and gastro-esophageal reflux disease without esophagitis. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #59 was unable to complete the Brief Interview for Mental Status (BIMS) or mood interview, required extensive to total assistance for nearly all activities of daily living, and had experienced two or more falls since the prior assessment. Review of the care plan for revealed Resident #59 was considered a fall risk due to debilitation, weakness, medical conditions, incontinence, Down Syndrome, a history of falls, and poor safety awareness. The goal was to reduce the factors that increased the chance of falling. Interventions included keeping a chair alarm in place and checked each shift, encouraging and reminding the resident to ask for help, ensuring the call light was always within reach, and placing floor mats on both sides of the bed each shift. Staff were to keep frequently used items close by, install a left assist bar on the bed to support mobility, and provide a new wheelchair cushion for better positioning and comfort. The resident was to be supervised during times of restlessness, have a pressure-sensitive bed alarm checked each shift, and receive help from one or two staff members for all transfers. Additional measures included offering rest periods, helping the resident get up early if awake before the end of the night shift, and making therapy referrals as needed.Review of the medical record revealed that Resident #59 experienced multiple falls on 04/09/25, 04/11/25, 04/21/25, 05/24/25, 06/11/25, 06/21/25, and 06/23/25. Post-fall assessments revealed delayed or incomplete investigations. For the 05/24/25 fall, no post-fall investigation or root-cause analysis was documented beyond recording vital signs and completing a head-to-toe assessment. The 06/23/25 fall assessment noted the resident sitting on the floor and implemented only a new get-up list intervention without a root-cause analysis into the fall.Interview on 09/10/25 at 1:19 P.M. with the Director of Nursing confirmed that following the 05/24/25 fall, the only action taken was to move the resident closer to nurse traffic, and no additional investigation/analysis into the root cause of the falls were completed. 2. Review of the medical record revealed Resident #92 was admitted on [DATE], re-entered on 06/25/25, and discharged on 09/10/25 to a skilled facility. Diagnoses included cerebrovascular disease unspecified, other specified disorders of the brain with bilateral symmetrical gliosis, schizophrenia unspecified, and type two diabetes mellitus without complications. Resident #92 was his own responsible party. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition, a mood score of 10, no behaviors, independence with most transfers and ambulation, and shortness of breath with exertion. Review of the care plan for Resident #92 revealed that the resident was at risk for falls with the potential for injury related to incontinence and multiple medical conditions, including psychotropic medication use and bilateral cataracts. Interventions included encouraging the resident to ask for assistance, ensuring the call light was within reach, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365195 If continuation sheet Page 3 of 6 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 365195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McNaughten Pointe Nursing and Rehab 1425 Yorkland Road Columbus, OH 43232 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)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete maintaining a clutter-free environment, monitoring side effects of psychotropic medications, and providing non-skid socks and proper footwear. Review of the progress notes for Resident #92 revealed the following: on 08/09/25 at 7:30 A.M., a nurse was informed by another staff member that the local emergency room (ER) had called to report that the resident was in the emergency room due to a fall on the street. The nurse went to the resident's room to check on him, and the roommate reported that the resident had put on his hat and told the roommate he was going to the store without notifying staff of his leave of absence. The Nurse Practitioner, Utilization Manager, Director of Nursing, and the resident's brother were notified of the incident. Later that day, at 11:49 A.M., the nurse received notifications from hospital that the resident was in the emergency room for evaluation following the fall on the sidewalk while on the leave of absence. Hospital staff reported the resident was alert and oriented to person, place, time, and situation and upon arrival he denied pain and exhibited no distress. The resident's physician and family were notified, with no concerns voiced. On 08/11/25 at 12:14 P.M., this writer spoke with Station 23 regarding the resident's encounter on 08/09/25. A medic on the run reported that a bystander found the resident face down on the sidewalk on Yorkland Road and called 911. Upon arrival, the resident was alert and oriented times three, able to answer questions appropriately, and stated that he had left the facility intending to go to the store when he lost his balance and fell forward on the sidewalk. Emergency medical staff documented that the resident reported he was headed to the store when he lost his balance and fell forward. The resident was transported to the emergency room for evaluation. A skin assessment was completed upon return, and an elopement assessment with wander guard placement followed. Further review of the medical record revealed there was no documented evidence that the facility conducted a root cause analysis or identified and implemented additional interventions to prevent future falls/accidents for Resident #92 following the 08/09/25 lack of supervision incident. Interview on 09/10/25 at 3:39 P.M. with the Regional Director of Nursing (RDON) revealed the immediate intervention was a hospital transfer. The RDON confirmed there was no specific root-cause analysis or ongoing interventions related to the fall. The care plan was updated only to include education for the resident to sign out prior to leaving the facility. No therapy referral or post-fall interdisciplinary team note was completed. Interview on 09/10/25 at 4:45 P.M. with Resident #92 revealed he tripped outside. He stated that when he returned to the facility, staff told him to sign out before leaving and not to do that. He was observed sitting in a chair wearing non-slip shoes. Review of the facility policy titled Fall Management, originally dated 10/17/16, focused on reducing fall risks through interdisciplinary assessment and care planning, with prompt attention for residents who fell. The process emphasized notifying the charge nurse, assessing injuries, and conducting an interdisciplinary evaluation of health conditions, environment, equipment, medications, staff, or resident practices to determine the root cause. Based on this, the team implemented interventions or training to prevent recurrence, updated the care plan, and communicated new fall reduction strategies accordingly. Event ID: Facility ID: 365195 If continuation sheet Page 4 of 6 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 365195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McNaughten Pointe Nursing and Rehab 1425 Yorkland Road Columbus, OH 43232 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)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy, the facility failed to obtain cultures and sensitivities prior to administering antibiotics for multiple episodes of urinary tract infections (UTIs) for Resident #36. This affected one (Resident #36) of three residents reviewed for UTIs. The facility census was 112.Findings include:Review of the medical record for Resident #36 revealed an admission date of 08/27/19 with diagnoses that included morbid (severe) obesity due to excess calories, type two diabetes mellitus with diabetic neuropathy (unspecified), dysuria, and lower abdominal pain (unspecified).Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The resident required extensive assistance including wheelchair use, setup for eating and oral hygiene, total dependence for toileting, bathing, lower-extremity dressing, and putting on/off footwear; maximal assistance for upper-extremity dressing and bed mobility; moderate assistance for personal hygiene; and was dependent upon staff or not assessed for most transfers. The resident was always incontinent of urine and frequently incontinent of bowel and reported no UTI in the past 30 days.Review of physician orders for Resident #36 showed treatment for multiple UTIs (an infection in the urinary tract with signs and symptoms associated with pain, burning, and urgency among other symptoms), including Levaquin 750 milligrams (mg) orally once daily from 03/14/25 through 03/19/25, Nitrofurantoin 100 mg orally twice daily from 05/10/25 through 05/15/25, and Ciprofloxacin 250 mg orally twice daily from 08/12/25 through 08/16/25. Orders also included a one-time urine culture with reflex culture collected on 07/24/25 for dysuria and lower abdominal pain, Pyridium 100 mg orally from 07/25/25 through 07/27/25, and a follow-up urology appointment scheduled for 08/26/25.Review of the progress notes for Resident #36 revealed a health status note dated 03/13/25 at 8:07 P.M. that stated the resident's urinary analysis (UA) returned and the Certified Nurse Practitioner (CNP) ordered Levaquin 500 mg daily for five days. On 03/14/25 at 7:27 P.M., an infection note stated that the antibiotic (ATB), Levaquin oral tablet one time a day for UTI for five days, was initiated.Review of the UA for Resident #36 with a collection date of 03/13/25 and a reported date of 03/15/25 revealed several abnormalities suggestive of a possible UTI, including turbid clarity, positive leukocyte esterase, elevated white blood cells (>50/high power field), mildly elevated red blood cells (3-5/high power field), and the presence of few bacteria, alongside elevated squamous epithelial cells indicating potential contamination. Despite these findings, a reflex urine culture identified 10,000 to 50,000 colonies per milliliter (mL) of Gram-negative bacilli (three kinds), which the laboratory interpreted as suggestive of contamination rather than a true infection, with a note to contact microbiology for further workup if desired. However, no sensitivity testing was performed to identify a specific pathogen to guide antibiotic therapy.Review of the orders for Resident #36 revealed that on 07/24/25, a UA with reflex culture was ordered for dysuria and lower abdominal pain and was discontinued on 08/11/25. The resident was started on Pyridium (a urinary analgesic used to relieve pain, burning, urgency and other discomforts from urinary tract irritations) from 07/25/25 through 07/27/25.Review of the UA results dated 07/24/25 revealed the statement autocancel by system.Further review of the medical record revealed the 07/24/25 UA with reflex culture was not obtained and there was no further evidence that the resident did not have any signs or symptoms of a UTI after the completion of Pyridium (which decreases the signs and symptoms of a UTI).Review of the progress notes for Resident #36 revealed on 08/11/25 at 1:34 P.M., the resident requested to be taken to the hospital due to complaints of bladder incontinence. The CNP ordered that the resident be taken to the local hospital for examination. Upon return from the hospital, Resident #36 had an active UTI and was ordered Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365195 If continuation sheet Page 5 of 6 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 365195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/11/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE McNaughten Pointe Nursing and Rehab 1425 Yorkland Road Columbus, OH 43232 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)

F 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ciprofloxacin 250 mg orally twice daily from 08/12/25 through 08/16/25.Interview on 09/08/25 at 10:56 A.M. with Resident #36 revealed that the resident stated they had been experiencing a UTI for some time, starting in June 2025, and had been treated with multiple antibiotics. The resident stated that the facility would run a urinary analysis (UA) but expressed uncertainty as to why the UTI would not resolve.Interview on 09/09/25 at 4:12 P.M. with the Director of Nursing (DON) confirmed that for the March 2025 episode, no culture and sensitivity was completed, and the laboratory noted three or more isolates present, indicating possible contamination with no follow-up. Regarding the July 2025 episode, the UA order placed on 07/25/25 had an end date of 08/11/25; the DON stated the nurse practitioner may have intended to wait until 08/11/25 to complete the UA. The DON confirmed the resident had been started on Pyridium for bladder pain, which may have masked UTI symptoms, and the DON was unsure why follow-up testing was not completed.Interview on 09/10/25 at 10:22 A.M. with the Director of Nursing (DON) revealed that the laboratory reported autocancelled UAs either due to inability to obtain a specimen or cancellation by the laboratory, though the laboratory could not specify the reason. Regarding the July 2025 UTI, the DON stated that the nurse practitioner cancelled the UA because the resident had no symptoms after two days of Pyridium (started on 07/25/25 through 07/27/25); however, the UA order's cancel date was 08/11/25. The DON again confirmed that Pyridium could mask UTI signs and symptoms, and when the resident went to the hospital, a UTI was confirmed, and antibiotics were prescribed upon return.Interview on 09/11/25 at 11:27 A.M. with Manager of Clinical Services #300 revealed that all antibiotics administered were broad-spectrum, and no culture or sensitivity testing was obtained for any of the broad-spectrum antibiotic courses.Review of the facility policy titled Antibiotic Stewardship Program, dated 11/28/17 with a revision date of April 2025, revealed that McGeer criteria shall be used to define infections, but providers may consider Loeb minimum criteria when determining whether to treat an infection with antibiotics. Reassessment of empiric antibiotics is conducted for appropriateness and necessity, factoring in results of diagnostic tests, laboratory reports, and/or changes in the clinical status of the resident. Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized. Additionally, antibiotic orders obtained upon admission or readmission to the facility shall be reviewed for appropriateness, as well as those obtained from consulting, specialty, or emergency providers. Event ID: Facility ID: 365195 If continuation sheet Page 6 of 6