Inspection·December 12, 2024

F 0610 Level of Harm - Minimal harm or potential for actual harm Interview on 12/11/24 at 1:07 P.M. with the Administrator revealed Resident #94's statement was incorporated in the allegation with details in the SRI summary. A follow up interview at 1:30 P.M. confirmed facility had no written statements or signed statements of Resident #94's direct account of the allegation. The Administrator also did not agree that the investigation was incomplete, but acknowledged the investigation summary was a summary of the evidence, but not actual evidence itself. Residents Affected - Few 2. Review of the medical record for Resident #86 revealed an admission date of 12/01/22. Diagnoses included hemiparesis, cerebral infarction, diabetes, dysphagia, anemia, heart failure and schizoaffective disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was cognitively intact with a BIMS of 14 and was dependent with transfers and activities of daily living. Review of Resident #86's progress notes dated 11/26/24 revealed the resident reported another resident entered her room and groped her breast. The police were notified and a report was made. Review of the Self-Reported Incident (SRI) #254518 dated 11/26/24 revealed Resident #86 reported a male resident (Resident #46) entered her room and touched her inappropriately and the resident was also asked to reveal her breasts. An unnamed staff reported the allegation to the Administrator and an investigation was initiated. The summary revealed police were notified and interviews with like residents and staff were also completed. Resident #86 was interviewed by social service staff and revealed she had no recollection of the allegation and she denied interactions with Resident #46. Review of the SRI investigation file revealed along with the summary of the investigation, only a face sheet and care plan for Resident #86 was included. Upon request of further documentation, the facility provided facility education, standardized questionnaire interviews with like residents and identical typed statements from staff. Review of the six staff statements revealed the facility had identical statements dated 11/27/24 that stated, I am unaware of any incident or allegation involving inappropriate behavior or touching between Resident #46 and #86 or of any allegation involving appropriate behavior or touching between any resident. None of the staff statements recalled events of the shift in questions or interactions with Resident #46 or Resident #86 during the shift in question. Review of the signed statement from Resident #46 revealed he denied any knowledge of the issue or wrongdoing. Review of the additional information provided for the SRI investigation revealed the facility had no interviews or statements from Resident #86 with specific details of her allegation. The facility had only provided a three-question questionnaire with yes or no answers from Resident #86. The questions were Do you feel safe? and the resident answered yes; Has another resident ever entered your room without being invited, if yes did you report it and what happened? the resident answered no; and If someone enters your room or touches you without consent, do you know how to report it? and the resident answered that they would call the police. Interview on 12/11/24 at 1:07 P.M. with the Administrator revealed Resident #86's statement was incorporated in the allegation with details in the SRI summary. A follow up interview at 1:30 P.M. confirmed the facility had no written statements or signed statements of Resident #86's direct account of the allegation. He also stated they facility came to the conclusion that Resident #46 was involved due to the initial report from Resident #86, but when the resident was re-interviewed, she denied anything happened. The Administrator also did not agree that the investigation was incomplete, but acknowledged the investigation summary was a summary of the evidence, but not actual evidence itself. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365315 If continuation sheet Page 2 of 3 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 365315 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Capital City Gardens Rehabilitation and Nursing Ce 920 Thurber Drive West Columbus, OH 43215 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of the medical record for Resident #95 revealed an admission date of 11/05/24 and discharge date of 11/22/24. Diagnoses included cervical displacement, cutaneous abscess, endocarditis, opioid use, bacteremia, chronic hepatitis, and bipolar disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #95 was cognitively intact with a BIMS of 15 and was independent with transfers and mobility. Review of the Self-Reported Incident (SRI) #253938 dated 11/11/24 revealed Resident #95 reported she was missing a half-carat diamond earring, but there was no specific allegation that it was stolen or as misappropriated. The resident had endorsed she wrapped the earring in a napkin and may have thrown it away, but an investigation was initiated. The summary revealed interviews were conducted with like residents and staff. Review of the SRI investigation file revealed standardized questionnaire interviews with like residents. The facility provided no evidence of interviews or statements from Resident #95, who reported the allegation, and also failed to provide any evidence of staff statements. Interview on 12/11/24 at 1:07 P.M. with Administrator revealed Resident #95's statement was incorporated in the allegation with details in the SRI summary. A follow up interview at 1:30 P.M. confirmed the facility had no written or signed statements of Resident #95's direct account of the allegation, nor any staff statements related to the investigation of missing items. The Administrator also did not agree that the investigation was incomplete, but acknowledged the investigation summary was a summary of the evidence, but not actual evidence itself. Interview on 12/12/24 at 8:18 A.M. with Regional Clinical Nurse #100 revealed the facility corporate office used universal statements. She acknowledged facility investigations should be complete and thorough and verified the investigation files were not complete and documents had to be located from various sources at the facility, and several items remained unaccounted for including staff statements and resident statements. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 10/27/17, revealed it was the facility's policy to investigate all alleged violations involving Abuse, Neglect, and Misappropriation. It stated the facility staff shall immediately report all such allegations to administration/designee. The policy revealed the allegation shall be investigated and the investigation shall include interviews with the accused and all witnesses. A statement shall be obtained from the resident(s) involved, the accused, and each witness. The policy further stated the evidence of the investigation should be documented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365315 If continuation sheet Page 3 of 3