Inspection·December 9, 2025

F 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few caregivers (Certified Nursing Assistant (CNA) #4 and Agency Nurse #687) during incontinence care on 11/17/25 at approximately 5:45 A.M. The facility placed both caregivers on administrative leave pending the investigation. A skin assessment was performed on 11/17/25 by Unit Manager #141 and Assistant Director of Nursing (ADON) #71 and revealed unmeasured black round marks on the back of Resident #55's bilateral hands and no fresh, bright red or maroon bruising were noted to the bilateral hands arms, or wrist. Additional assessments revealed Resident #55 denied pain or discomfort, nor did she express non-verbal pain indicators. The facility also contacted the local Police Department and filed a police report. Review of the preliminary police report #250847274, dated 11/17/25 revealed the residents responsible party noticed two male employees, and RN and an aide, at the residential home were her mother resided, changed her clothing and generally tended to her. It noted Resident #55 had a past trauma event involving males in general and also had dementia. Resident #55 was advising the two males to stop what they were doing and stated that they were hurting her. The resident's family believed this was assault and had the video saved from the incident. Review of Resident #55's video footage dated 11/17/25 at approximately 6:00 A.M. revealed two male caregivers (CNA #4 and Agency Nurse #687) providing incontinence care for Resident #55. Resident #55's bed was against the wall and the two male caregivers backs were facing the camera. The resident was addressed by name, was told by staff to hold their hand while they performed incontinence care. Resident #55 objected to incontinence care and yelled no multiple times. The two caregivers proceeded with incontinence care and the resident then yelled, you are breaking my hand. The video then showed a night gown was removed from the resident and placed on the top of the bed, then shortly after, a female staff (RN #95) arrived and she provided the remaining care to the resident while the two male caregivers left the room.Review of photos provided anonymously dated 11/18/25 revealed Resident #55 had black bruises to the back of the bilateral hands, bruises the front and back of the right wrist, a bruise to the right wrist, and a bruise to the right forearm. Resident #55's face was in the photos showing the back of the bilateral hands and arms. Review of Resident #55's skin assessment dated [DATE] revealed a skin tear to the right lower leg (from a previous unrelated injury) and no documentation of bruising to the resident's hands and arms. Review of the unsigned and undated witness statement filled out for CNA #4 by Assistant Director of Nursing (ADON) #71 revealed during evening report on 11/16/25, CNA #4 introduced himself to Resident #55's family and was handed clothes and told to change the resident. The resident did not object to being changed and allowed CNA #4 to provide incontinence care at midnight and 3:00 A.M. without issue. On the last round the resident said no and held a blanket to herself. CNA #4 contacted the supervisor, RN #95 and were told the supervisor would be down. RN #687 assisted the CNA with incontinence care by holding the resident's hands and RN #95 changed the residents shirt. Review of Agency Nurse #687's witness statement revealed the nurse observed CNA #4 provide incontinence care throughout the evening [indicating from 11/16/25 into 11/17/25] to Resident #55 without issue. At approximately 4:00 A.M. [on 11/17/25] the resident was noted to be soiled and had soaked through her depends and onto her nightgown. Resident #55 allowed CNA #4 to provide incontinence care but refused to allow her night gown to be changed. Further review revealed the nurse did not feel comfortable leaving the resident in soiled clothes due to the behavior the daughter exhibited the night before during shift change. While providing care to the resident, the resident refused care and a short break in care was performed to call the night shift supervisor. Afterwards the residents soiled night gown was removed from the resident and the night shift supervisor arrived and finished changing the resident. The witness statement did not specify the behavior that the residents daughter exhibited the night before. Interview on 12/03/25 at 10:51 A.M. with Unit Manager #141 confirmed when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365436 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 365436 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/09/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mother Angeline McCrory Manor 5199 East Broad Street Columbus, OH 43213 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 0742 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Resident #55 was admitted the family requested no male caregivers. The request was accommodated until the resident was moved from the fourth floor to the second floor and then the resident had a male caregiver again. The family was aware and didn't express concerns at that time. The resident was later moved to the third floor and continued receiving assistance from male caregivers without incident until 11/17/25. Observation on 12/03/25 at 12:23 P.M. of Resident #55 revealed a small red area with dark edges to the right forearm and slight discoloration to the back of the left hand but no bruising or dark marks to the back of the bilateral hands or wrist. Resident #55 was unable to provide any information regarding the 11/17/25 incident. During an interview on 12/04/25 at 9:35 A.M. with CNA #4 revealed they had no recollection of the 11/17/25 event with Resident #55 and could not recall giving a witness statement of the event. Interview on 12/04/25 at 11:09 A.M. with the Director of Nursing (DON) and review of the video from 11/17/25 at approximately 6:00 A.M. of Resident #55 receiving incontinence care, confirmed the presence of two male caregivers (CNA #4 and Agency RN #687), the resident refusing care and the care givers continuing to provide incontinence care by lifting a gown over the residents head, and the resident and yelling you are breaking my hand. The DON confirmed that resident care plans are to be followed and when Resident #55 told the caregivers no, they should have stopped and came back shortly after to continue providing care. Interview on 12/04/25 at 3:49 P.M. with the DON and review of Resident #55's photos provided confirmed they were dated 11/18/25 and confirmed the presence of dark areas on the back of the right hand, the back of the left hand, the right thumb, and the right forearm and confirmed the facility did not have supportive documentation showing the bruises were present during the 11/15/25 or 11/19/25 skin assessment. The facility suspected the dark area on the back of the right hand was from a lab draw performed on 11/07/25. The facility suspected the dark area on the back of the left hand was from a lab draw performed on 10/24/25. The facility suspected the dark area on the right thumb and the dark area to the right forearm were from a fall on 11/15/25. Review of facility policy, Dementia Care implemented 01/11/25 revealed care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity autonomy, privacy, socialization, independence, choice, and safety.This deficiency represents non-compliance investigated under Complaint Number 2676381. Event ID: Facility ID: 365436 If continuation sheet Page 3 of 3