Health inspection·August 31, 2021

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, the facility failed to apply a physician ordered palm guard device for Resident #55. This affected one resident (#55) of one resident reviewed for range of motion. The facility identified 22 residents with contractures. The facility census was 80. Findings include: Review of the medical record for Resident #55 revealed he was admitted on [DATE]. Diagnoses included a history cerebral infarction (stroke) and hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side. Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/06/21, revealed the resident had impaired cognition. The resident required supervision assistance for bed mobility, and limited assistance of one staff for dressing. Review of the physician orders, dated 10/14/19, revealed an order to apply a palm guard to the right hand in the afternoon as tolerated, remove for skin care and hygiene. The orders stated Resident #55 was to wear the palm guard for four to six hours daily. The palm guard was ordered to be cleaned in the laundry weekly, and as needed. The palm guard was to be applied from 2:00 P.M. through 8:00 P.M. each day. Review of the plan of care for Resident #55, dated 05/08/21, revealed the resident had altered health maintenance related to progressive physical and mental status: cardiovascular accident and right sided impairments. Interventions included to apply palm guard to the right hand daily for four to six hours. The plan of care, dated 04/30/21, revealed the resident may require assistance with activities of daily living and may be at risk for developing complications associated with decreased activities of daily living self-performance. Interventions include to apply the palm guard to the right hand for four to six hours daily, remove for skin care and hygiene. Review of Resident #55's Treatment Administration Record (TAR) from 08/01/21 to 08/23/21, revealed the nurse signatures signed off as having applied the right hand palm guard as ordered by the physician every day including 08/23/21. Observation and interview on 08/23/21 at 04:22 P.M. with Resident #55 revealed the resident sitting up in bed. The resident's right arm was hanging down his side with his right hand balled into a fist and resting near his right hip. The resident was not observed to be wearing the physician ordered palm guard on his right hand. Resident #55 shared that he has not been wearing the palm guard, the nurse does not put it on and he does not know where it was. Resident #55 shared that he could not remember the last time he wore the palm guard. Interview on 08/23/21 at 4:30 P.M. with Licensed Practical Nurse (LPN) #130 confirmed Resident #55 was not wearing the palm guard. The nurse confirmed she did sign off on the TAR as having put the palm guard on Resident #55 today (08/23/21) even though she did not actually apply the palm guard for Resident #55. LPN #130 further revealed she threw the old palm guard away because it was dirty and signed off by mistake. LPN #130 revealed the palm guard was ordered to keep resident's hand from contracting and prevent skin impairment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 2 of 13 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 365929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on review of the facility's policy, staff interview and record review, the facility failed to administer a physician ordered medication for Resident #12. This affected one (Resident #12) of six residents reviewed for physician ordered medications. The facility census was 80. Findings include: Review of Resident #12's medical record revealed the resident had a readmission date on 01/06/21. Diagnoses included hypothyroidism. Review of the significant change Minimum Data Set (MDS) 3.0 assessment, dated 05/24/21, revealed Resident #12 had severely impaired cognition. Review of the physician's orders, dated 01/06/21, revealed Resident #12 had an order for Levothyroxine Sodium (Synthroid) Tablet 25 micrograms (mcg.) orally daily for hypothyroidism. The resident did not have a routine physician order for the thyroid stimulating hormone (TSH) lab draw. Review of the Medication Administration Record (MAR) for March 2021 revealed Levothyroxine Sodium Tablet 25 mcg was scheduled for administration at 5:00 A.M. Resident #12 did not receive the medication on 03/02/21, 03/04/21, 03/05/21, 03/08/21, 03/09/21, 03/14/21 through 03/20/21 (seven days), 03/22/21 through 03/25/21 (four days), 03/28/21, 03/29/21, or 03/31/21. The medication was not shown as administered on 19 total days out of the month. Review of the MAR for April 2021 revealed Resident #12 did not receive the Levothyroxine Sodium medication on 04/04/21 through 04/09/21 (six days), 04/14/21, 04/15/21, 04/18/21 through 04/21/21 (four days), 04/28/21, and 04/30/21. The medication was not shown as administered on 14 total days out of the month. Review of the MAR for May 2021 revealed Resident #12 did not receive the Levothyroxine Sodium medication on 05/01/21 through 05/03/21 (three days), 05/06/21, 05/08/21 through 05/10/21 (three days), 05/13/21 through 05/17/21 (five days), 05/20/21, 05/23/21, 05/24/21, 05/27/21, 05/29/21, and 05/31/21. The medication was not shown as administered on 18 total days out of the month. Review of the MAR for June 2021 revealed Resident #12 did not receive the Levothyroxine Sodium medication on 06/04/21, 06/06/21 through 06/08/21 (three days), 06/10/21 through 06/16/21 (seven days), 06/22/21, 06/23/21, 06/25/21, 06/26/21, and 06/30/21. The medication was not shown as administered on 16 total days out of the month. Review of the MAR for July 2021 revealed Resident #12 did not receive the Levothyroxine Sodium medication on 07/01/21, 07/02/21, 07/04/21 through 07/06/21 (three days), 07/08/21 through 07/10/21 (three days), 07/14/21 through 07/16/21 (three days), 07/18/21, 07/19/21, 07/21/21 through 07/24/21 (four days), and 07/28/21 through 07/30/21 (three days). The medication was not shown as administered on 20 total days out of the month. Review of the MAR for August 2021 revealed Resident #12 did not receive the Levothyroxine Sodium medication on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 3 of 13 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 365929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235 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 0755 Level of Harm - Minimal harm or potential for actual harm 08/01/21, 08/02/21, 08/13/21, 08/17/21, 08/22/21, and 08/26/21. The medication was not shown as administered on five total days out of the month. Review of laboratory testing from August 2020 to current for Resident #12 revealed the resident received one lab test on 02/10/21 and the resident's TSH)= was within normal levels. Residents Affected - Few Interview on 08/24/21 at 3:05 P.M. with the Director of Nursing (DON) and the Regional Director of Clinical Services (RDOCS) confirmed the MARs from March to August showed Resident #12's Levothyroxine was not administered daily as ordered by the physician every month. The RDOCS stated it was probably a technical error because the medication was scheduled for 5:00 A.M. and the shift changes at 6:00 A.M. The nurse may not have been able to mark the medication as administered. The DON confirmed nurses were allowed one hour before (4:00 A.M) and one hour after (6:00 A.M.) the scheduled administration time to administer the medication. The DON confirmed she was not aware of any nurses who were not able to sign off on the MAR when medications were administered. Review of the facility's policy titled Medication Administration, dated 06/21/17, stated to return to the medication cart and document medication administration with initials on the Medication Administration Record (MAR) immediately after administering medication to the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 4 of 13 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 365929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's policy, observation, staff interview, and record review, the facility failed to ensure their medication error rate was less than five percent. There were 26 medications administered with four errors made, resulting in a medication error rate of 14.8%. This affected three residents (Residents #22, #33, and #44) of four residents reviewed for medication administration. The facility census was 80. Residents Affected - Few Findings include: Observation of medication administration on 08/25/21 and 08/26/21 for four residents (#19, #22, #33, and #44) by three nurses revealed 26 medications to be administered and four errors to be made, resulting in a medication error rate of 14.8%. 1. Review of the medical record for Resident #44 revealed the resident to be admitted to the facility on [DATE]. Diagnoses include diabetes, schizophrenia, bipolar and hypertension. Review of the physician orders, dated 11/11/20, revealed an order for insulin isophane and regular suspension pen injector (70-30) 100 unit per milliliter (ml) (long acting insulin), inject 14 units subcutaneously two times per day. The physician order, dated 06/09/21, revealed orders for Novolog solution 100 units per ml (short acting insulin), inject subcutaneously before meals for type two diabetes, per sliding scale: if 151-200 = two; 201-250 = four; 251-300 = six; 301-350 = eight; 351-400 = 10; and if blood sugar less than 60 or greater than 400 call the doctor. Observation of medication administration on 08/25/21 at 8:00 A.M. revealed Registered Nurse (RN) #141 assessed Resident #44's blood sugar to be 202. RN #141 prepared and administered 14 units of Novolog Solution 100 unit/ml. and four units of Isophane and regular suspension pen injector (70-30) to Resident #44. Interview on 08/25/21 at 9:48 A.M. with RN #141 confirmed she did reverse the short acting and long acting insulin medications and gave the wrong doses of insulin to Resident #44. LPN #141 then assessed Resident #44 and called the physician for orders. Review of the facility's policy titled Medication Administration; Insulin Administration, dated 06/21/17, revealed Insulin is a high risk drug and warrants additional precautions for the safe and effective administration and that is is important that the nurse is familiar with the type of insulin prescribed. Additionally, the nurse should verify insulin manufacturer's printed name of drug, pharmacy label, medication administration record and the chart order are the same drug name upon delivery and before administration. 2. Review of the medical record for Resident #33 revealed an admission date of 09/27/20. Diagnoses include congestive heart failure, chronic respiratory failure, and dementia. Review of the physician orders for Resident #33, dated 09/28/20, revealed an order for isosorbide (treats heart failure) 10 milligrams (mg.), aspirin (anti-inflammatory and blood thinner) 81 mg., Senna plus (laxative), Lasix (diuretic) 40 mg., and memantine (treats dementia) 10 mg. Observation on 08/25/21 at 8:40 A.M. of the medication administration for Resident #33 by RN #142 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 5 of 13 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 365929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few revealed the nurse pulled five pills out of the medication cart for Resident #33. The medications were isosorbide 10 mg., aspirin 81 mg., Senna plus, Lasix 40 mg., and memantine 10 mg. The nurse opened the single dose medication packs, put the pills into the medication cup, then threw the medication packs into the trash. The nurse verified there were four pills in the cup. The nurse poured a cup of water, entered Resident #33's room with the medicine cup and the water and explained to the resident she was going to administer medication. During an interview with RN #142 immediately following her entrance into Resident #33's room and prior to her administering the medications to Resident #33, the nurse was asked to count the pills in the cup again. The nurse, again, verified there were only four pills in the cup. The nurse then verified the orders from the Medication Administration Record (MAR) and confirmed there should have been five pills in the cup and one of the ordered medications was missing from the cup. The nurse checked the trash and found the unopened package of memantine 10 mg. in the trash. The nurse pulled a new package of memantine from the medication cart, added it to the medicine cup with the other four pills and administered the medication to Resident #33. Further interview with RN #142 confirmed she would not have given the physician prescribed memantine to Resident #33 because she inadvertently threw it in the trash. 3. Review of the medical record for Resident #22 revealed an admission date of 12/04/20. Diagnoses include dementia, seizures, hyperlipidemia, and osteoarthritis. Review of the physician orders dated 04/24/21 revealed orders to administer Ferrous Sulfate 325 mg. (containing 65 mg. of iron). Observation on 08/26/21 at 8:37 AM of the medication administration for Resident #22 by RN #151 revealed the nurse to administer ferrous gluconate 324 mg. (containing 38 mg. of iron) to Resident #22. Subsequent interview with RN #151 confirmed the medication and dose administered to Resident #22 was not the same medication and dose ordered by the physician. The nurse further confirmed ferrous gluconate 324 mg. is the only iron supplement available in the medication cart and this was what was used for residents who were ordered ferrous sulfate 325 mg, Review of the facility's policy titled Medication Administration, dated 06/21/17, revealed the facility nurse should read the medication label comparing to the medication administration record, prior to administering the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 6 of 13 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 365929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure residents were free from significant medication errors when one resident (#44) was administered the wrong doses of insulin. This affected one resident (#44) of four residents observed for medication administration. Residents Affected - Few Findings include: Review of the medical record for Resident #44 revealed the resident to be admitted to the facility on [DATE]. Diagnoses include diabetes, schizophrenia, bipolar and hypertension. Review of the physician orders, dated 11/11/20, revealed an order for insulin isophane and regular suspension pen injector (70-30) 100 unit per milliliter (ml) (long acting insulin), inject 14 units subcutaneously two times per day. The physician order, dated 06/09/21, revealed orders for Novolog solution 100 units per ml (short acting insulin), inject subcutaneously before meals for type two diabetes, per sliding scale: if 151-200 = two; 201-250 = four; 251-300 = six; 301-350 = eight; 351-400 = 10; and if blood sugar less than 60 or greater than 400 call the doctor. Observation of medication administration on 08/25/21 at 8:00 A.M. revealed Registered Nurse (RN) #141 assessed Resident #44's blood sugar to be 202. RN #141 prepared and administered 14 units of Novolog Solution 100 unit/ml. and four units of Isophane and regular suspension pen injector (70-30) to Resident #44. Interview on 08/25/21 at 9:48 A.M. with RN #141 confirmed she did reverse the short acting and long acting insulin medications and gave the wrong doses of insulin to Resident #44. LPN #141 then assessed Resident #44 and called the physician for orders. Review of the facility's policy titled Medication Administration; Insulin Administration, dated 06/21/17, revealed Insulin is a high risk drug and warrants additional precautions for the safe and effective administration and that is is important that the nurse is familiar with the type of insulin prescribed. Additionally, the nurse should verify insulin manufacturer's printed name of drug, pharmacy label, medication administration record and the chart order are the same drug name upon delivery and before administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 7 of 13 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 365929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of resident diets, review of dietary spreadsheets, observation, and staff interview, the facility failed to follow the dietary spreadsheet for residents on a pureed diet. This affected four (Residents #1, #7, #40, and #47) of four residents who were prescribed a pureed diet. The facility census was 80. Findings Include: Review of the Diet Type Report, dated 08/23/21, revealed Residents #1, #7, #40, and #47 were prescribed a pureed diet. Review of the dietary spreadsheet for the lunch meal on 08/25/21 revealed residents on a pureed diet were to receive eight ounces of pureed tortilla casserole, one pureed corn shape, six ounces of tomato juice, two ounces of pureed cornmeal muffin, 2.67 ounce of pureed snickerdoodle cookie, four ounces of milk, eight ounces of water, one packet of margarine, and two tablespoons of sour cream. Observation on 08/25/21 from 12:00 P.M. to 12:45 P.M. of preparation for the lunch meal showed the kitchen staff provided two ounces of salsa in small plastic container cups with lids on every resident's lunch tray. None of the plastic cups contained tomato juice as indicated on the dietary spreadsheet for those residents who received a pureed diet. Interview with the Regional Dietitian (RD) #203 on 08/25/21 at 12:45 P.M. confirmed the kitchen staff had not provided tomato juice instead of salsa to the residents who were on a pureed diet. The RD verified the two ounces of salsa was not equivalent to the six ounces of tomato juice on the spreadsheet. RD #203 stated, we will get that corrected right away. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 8 of 13 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 365929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, staff interviews, and facility policy review, the facility failed to ensure food was prepared and served in a sanitary manner. This had the potential to affect all 80 residents who received food from the kitchen. Findings Include: 1. Observation of dining in the locked dementia unit on 08/23/21 at 12:27 P.M. during the lunch meal revealed Activities Aide (AA) #101 washed her hands at the sink and donned clean gloves. AA #101 was observed touching the handle of the serving cart with her gloved hands to wheel the resident's food around to the tables and serve the residents. AA #101 was observed serving ravioli to each resident and then reached into a plastic bag of dinner rolls and removed one roll for each resident and placed it on each resident's place without changing her gloves or washing her hands after touching the serving cart. There were 16 residents eating in the dining room and each was served a roll. After serving all the residents, AA #101 removed her gloves and washed her hands at the sink. Interview on 08/23/21 at 1:05 P.M. with AA #101 confirmed she had touched the handle of the serving cart with her gloved hands, then proceeded to touch each resident's dinner roll without changing her gloves or washing her hands. AA #101 stated the meal was a lunch bunch activity and was not the planned meal for the other units. AA #101 stated she did not usually serve meals to the residents except for once a month when the residents were prepared a special meal. 2. Observation of the kitchen staff during preparation, plating, and serving the lunch meal on 08/24/21 from 12:00 P.M. to 12:45 P.M. revealed [NAME] #105 making a hamburger as requested by a resident on the meal ticket. The cook had gloves on. [NAME] #105 touched the outside of the plastic bag of hamburger buns with his gloved hands, opened the bag and reached in and grabbed one hamburger bun from the bag and placed it on a clean plate. The cook used his gloved hands to separate the bun. Then, [NAME] #105 used a pair of tongs to remove a hamburger patty from the steam table and placed it on the hamburger bun. Next, [NAME] #105 grabbed a metal bin which held pre-cut lettuce, tomato slices, and onion slices. The cook removed the plastic wrap from the bin and, with the same gloves on, grabbed a lettuce leaf, a slice of tomato, and a slice of onion from the bin and placed them each on top of the hamburger patty on the hamburger bun. The Dietary Supervisor (DS) #500 intervened at this time and instructed [NAME] #105 to remove his gloves, wash his hands at the sink, and don new clean gloves. [NAME] #105 followed the instructions. At 12:25 P.M., [NAME] #105 was observed making a grilled cheese sandwich for a resident as requested on the meal ticket. With gloved hands, [NAME] #105 grabbed a plastic bag with pre-made cheese sandwiches in it and opened the bag to remove a sandwich. The cook touched the knob on the front of the stove to turn the burner on. The cook used clean tongs to remove the sandwich, place it in the pan to cook, and remove it from the pan. Then, [NAME] #105 turned off the burner using the same knob on the front of the stove, and placed it on a clean plate using the tongs. Next, without changing his gloves or washing his hands, the cook was observed touching a piece of tortilla casserole in order to place it on the plate from the serving spatula. Then, the cook returned to the stove, touched the knob again to turn the burner back on in order to make another grilled cheese sandwich. [NAME] #105 did not change his gloves or wash his hands at the sink. After touching the knob again with the same gloves on to turn the burner back off, the Regional Dietitian (RD) #203 intervened and instructed [NAME] #105 to remove his gloves and wash his hands at the sink again. [NAME] #105 followed the instructions and donned new, clean gloves at this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 9 of 13 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 365929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Interview with the DS #500 and RD #203 on 08/24/21 at 12:45 P.M. confirmed observations of [NAME] #105 touching several different items in the kitchen, as described above, and did not complete any hand hygiene or change his gloves until the DS and RD intervened and instructed [NAME] #105 to remove his gloves and wash his hands. Review of the facility's policy titled Infection Control-Dietary/Food Handling, revised 02/2016, revealed food handlers much wash their hands: before handling any food or food contact surface; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks; and/or after engaging in other activities that contaminate the hands. Before putting on gloves, when beginning a new task when working with food and not needed during the same task of changing the gloves. Food handlers must change single-use gloves as follows: as soon as they become soiled or torn, before beginning a different task, at least every four hours during continual use without any break in task, after handling raw meat, seafood, or poultry, and before handling ready-to-eat-food. Event ID: Facility ID: 365929 If continuation sheet Page 10 of 13 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 365929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, review of the Center for Disease Control (CDC) guidelines and COVID-19 Nursing Home data, and facility policy review, the facility failed to follow infection control protocols when they did not maintain transmission-based precautions (TBP) for two residents (Residents #334 and #337), failed to use appropriate signs to inform visitors and staff of isolation precautions for one resident (Resident #39), and failed to ensure staff were wearing appropriate eye protection while administering medications. This affected four residents (#12, #39, #334, and #337) reviewed for infection control. The facility census was 80. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #334 revealed an admission date of 08/21/21 with diagnoses including malignant neoplasm of stomach and major depressive disorder. Review of the admission assessment and baseline care plan, dated 08/21/21, revealed the resident was on droplet precautions. Review of the physician's orders, dated August 2021, revealed an order for contact and droplet precautions for COVID-19 beginning on 08/23/21 and ending on 09/05/21. On 08/23/21 at 12:07 P.M. and 12:24 P.M., observation of Resident #334's room revealed two signs indicating the resident was on droplet and contact precautions. An additional sign titled Sequence for putting on Personal Protective Equipment (PPE) was present identifying the proper method to don PPE. It indicated the appropriate PPE was a gown, mask or respirator, face shield or goggles, and gloves. Observation at that time revealed a visitor in Resident #334's room, and the only PPE he was wearing was a surgical mask. On 08/23/21 at 12:29 P.M., an interview with the Assistant Director of Nursing (ADON) #103 confirmed Resident #334's husband was visiting her and the only PPE he was wearing was a surgical mask. ADON #103 stated she was unsure of the visitor policy beyond screening them when they came in. She stated Resident #334 was only on transmission-based precautions because she was new and they had not been able to confirm she had received the COVID-19 vaccine. ADON #103 additionally stated the staff were wearing full PPE, like the sign indicated, when they entered the resident's room but she was unsure if this applied to visitors as well. On 08/25/21 at 9:20 A.M., an observation of Resident #334's room revealed her husband was once again visiting her, the only PPE he was wearing was a surgical mask. Observation at that time revealed the signs indicating TBP remained. At that time Social Services Designee #154 entered Resident #334's room wearing PPE as indicated on the sign. On 08/25/21 at 9:27 A.M., Social Services Designee #154 exited Resident #334's room. In an interview at that time, Social Services Designee #154 confirmed Resident #334's visitor had only been wearing a surgical mask. She stated she thought visitors in quarantine rooms needed to be wearing gowns as well and had asked him to put one on. On 08/25/21 at 2:47 P.M., an interview with the Director of Nursing (DON) revealed staff had attempted to educate Resident #334's husband on the PPE requirements but due to language barriers he did not seem to be understanding. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 11 of 13 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 365929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235 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 0880 Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #337 revealed an admission date of 08/24/21 with diagnoses including type two diabetes mellitus and chronic kidney disease stage four. Review of the admission assessment and baseline care plan, dated 08/24/21, revealed the resident was on droplet precautions and was alert and oriented. Residents Affected - Some Review of the physician's orders, dated August 2021, revealed an order for contact and droplet precautions for COVID-19 admission precautions from 08/24/21 to 09/07/21. Review of the nurse's progress note, dated 08/24/21, revealed the resident was placed on isolation droplet precautions due to not having the COVID-19 vaccine. On 08/24/21 at 2:07 P.M., an observation of Resident #337's room revealed signs indicating he was on droplet and contact precautions. An additional sign divided into two portions was present. The top half titled Donning (Putting on the gear) listed the procedure to put on PPE and included an isolation gown, respirator or facemask, face shield or goggles, and gloves. The second half of the sign indicated the procedure to doff PPE. Further observation at that time revealed a visitor exiting Resident #337's room in a surgical mask, the visitor spoke to Agency Registered Nurse (RN) #201 and returned to the room. Observation of Resident #337's room revealed an additional visitor, and the only PPE both visitors were wearing was a surgical mask. On 08/24/21 at 2:10 P.M., an interview with Agency RN #201 confirmed Resident #337 was under transmission based precautions and the visitors in his room were only wearing surgical masks. He stated he was agency and unsure of the policy for visitors. On 08/24/21 at 2:35 P.M., an interview with the Human Resource (HR) Director #118 and Office Personnel #140 revealed visitors should be wearing surgical masks in the facility. HR Director #118 was uncertain but believed visitors for quarantined rooms needed to be wearing gowns as well as surgical masks. Both staff members stated the nurses updated them on residents in quarantine or isolation. Office Personnel #140 stated she did not think anyone was on quarantine or isolation at the time and HR Director #118 agreed with her. Observations on 08/23/21, 08/24/21, and 08/25/21 revealed a sign to the right of the entrance of the facility next to the thermometer titled Welcome Back! Resident Visitation Status UPDATE the policy indicated visitors for quarantined residents should wear full PPE in residents' room that would be removed when exiting the room. Interview on 08/25/21 at 2:47 P.M. and 3:56 P.M. with the DON confirmed the sign was the only related policy they had. She stated full PPE meant what was required based on the signs on residents' doors. Review of the policy titled Standard and Transmission-based Precautions, dated 11/28/17, revealed the facility should apply Transmission-based precautions to residents who develop signs and symptoms of a transmissible infection or have a laboratory confirmed infection and are at risk for transmitting the infection to other residents. The policy stated the precautions should be maintained as long as necessary to prevent the transmission of infection. 3. Record review of Resident #39 revealed an admission date of 09/30/16 with diagnoses including type two diabetes mellitus and hypertension. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 12 of 13 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 365929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235 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 0880 Review of a physician order, dated 08/19/21, revealed the resident was in contact isolation until 08/26/21. Level of Harm - Minimal harm or potential for actual harm Observation on 08/23/21 at 10:15 A.M. revealed Resident #39 room had a plastic tub of personal protective equipment (PPE) outside the door. There was not a sign indicating to see nurse prior to entrance to the room or what kind of isolation precautions the Resident was on. Residents Affected - Some Interview with Licensed Practical Nurse (LPN) #132 on 08/23/21 at 10:20 A.M. verified Resident #39 is on contact precautions for shingles and there was not a sign telling staff or visitors to see nurse or what kind of isolation precautions to use. Review of the facility's policy infection control policy procedure manual, revised 11/28/17, revealed isolation signs are used to alert staff, family members, and visitors to speak with the nurse regarding isolation precautions. 4. Review of the medical record for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia and hypertension. Observation on 08/26/21 at 8:00 A.M. revealed Registered Nurse (RN) #151 standing at the medication cart, in the common room on the 400 unit, with her face shield resting on the top of her head. RN #151's face shield was not covering her eyes, nose or mouth. At the time of the observation, RN #151 confirmed she was not wearing her face shield correctly. Observation on 08/26/21 at 8:37 A.M. revealed RN #151 to have her face shield on the top of her head, again not covering her eyes, nose or mouth, while she administered medication to Resident #12. At the time of the observation, RN #151 confirmed she was not wearing the face shield properly while passing medication to Resident #12. RN #151 further revealed that she was hot with the face shield covering her face. Observation on 08/26/21 at 9:45 A.M. revealed RN #151 standing at the medication cart in the common area of the 400 unit with her face shield worn on the top of her head. RN #151 confirmed she was not wearing her face shield appropriately. Review of the COVID-19 Nursing Home data website (https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg) of the most recent county positivity rates revealed the facility's county percent positivity in prior fourteen days was coded the color red indicating substantial community transmission. Review of the Center for Disease Control (CDC) guidelines at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html., revealed Health Care Professionals (HCP) working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). They should also, wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 13 of 13