Health inspection·July 10, 2023

F 0677 This deficiency represents non-compliance investigated under Complaint Number OH00143835, Complaint Number OH00132743, and Complaint Number OH00132578. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 2 of 7 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 07/10/2023 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's investigation, staff interview, review of the coroner's report, and review of the facility's policies, the facility failed to provide a resident with adequate supervision to prevent an avoidable fall. This resulted in Actual Harm to Resident #86 when State Tested Nursing Aide (STNA) #130 stepped away from Resident #86 to obtain a blanket, leaving the resident alone in the shower chair when Resident #86 stoop up and subsequently fell, sustaining an acute intertrochanteric hip fracture requiring surgical repair. This affected one (Resident #86) of three residents reviewed for falls. The facility census was 81. Findings include: Review of Resident #86's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, type II diabetes mellitus, anxiety, and a history of transient ischemic attack (TIA). Review of the Fall Risk assessment dated [DATE] revealed Resident #86 was not at risk for falls. The assessment stated Resident #86 did not have a fall in the last 90 days. Review of the physical therapy (PT) note dated [DATE] revealed Resident #86 was a standby assist (SBA) with transfer from sit to stand. The goal was for an elderly mobility scale (a score between 14 and 20 suggests that the older resident has good mobility overall and they should be able to handle most activities of daily living (ADL) on their own) to be 15/20 to demonstrate the decreased risk for falls. The current score was eight (The elderly resident will have to depend on someone for help with ADL.) on [DATE]. Resident #86's mobility on the unit was without an assistive device with SBA. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was severely cognitively impaired. Resident #86 required limited assistance one-person physical assist for transfers and was one-persona physical assistance with bathing. FSR #86 had no durable medical equipment for mobility. Review of the care plan dated [DATE] revealed Resident #86 was at risk for falls related to dementia, osteoporosis, impaired cognition, debilitation, and weakness. The goal was to minimize potential risk factors to rule out falls. Interventions included to ensure the call light was within reach, ensure the environment was free of clutter, and have commonly used articles within easy reach. Review of the progress note dated [DATE] at 11:47 A.M. revealed Registered Nurse (RN) #220 was called to the bathroom and found Resident #86 on the floor, lying flat on his back. State Tested Nursing Aide (STNA) #130 stated she was giving Resident #86 a shower and left Resident #6 sitting on the shower chair to go get a blanket (located in the shower room). STNA #130 came back and found Resident #86 on the floor. Resident #86 was put in a sitting position on the floor, and neurological checks were initiated, and vital signs were checked. Resident #86 was unable to bare weight on his left leg and complained of pain when touched or moved. No visible signs of any bruising or swelling currently. The nurse practitioner was notified, and x-rays were ordered. Family member and nurse management was aware. On [DATE] at 8:46 P.M., the x-ray results showed an acute intertrochanteric (IT) hip fracture. The physician was notified, and the physician ordered Resident #86 to be sent to the hospital for evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 3 of 7 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 07/10/2023 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 0689 Level of Harm - Actual harm Residents Affected - Few Review of the facility's fall investigation dated [DATE] revealed Resident #86 had a fall in the shower room. STNA #130 stated Resident #86 was given a shower in the shower chair. STNA took eight to 10 steps to the linen cart to obtain a blanket for Resident #86. STNA then took eight to 10 steps back to the resident. Resident #86 was lying on the floor. The new intervention was to place a blanket on the shower chair to ensure Resident #86 does not slide out of it. Review of STNA #130's witness statement dated revealed Resident #86 was not left alone in the shower room prior to his fall. STNA #130 took a few steps away from Resident #86 to obtain a blanket and by the time she turned around to get back to Resident #86, he was on the floor. STNA #130 then left the shower room to obtain a nurse for assistance with Resident #86's fall. STNA #130 stated Resident #86 was not talking at the time of the fall and not exhibiting any behaviors. Review of the hospital documentation dated [DATE] revealed Resident #86 was seen at emergency room for a left femur fracture. The hospital diagnosis was closed left IT hip fracture with left hip intramedullary nail. The history of present illness (HPI) said Resident #86 was ambulatory with a cane and the resident stated he fell while in shower being assisted by staff. Review of the progress note dated [DATE] revealed Resident #86 returned from the hospital status post-surgery for the left femur fracture. Resident #86 did not have any other falls at the facility from [DATE] to [DATE]. Review of the progress note dated [DATE] revealed Resident #86 was hypoxic and had shortness of breath and emergency 9-1-1 services were called. Resident #86 was sent to the emergency room (ER) and died in the ER on [DATE]. Review of the coroner's report revealed the immediate cause of Resident #86's death was complications of blunt impact to trunk and extremities with left femur fracture because of a fall. Other significant conditions were hypertension, diabetes mellitus, and dementia. The manner of death was accident. Observation of the shower room on [DATE] at 3:40 P.M. revealed there was a linen closet and linen cart in the shower room. Two call lights were in the shower room and were functioning. The shower chair was plastic and had a bar at the feet so a resident's feet could rest on the bar. All four wheels of the shower chair had working brakes. Interview on [DATE] at 4:04 P.M. with STNA #130 stated she gave Resident #86 a shower in a shower chair on [DATE]. STNA #130 stated she walked a few steps away from Resident #86 to obtain a blanket from the linen cart. Resident #86 stood up from his shower chair and fell onto the shower room floor. Interview on [DATE] at 7:57 A.M. with RN #220 stated STNA #130 came out of the shower room after Resident #86 had fallen. RN #220 stated Resident #86 was on his back on the floor. RN #220 stated Resident #86 did not complain of pain at that time, but his left leg would not move upon assessing. RN #220 stated she notified the physician right away, received an order for an x-ray, and sent Resident #86 to the hospital after the results were received. Interview on [DATE] at 9:45 A.M. with the Director of Nursing (DON) stated even if STNA #130 was standing next to Resident #86, he could have still fallen. The DON stated STNA #130 turned around to grab a bath blanket off the linen cart. The DON stated STNA #130 never left the shower room when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 4 of 7 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 07/10/2023 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 0689 Resident #86 was on the shower chair. The DON stated the STNAs at the facility were to grab supplies for the residents before a shower was performed. Level of Harm - Actual harm Residents Affected - Few Subsequent interview on [DATE] at 10:30 A.M. with STNA #130 stated she did lock all four wheels to the shower chair before transferring him to and bathing him in the shower. STNA #130 stated Resident #86 had never fallen before and could understand small commands to assist in care. STNA #130 stated she grabbed the bath blanket to assist with water on the floor. STNA #130 stated she was so nervous that Resident #86 had fallen on the floor, she forgot to use the call light, and rushed to the nurse on the hall to get help. Review of the facility policy titled Fall Management, dated [DATE], revealed a fall risk evaluation was completed on admission, after a significant change, quarterly, and as necessary. After a fall resident was assessed, prompt medical attention provided, emergency services contacted, when necessary, notify responsible party and physician, nurse gathers and records much pertinent data of fall, care plan was updated, and new fall intervention are communicated. Review of the facility's bathing/shower policy, last revised 04/2002, revealed the purpose was to provide cleanliness and comfort, stimulate circulation, and observe condition of resident. The supplies to obtain included a bath blanket, if necessary. The procedure included to assemble supplies in shower room, except the chair and bath blanket. This deficiency represents non-compliance investigated under Complaint Number OH00144046. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 5 of 7 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 07/10/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interview, and facility policy review, the facility failed to provide timely incontinence care to the residents. This affected two (Residents #23 and #24) of three residents reviewed for incontinence care. The facility census was 81. Findings include: 1. Review of Resident #23's medical record revealed admission date 05/19/23. Diagnoses included chronic pulmonary disease, spinal stenosis, dementia, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was severely cognitively impaired. Resident #23 required total dependence with two-person assistance for toileting. Review of the plan of care dated 06/01/23 revealed Resident #23 had risk to alteration in elimination related to incontinent of bowel and bladder. Interventions included to monitor for signs and symptoms of urinary tract infection and provide incontinence care as needed. Observations and interviews on 07/03/23 starting at 3:15 P.M. with State Tested Nursing Aides (STNA) #804 and #777 revealed they took Resident #23 to her room to have incontinence care. At 3:17 P.M., STNA #804 verified that she did not check and change Resident #23 for incontinence since 7:30 A.M STNA #804 stated Resident #23 was changed last today at 7:30 A.M. STNA #777 stated she did not check and change Resident #23 until now. STNA #804 stated the floor was short an STNA that day (07/03/23). At 3:30 P.M., STNA #804 verified Resident #23's brief was heavily saturated with urine and had diarrhea that leaked over to front of perineum that covered her vagina. STNA #804 verified Resident #23 who had a pink bottom and no skin breakdown. 2. Review of Resident #24's medical record revealed an admission dated 08/19/20. Diagnoses included Alzheimer's disease, chronic kidney disease, peripheral vascular disease, and major depression disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #24 was severely cognitively impaired. Resident required extensive two-person assistance for toilet use. Review of the plan of care dated 01/22/19 revealed Resident #24 had a self-care deficit related to Alzheimer's and dementia. Interventions included the resident was incontinent of bowel and bladder and toileting assistance was needed. Resident #24 was also at risk for elimination related to chronic kidney disease and history of urinary tract infections. Inventions included to provide incontinence care as needed and monitor for skin breakdown. Observations and interview on 07/03/23 starting at 3:05 P.M. with State Tested Nursing Aides (STNA) #804 revealed she asked Resident #24 if she was ready to be checked and changed for incontinence and proceeded to take Resident #24 to her room. At 3:17 P.M., STNA #804 verified she did not check and change Resident #24 for incontinence since 7:45 A.M STNA #804 stated Resident #24 was changed last today at 7:45 A.M. STNA #804 stated the floor was short an STNA that day (07/03/23). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 6 of 7 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 07/10/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 07/06/23 at 3:00 P.M. with STNA #804 verified Resident #24 had moderate saturation of urine in incontinence brief on 07/03/23 at 3:17 P.M. Review of the facility policy titled Incontinence Care Protocol dated 06/14/2005, revealed the facility will provide incontinence care for the resident to assist in maintaining skin integrity, preventing skin breakdown, controlling odor and providing comfort and self-esteem for the resident. This deficiency represents non-compliance investigated under Complaint Number OH00143835, Complaint Number OH00132743, and Complaint Number OH00132578. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 7 of 7