Health inspection·October 14, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Interview on 10/13/23 at 8:33 A.M. with Resident #65 revealed about a month ago, her daughter walked in when an STNA was not speaking kindly to her. Resident #65 revealed the STNA was saying bad things to her. Resident #65 felt what the STNA was saying was abusive and disrespectful. Resident #65 could not remember the STNAs name but knew she no longer worked in the facility. Resident #65 denied any negative long-term psychosocial effects from the incident. Residents Affected - Few Telephone interview on 10/13/23 at 10:50 A.M. with STNA #104 revealed she was terminated from employment around the first of October (2023) due to an incident with the daughter of Resident #65. STNA #104 revealed she at no time was verbally abusive to any of the residents. She reported Resident #65 had put her light on for incontinence care, and she had already changed her three times. STNA #104 had asked Resident #65 to give her a minute and then she would be back. Resident #65's daughter overheard her telling Resident #65 to wait and became very upset. STNA #104 revealed she and Resident #65's daughter had words in the hallway, and they were each speaking inappropriately. STNA #104 revealed she never verbally abused Resident #65 but was verbally abusive to Resident #65's daughter. Interview on 10/13/23 at 11:31 A.M. with the Administrator revealed during the verbal abuse investigation with STNA #104, it was discovered that she did not treat a family member of a resident with dignity and respect. He reported due to this behavior, STNA #104 was terminated. He denied any findings regarding residents not being treated with dignity/respect or residents being verbally, mentally, or physically abused. Telephone interview on 10/13/23 at 11:40 A.M. with Registered Nurse (RN) #106 revealed she was the nurse on duty the night of the alleged verbal abuse of Resident #65. She revealed she did not witness/hear any verbal abuse. RN #106 reported she was in the hallway and did not hear the exchange between STNA #104, Resident #65 or Resident #65's daughter. RN #106 revealed STNA #104 did report to her she used the F word in a conversation she had with Resident #65's daughter. She reported Resident #65's daughter came out of the room to her and wanted STNA #104 off the floor and wanted to speak to the charge nurse. Telephone interview on 10/13/23 at 12:11 P.M. with Licensed Social Worker (LSW) #112, who was Resident #65's guardian and worked for the County Guardianship Service Board, revealed she had sent the facility Administrator video and audio footage which she had received from Resident #65's daughter regarding the alleged verbal abuse on 09/21/23. LSW #112 then forwarded the video and audio footage to this surveyor. Review of the video and audio footage on 10/13/23 at 12:18 P.M., which was provided by a LSW #112, revealed on 09/21/23 a 47 second recording of STNA #104 using the curse word f*ck while providing care and services to Resident #65. Resident #65's daughter was not in the room but outside the room when the curse work f*ck was verbalized. At the end of the recording, STNA #104 admitted and apologized to Resident #65's daughter for her verbal abuse toward Resident #65. Interview on 10/13/23 at 12:45 P.M. with Licensed Practical Nurse (LPN) #110 revealed she had spoken with Resident #65's daughter over the phone the evening of 09/21/23 when the alleged verbal abuse occurred. She revealed Resident #65's daughter was upset about how STNA #104 spoke to her mother and also that her mother was constipated. LPN #110 revealed the daughter did not want STNA #104 to care for her mother. LPN #110 watched the video and audio footage recorded by Resident #65's daughter and verified in the video and audio footage Resident #65's daughter told STNA #104 she was verbally abusing her mother and STNA #104 replied I know, and I apologize. LPN #110 reported she had seen only approximately the first 20 seconds of the video and audio footage and didn't realize STNA #104 had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 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 365929 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2023 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 0600 replied I know, and I apologize when confronted by Resident #65's daughter about verbal abuse. Level of Harm - Minimal harm or potential for actual harm Interview on 10/13/23 at 12:56 P.M. with the Administrator revealed the investigation was found inconclusive for verbal abuse because watching the video and audio footage confirmed there was a verbal altercation, but he did not know the context of the video. The Administrator revealed part of the investigation was to discover what happened prior to the video and audio footage and he made multiple phone calls to Resident #65's daughter, LSW #112 and STNA #104 but no one would return his calls. The Administrator revealed that due to the lack of information about what occurred prior to the video and audio footage, the verbal abuse allegation was found inconclusive. Residents Affected - Few Telephone interview on 10/13/23 at 2:29 P.M. with the Resident #65's daughter revealed she did record the incident of verbal abuse of her mother by STNA #104 on 09/21/23 and she had forwarded the video and audio footage to guardian, LSW #112. Review of facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 11/21/16, revealed the definition of abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology, such as through the use of photographs and recording devised to demean or humiliate a resident. Further review under the subsection of prevention and identification include the supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, and directing residents who need toileting assistance to urinate or defecate in their beds. This deficiency represents non-compliance investigated under Complaint Number OH00146683. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 3 of 3