Health inspection·March 13, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of investigations, review of self-reported incidents, staff interview, and review of a facility policy, the facility failed to timely report an injury of unknown origin to the State Survey Agency. This affected one (#6) of one residents reviewed for skin conditions. The facility census was 86. Findings include: Review of the medical record for Resident #6 revealed an admission date of 01/16/23 with diagnoses including Alzheimer's disease, depression, gastroesophageal reflux disease, and senile degeneration of the brain. Review of Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #6's progress notes dated 10/01/23 through 10/19/23 revealed no concerns related to a fall or injury. Review of Resident #6's progress note dated 10/21/23 at 12:16 P.M. revealed Resident #6 was noted to have edema to the left elbow. Hospice was updated and they advised the facility to monitor for changes. Review of Resident #6's incident investigation dated 10/21/23 and completed on 10/24/23 revealed Resident #6 had swelling to the left elbow. Licensed Practical Nurse (LPN) #105 and State Tested Nurse Aide (STNA) #145 were interviewed. No additional staff, residents, or family members were interviewed. The summary of the incident indicated the nurse noted edema to Resident #6's left elbow. The resident was noted to be combative with care that morning. The resident was frequently combative with care. She would swing her arms and attempt to hit the staff. Resident #6 frequently yelled out. Hospice, guardian, and physician were all noted. A head-to-toe assessment was completed and no other areas were noted. Resident #6 was swinging at the nurse during the assessment. An x-ray was ordered for a possible distal humeral fracture. An orthopedic referral was given, but the resident's guardian was not interested in the referral. No pain or discomfort noted. Review of Resident #6's progress note dated 10/22/23 at 12:00 P.M. revealed Resident #6's guardian was updated on the edema to the elbow. Review of Resident #6's physician order dated 10/24/23 revealed an order for an x-ray, two views, Page 1 of 23 365929 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0609 to the left swollen elbow and arm. Level of Harm - Minimal harm or potential for actual harm Review of Resident #6's progress notes dated 10/24/23 revealed an order was placed for an x-ray to the left arm. The x-ray results were received and showed massive soft tissue swelling of the elbow was noted with a possible distal humeral fracture. A new order for an orthopedic appointment was created. Residents Affected - Few Review of Resident #6's x-ray dated 10/24/23 revealed two radiographs of the left elbow were completed. Massive edema of the elbow, distal arm, and forearm were noted. There was a possible supracondylar fracture of the humerus but it was unclear. Additional imaging was recommended. Review of Resident #6's progress note dated 10/26/23 revealed the resident's guardian was not interested in an orthopedic referral. Review of Resident #6's physician progress note dated 10/30/23 revealed Resident #6 had edema to her left arm by an unknown source. An x-ray was completed with a possible distal humerus fracture. Hospice would not complete a full work up with orthopedics. Review of the facility's self-reported incidents (SRIs) from 10/21/23 to 03/10/24 revealed there were no SRIs reported to the State Survey Agency involving Resident #6. Interview on 03/11/24 at 1:20 P.M. with Regional Nurse #200 verified Resident #6's injury was not reported as an SRI. Interview on 03/12/24 at 1:55 P.M. with the Director of Nursing (DON) verified an SRI was not submitted to the State Survey Agency regarding Resident #6's injury of unknown origin and should have. Review of the policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 11/21/16, revealed an injury was classified as an injury of unknown source when both of the following conditions are met including the source of the injury was not observed or could not be explained by the resident and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed, or the incidence of injuries over time. In response to allegations the facility must ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator or designee of the facility and to other officials including the State Survey Agency. This must be reported immediately, but not later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury. It should be reported no later than 24 hours if the events do not involve abuse and do not result in serious bodily injury. The facility needs to provide evidence that all alleged violations are thoroughly investigated and report the results to the administrator and State Survey Agency within five working days of the incident. 365929 Page 2 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of investigations, staff interview, and policy review, the facility failed to thoroughly investigate an injury of unknown origin. This affected one (#6) of one resident reviewed for skin conditions. The facility census was 86. Residents Affected - Few Findings include: Review of the medical record for Resident #6 revealed an admission date of 01/16/23 with diagnoses including Alzheimer's disease, depression, gastro-esophageal reflux disease, and senile degeneration of the brain. Review of Resident #6's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #6's progress notes dated 10/01/23 through 10/19/23 revealed no concerns related to a fall or injury. Review of Resident #6's progress note dated 10/21/23 at 12:16 P.M. revealed Resident #6 was noted to have edema to the left elbow. Hospice was updated and they advised the facility to monitor for changes. Review of Resident #6's incident investigation dated 10/21/23 and completed on 10/24/23 revealed Resident #6 had swelling to the left elbow. Licensed Practical Nurse (LPN) #105 and State Tested Nurse Aide (STNA) #145 were interviewed regarding Resident #6's condition. No additional staff members, residents, or family members were interviewed. The summary of the incident indicated the nurse noted edema to Resident #6's left elbow. The resident was noted to be combative with care that morning. The resident was frequently combative with care. She would swing her arms and attempt to hit the staff. Resident #6 frequently yelled out. The hospice provider, Resident #6's guardian, and physician were notified. A head-to-toe assessment was completed, and no other areas were noted. Resident #6 was swinging at the nurse during the assessment. An x-radiation (x-ray) image was ordered and a possible distal humeral fracture was noted. An orthopedic referral was given, the guardian was not interested in the referral. There was no pain or discomfort noted. Review of Resident #6's progress note dated 10/22/23 at 12:00 P.M. revealed Resident #6's guardian was updated on the edema to the elbow. Review of Resident #6's physician order dated 10/24/23 revealed an order for an x-ray, two views, to the left swollen elbow and arm. Review of Resident #6's progress notes dated 10/24/23 revealed an order was placed for an x-ray to the left arm. The x-ray results were received with a finding of massive soft tissue swelling of the elbow noted with a possible distal humeral fracture. A new order for an orthopedic appointment was given. Review of Resident #6's x-ray results dated 10/24/23 revealed two radiographs of the left elbow were completed. Massive edema of the elbow, distal arm, and forearm were noted. There was a possible supracondylar fracture of the humerus, but it was unclear, and additional imaging was recommended. 365929 Page 3 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #6's progress note dated 10/26/23 revealed the resident's guardian was not interested in an orthopedic referral. Review of Resident #6's physician progress note dated 10/30/23 revealed Resident #6 had edema to her left arm by an unknown source. An x-ray was completed with a possible distal humerus fracture. Hospice would not complete a full work up with orthopedics. Interview on 03/11/24 at 3:10 P.M. with STNA #145 revealed Resident #6 required total care with most activities of daily living. STNA #145 verified Resident #6 could get combative, but reported if the resident was somewhat combative they would get a second staff member, and if she remained combative, they would leave her and come back later. STNA #145 could not recall the events that lead to Resident #6 injuring her arm. Interview on 03/12/24 at 1:55 P.M. with the Director of Nursing (DON) stated Resident #6's guardian and hospice did not want to follow up after the x-ray. The DON verified only two staff were interviewed and witness statements were not collected. The DON additionally verified the investigation was not thorough. Review of the policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 11/21/16, revealed an injury was classified as an injury of unknown source when both of the following conditions are met including the source of the injury was not observed or could not be explained by the resident and the injury was suspicious because of the extent of the injury, the location of the injury, the number of injuries observed, or the incidence of injuries over time. In response to allegations the facility must ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator or designee of the facility and to other officials including the State Survey Agency. This must be reported immediately, but not later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury. It should be reported no later than 24 hours if the events do not involve abuse and do not result in serious bodily injury. The facility needs to provide evidence that all alleged violations are thoroughly investigated and report the results to the administrator and State Survey Agency within five working days of the incident. 365929 Page 4 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interviews, the facility failed to ensure adequate nail care was provided for dependent residents. This affected two (#22 and #42) of seven residents reviewed for activities of daily living. The facility census was 86. Residents Affected - Few Findings Include: 1. Review of the medical record for Resident #22 revealed an initial admission date of 06/01/19 with the latest readmission date of 12/02/22. Diagnoses included acute and chronic respiratory failure with hypoxia, cerebrovascular accident (CVA) with right sided hemiplegia, aphasia, hypothyroidism, hypertension, gastro-esophageal reflux disease, anemia, and anxiety disorder. Review of the plan of care dated 06/02/19 revealed Resident #22 required assistance with activities of daily living (ADLs) and may be at risk for developing complications associated with decreased ADL self-performance and indicated the resident used an electric wheelchair. Interventions included the resident wore incontinence briefs, required assistance with bathing, dressing, grooming (nails/shave/hair), supervision with bed mobility, preferred showers, had bilateral assist bars, wore glasses, and had lower partial dentures to be removed at bedtime. Review of Resident #22's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. Review of the resident's quarterly clinical care assessment dated [DATE] revealed the resident required substantial/maximal assistance with personal hygiene. On 03/10/24 at 11:08 A.M., observation of Resident #22's finger nails revealed they were long, dirty, and jagged with a brown substance under the nails. On 03/11/24 at 10:46 A.M., observation of Resident #22' finger nails revealed they remained long, dirty, and jagged with a brown substance under the nails. On 03/12/24 at 11:41 A.M., interview with Registered Nurse (RN) #164 verified Resident #22's finger nails were long, jagged, and dirty with a brown substance under them. 2. Review of the medical record for Resident #42 revealed an initial admission date of 01/12/24 with diagnoses including senile degeneration of the brain, diabetes mellitus, obstructive sleep apnea, chronic kidney disease, anemia, hyperlipidemia, atrial fibrillation, hypertension, and altered mental status. Review of the plan of care dated 01/13/24 revealed Resident #42 may require assistance with ADLs and may be at risk of developing complications associated with decreased ADL self-performance. Interventions include Resident #42 was blind in both eyes and kept the right eye closed, the resident was dependent on staff for transfers, toileting, grooming, was incontinent of both bowel and bladder, was non-ambulatory, and required assistance with bathing. Review of the significant change MDS assessment dated [DATE] revealed Resident #42 had a severe cognitive deficit. 365929 Page 5 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0677 Level of Harm - Minimal harm or potential for actual harm On 03/10/24 at 10:50 A.M., observation of Resident #42's finger nails revealed they were long, jagged, and dirty with a brown substance under the nails. On 03/11/24 at 12:55 P.M., observation of the resident revealed his finger nails remained long, jagged, and dirty with a brown substance under the nail. Residents Affected - Few On 03/11/24 at 1:15 P.M., interview with the Director of Nursing (DON) verified Resident #42's nails were long, jagged, and dirty with a brown substance under the nails. 365929 Page 6 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of activity calendars, and policy review, the facility failed to ensure activities were offered to residents throughout the week based on assessment, care plan, and resident preference to promote resident well-being. This affected two (#6 and #55) of two residents reviewed for activities. The facility census was 86. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #6 revealed an admission date of 01/16/23 with diagnoses including Alzheimer's disease, depression, gastro-esophageal reflux disease, and senile degeneration of the brain. Review of Resident #6's activity assessment dated [DATE] revealed she preferred activities in a one-on-one setting. Resident #6's preferred activities included watching television and listening to music or the radio. The assessment did not indicate what type of music or television she preferred. Review of Resident #6's comprehensive Minimum Data Set (MDS) 3.0 dated 10/18/23 revealed the resident was rarely or never understood. According to her family, it was somewhat important to listen to music Resident #6 liked, to be around animals, go outside when the weather was good, participate in religious services, and do favorite activities. Review of Resident #6's quarterly MDS 3.0 assessment dated [DATE] revealed the resident was rarely or never understood. Review of Resident #6's plan of care dated 01/30/24 revealed she was withdrawn from large group activity settings. She was to be offered one-on-one engagement and sensory stimulating activities as tolerated. Interventions included offering small group or one-on-one engagement as the resident may become agitated in large groups. It was additionally noted that Resident #6 spent most of the day in bed but would request to be out of bed around dinner time. The resident was to be offered sensory stimulating activities in her room. Review of the activities calendar for February 2024 revealed activities were mostly scheduled from 9:30 A.M. to 3:00 P.M. One activity was scheduled at 7:30 P.M. on 02/11/24, and it was the only activity after 3:00 P.M. Review of Resident #6's activities documentation for February 2024 revealed for the weekend of 02/03/24 and 02/04/24 and the weekend of 02/10/24 and 02/11/24 only one activity was offered (a manicure) and it was refused. For the weekend of 02/17/24 and 02/18/24 one activity was offered (a manicure) and it was accepted. For the weekend of 02/24/24 and 02/25/24 there were no weekend activities offered. Review of the activities calendar for March 2024 revealed activities were scheduled from 9:00 A.M. to 3:00 P.M. There were no activities scheduled after 3:00 P.M. Review of Resident #6's activities documentation from 03/01/24 to 03/09/24 revealed for the weekend of 03/02/24 and 03/03/24 all activities were marked with an 'X'. On 03/09/24 no activities were offered. 365929 Page 7 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. Review of the medical record for Resident #55 revealed an admission date of 11/06/20 with diagnoses including type two diabetes mellitus, respiratory disorders, insomnia, hyperlipidemia, and generalized osteoarthritis. Review of Resident #55's plan of care dated 09/24/21 revealed the resident had been more withdrawn recently related to family not visiting her very often. The resident needed encouragement to attend activities so she could have interactions with others. Interventions included encouraging and assisting the resident to go outdoors, inviting and encouraging her to attend special events, offering assistance getting to activities, offering supplies for leisure activities, and respecting her choice for what she does and does not want to do. Review of Resident #55's activity assessment dated [DATE] revealed Resident #55 preferred small group activities and one-on-one activities. She preferred chair exercises, cooking and baking, family-oriented activities, television and movies, and music and radios. The assessment did not indicate what type of music or television the resident preferred. Resident #55 spent a lot of time in common areas listening to the television and enjoying occasional visitors. Review of Resident #55's comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #55 was rarely or never understood. An interview for activities with the resident was conducted and revealed it was somewhat important to listen to music she liked and somewhat important to go outside when the weather was nice. Review of the activities calendar for February 2024 revealed activities were mostly scheduled from 9:30 A.M. to 3:00 P.M. One activity was scheduled at 7:30 P.M. on 02/11/24, it was the only activity after 3:00 P.M. Review of Resident #55's activities for February 2024 revealed there were no activities provided on four (02/03/24, 02/10/24, 02/17/24, and 02/24/24) of four Saturdays in the month. Review of the activities calendar for March 2024 revealed activities were scheduled from 9:00 A.M. to 3:00 P.M. There were no activities scheduled after 3:00 P.M. Review of Resident #55's activities from 03/01/24 to 03/09/24 revealed for the weekend of 03/02/24 and 03/03/24 all activities were marked as 'X.' Resident #55 had no activities listed on Saturday 03/09/24. Interview on 03/13/24 at 10:20 A.M. and 12:30 P.M. with Activities Director (AD) #122 revealed activities personnel included her and one assistant and they worked until 4:00 P.M. and 4:30 P.M. AD #122 reported the activities assistant came in every other weekend and she would come in at times to assist with getting residents to the in-facility church services. AD #122 verified Resident #6 and Resident #55 did not have many activities listed for the weekend. AD #122 revealed weekend activities for the cognitively impaired residents included church services. AD #122 verified the only activities assessment in Resident #6's medical record was from 01/28/23, which was over a year ago. She believed there were additional assessments, but she was unable to produce them. AD #122 verified 3:00 P.M. was the last scheduled activity and the activity usually went until 4:00 P.M. AD #122 reported sometimes in the evenings nursing staff would turn on the radio in common areas or put on a comedy show. AD #122 additionally reported the 'X' on the activity documentation for Resident #6 and Resident #55 meant the usually accepted or preferred activities were not offered or on the calendar that day. 365929 Page 8 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0679 Level of Harm - Minimal harm or potential for actual harm Review of the policy titled, Program Planning and Scheduling, dated March 2007, revealed the activities calendar was to include some evening and weekend activities and were to be geared to all groups residing in the facility. Residents Affected - Few 365929 Page 9 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #12 revealed an initial admission date of 06/20/22 with the diagnoses including anemia, asthma, hypertension, gastro-esophageal reflux disease, traumatic brain injury and thrombocytopenia. Review of the plan of care dated 06/28/22 revealed Resident #12 was at risk for falls related to impaired balance, history of traumatic brain injury, and had been frequently putting self on the floor. Interventions included to provide two staff assist from the wheelchair to the bed at night for safety, encourage and remind to ask for assistance, ensure the call light was within reach, have commonly used items within easy reach, new sturdy rubber soled shoes were purchased for safety, no pillow to the back of wheelchair for safety, non-skid strips to the left side of bed, non-skid strips to the floor in front of the window for safety, alarm to the bathroom door to alert staff when resident was trying to toilet without assistance, wear proper non-slip footwear, therapy referral as needed, and Velcro to bedside table and bottom of basket to keep frequently used items within close reach and verbal reminders. Review of the fall risk evaluation dated 10/30/23 revealed a score of 9.5 indicating Resident #12 was at risk for falls. Review of Resident #12's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a moderate cognitive deficit. The assessment indicated the resident had two or more falls since the prior assessment with no injuries. Review of Resident #12's physician orders identified no orders related to fall interventions. On 03/12/24 at 9:45 A.M., observation of Resident #12's fall interventions revealed no non-skid strips in front of the resident's bed, the tab alarm to the resident's bathroom door was not activated to sound to alert staff of the resident's self attempts with toileting, and the resident's basket with Velcro was not in place. On 03/12/24 at 9:49 A.M., interview with Registered Nurse (RN) #164 verified Resident #12 had no non-skid strips in place in front of his bed, tab alarm was not activated to alert staff, and the resident had no basket on his bedside table with Velcro on the bottom per the fall risk care plan. Review of the facility's policy titled, Fall Management, dated 10/17/16, revealed understanding the significance of mobility, movement and the ingrained nature of walking, it is our intention to promote programs geared to improving mobility, stamina and reduce the risk of falls through a comprehensive interdisciplinary process of assessment, care plan development and implementation with ongoing monitoring and review. An interdisciplinary plan of care will be developed, implemented, reviewed and updated as necessary to reflect each resident's current safety needs and fall reduction interventions. Based on observation, staff interview, and policy review, the facility failed to ensure fall interventions were in place and resident transfers were performed in a manner to prevent falls. This affected two (#12 and #50) of seven residents reviewed for falls. The census was 86. 365929 Page 10 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0689 Findings include: Level of Harm - Minimal harm or potential for actual harm 1. Review of the medical record for Resident #50 revealed an admission date of 05/02/23 with diagnoses including type two diabetes mellitus, Parkinsonism, anxiety disorder, major depressive disorder, and combined systolic and diastolic heart failure. Residents Affected - Few Review of Resident #50's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #50 had severely impaired cognition. Review of Resident #50's plan of care dated 05/11/23 revealed the resident was at risk for falls due to debilitation, weakness, disease process, and use of psychotropic medications. Interventions included encouraging and reminding the resident to ask for assistance, ensuring the call light was within reach, keeping commonly used articles within easy reach, providing a mat to the floor for safety when the resident was in bed, and added 11/29/23, state tested nurse aides (STNAs) were reeducated on proper use of the sit-to-stand lift. Review of Resident #50's progress note dated 11/26/23 revealed an assessment was completed and Resident #50 was transferred to bed with a two-person assistance. No injuries were noted; however, the resident complained of lower back pain and an x-ray was ordered. Review of Resident #50's progress note dated 11/27/23 revealed the x-ray was negative for fracture. Review of Resident #50's interdisciplinary team (IDT) fall review dated 11/30/23 revealed on 11/26/23 at 8:30 A.M. the STNA was transferring Resident #50 to the wheelchair via the sit-to-stand lift. The resident slid to the floor with assistance of the STNA. The STNA notified the nurse and an assessment was completed. There were no visible injuries noted and no complaints of pain. The resident was assisted to the wheelchair via two staff members. The STNA was reeducated on the use of the sit to stand lift, and the intervention was to make Resident #50 a two-person assistance with transfers. Interview on 03/11/24 at 1:20 P.M. with Regional Nurse #200 verified Resident #50's progress notes did not indicate what led to the fall on 11/26/23. Interview on 03/12/24 at 1:55 P.M. with the Director of Nursing (DON) revealed staff were reeducated on the sit-to-stand lift. The DON stated, based on what she saw from the STNA who assisted Resident #50, the STNA did not have the strap on the sit-to-stand lift appropriately for the lift. 365929 Page 11 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure adequate fluids were available and provided throughout the day to promote hydration. This affected one (#6) of seven residents reviewed for nutrition. The facility census was 86. Residents Affected - Few Findings Include: Review of the medical record for Resident #6 revealed an admission date of 01/16/23 with diagnoses including Alzheimer's disease, depression, gastro-esophageal reflux disease, and senile degeneration of the brain. Review of Resident #6's nutrition assessment dated [DATE] revealed the resident required 2190 milliliters (ml) of fluid a day. Review of Resident #6's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was rarely or never understood. The resident was on a mechanically altered and therapeutic diet. Review of Resident #6's fluid intake from 02/12/24 to 03/10/24 revealed fluid intake was only documented on six days. Fluid intake included 120 ml on 02/12/24, 360 ml on 02/13/24, 240 ml on 02/23/24, 240 ml on 02/24/24, 240 ml on 03/01/24, and 80 ml on 03/07/24. Review of Resident #6's plan of care dated 03/07/24 revealed the resident had the potential for alteration in nutrition and hydration related to diagnoses, overweight status, requiring a mechanically altered diet, pressure wounds, and hospice status. Interventions included adaptive equipment as ordered, hospice services, medications as ordered, monitoring the consistency of diet served, providing assistance with meals as necessary, providing supplement as ordered, weighing as ordered, and providing foods and fluids the resident could tolerate and enjoy. Review of Resident #6's physician order dated 03/10/24 revealed an order for regular diet, with a pureed texture, and fluids were to be regular consistency. Observation on 03/10/24 at 10:33 A.M., 11:40 A.M., and 1:49 P.M. revealed Resident #6 was in bed with a large cup of water on the nightstand; however, the nightstand was at the end of the bed next to the resident's feet. Observation on 03/11/24 at 7:58 A.M., 8:59 A.M., 9:30 A.M., 10:16 A.M., 10:49 A.M., 11:40 A.M., and 4:40 P.M., revealed Resident #6 was in bed with a large cup of water on the nightstand; however, the nightstand was at the end of the bed next to her feet. Observation on 03/12/24 at 7:53 A.M. revealed Resident #6 was in her chair in her room. There was water located several feet away from the resident. Observation on 03/12/24 at 9:47 A.M., 10:16 A.M., and 11:03 A.M. revealed Resident #6 was in her chair at a table in the common area and there was no water at the table. Observation on 03/12/24 at 3:09 P.M. revealed Resident #6 was in her bed, there was no water observed in her room. 365929 Page 12 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0692 Level of Harm - Minimal harm or potential for actual harm Interview on 03/12/24 at 3:09 P.M. with State Tested Nurse Aide (STNA) #156 verified there was no water available to Resident #6. STNA #156 reported Resident #6 had just been laid down for a nap, so she did not bring her water. STNA #156 verified water should not be placed on the nightstand as Resident #6 could not reach it there. STNA #156 reported she usually brought water for Resident #6 to drink on her own, and when she did this, she put the bedside table by the head of the bed. Residents Affected - Few Observation on 03/12/24 at 4:40 P.M. revealed Resident #6 remained in bed and there was no water observed in her room. Observation on 03/13/24 at 9:11 A.M. revealed Resident #6 was in her chair at a table in the common area and there was no water at the table. Interview on 03/13/24 at 9:25 A.M. with Dietary Technician (DT) #201 revealed residents were to receive 1440 mls of fluids on meal trays and she expected them to have water pitchers at bedside in between meals. DT #201 verified Resident #6 required more fluids than what came from the kitchen. DT #201 additionally reported Resident #6 could eat and drink on her own, but her assistance needs could vary at times. Interview on 03/13/24 at 9:47 A.M. with the Administrator revealed they did not have a hydration policy. The Administrator stated he expected staff to replenish the residents' water in the morning. Alert and oriented residents could call for more water as needed and residents who were not physically able to drink on their own should be offered fluids every two hours. 365929 Page 13 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to administer supplemental oxygen as ordered. This affected one (#339) of one residents reviewed for oxygen administration. The facility census was 86. Residents Affected - Few Findings include: Review of the medical record revealed Resident #339 was admitted to the facility on [DATE] with diagnoses including emphysema, chronic obstructive pulmonary disease, and fracture of lumbosacral spine and pelvis. Review of the care plan dated 03/08/24 revealed Resident #339 had a history of respiratory deficiencies and staff interventions include administering oxygen as ordered. Review of current physician orders for Resident #339 revealed an order for continuous oxygen at three liters per nasal cannula with a start date of 03/08/24. Observation on 03/11/24 at 1:34 P.M., on 03/12/24 at 9:36 A.M., and on 03/12/24 at 11:41 A.M. revealed Resident #339 was observed wearing supplemental oxygen set at 4.5 liters via nasal cannula. Interview on 03/12/24 at 11:41 A.M. with Licensed Practical Nurse (LPN) #110 confirmed Resident #336 had an order to receive three liters of oxygen, and confirmed the resident was receiving 4.5 liters of oxygen at the time of the interview. Interview on 03/12/24 at 3:45 P.M. with the Director of Nursing (DON) confirmed Resident #339 had an order for three liters of oxygen nasal cannula. Review of the oxygen administration policy dated 04/17/23 revealed oxygen is administered under orders of a physician and the physician will be notified as needed for changes. 365929 Page 14 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure dialysis services were completed thoroughly including obtaining resident weights before and after dialysis services. This affected one (#8) of one residents reviewed for dialysis. The census was 86. Residents Affected - Few Findings Include: Review of the medical record revealed Resident #8 was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, type II diabetes, unspecified hemorrhoids, lack of coordination, weakness, dysphagia, end stage renal disease, atrial fibrillation, and dependence on renal dialysis. Review of Resident #8's Minimum Data Set (MDS) assessment, dated 01/11/24, revealed the resident was cognitively intact. Review of Resident #8's current physician orders revealed the resident had scheduled dialysis services three days a week, on Mondays, Wednesdays, and Fridays. Review of Resident #8 dialysis notes, dated 12/01/23 to 03/11/24, revealed there were no documented preor post- weights documented for Resident #8 on 12/22/23, 01/10/24, 01/12/24, 01/15/24, 01/17/24, 01/19/24, 01/22/24, 01/24/24, 01/26/24, 01/29/24, 01/31/24, 02/02/24, 02/05/24, 02/07/24, 02/09/24, 02/12/24, 02/19/24, 02/21/24, 02/23/24, 02/26/24, 02/28/24, 03/04/24, 03/08/24, and 03/11/24. Further review revealed no documentation of a pre-weight on 02/16/24, and no documentation of a post-weight on 12/01/23, 12/11/23, 12/15/23, 12/18/23, and 02/12/24. Review of Resident #8's weights obtained by the facility dated between 12/01/23 and 03/11/24 revealed no weights to support a pre- or post-weight completed on the days the resident had dialysis and the weights were not documented. Interview with the Director of Nursing (DON) on 03/13/24 at 9:12 A.M. confirmed the facility had difficulty getting completed dialysis documentation back from the dialysis center. The DON confirmed she would contact them to see what documentation they could provide. Interview with DON and Regional Nurse #200 on 03/13/24 at 9:36 A.M. confirmed there were no pre- and post-weights on Resident #8's dialysis communication forms from the date with missing weights. Interview with Dietary Technician (DT) #201 on 03/13/24 at 10:45 A.M. confirmed the dialysis center was not obtaining weights as they should be each day Resident #8 received dialysis. DT #201 confirmed the new process for weights with residents who go to dialysis would be the facility staff will take a pre- and post-weight to confirmed it was being completed, even if the dialysis center started documenting the weights on the medical records. 365929 Page 15 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure adequate monitoring was completed for a medication as ordered. This affected one (#35) of six residents reviewed for medications. The facility census was 86. Residents Affected - Few Findings include: Review of the medical record for Resident #35 revealed an admission date of 09/14/22 with diagnoses including cerebral infarction, hemiplegia and hemiparesis affecting an unspecified side, atherosclerotic heart disease, and vascular dementia. Review of Resident #35's plan of care dated 09/26/22 revealed the resident had altered health maintenance related diagnoses including hypertension and coronary artery disease. Interventions included administering medications as ordered, monitoring for signs of cardiac distress, monitoring for signs of infection, and monitoring for signs of bleeding. Review of Resident #35's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had impaired cognition. Review of Resident #35's physician order dated 02/15/24 revealed an order for the blood pressure medication nifedipine extended release tablet 60 milligrams (mg), one tablet by mouth one time a day for hypertension. Further review of the order revealed the medication was to be held if the systolic blood pressure was less than 110 millimeters of mercury (mmHg). Review Resident #35's medication administration record (MAR) from 02/15/24 to 03/10/24 revealed Resident #35 received nifedipine 60 mg every day as ordered. Additionally, during this timeframe Resident #35's blood pressure was only documented once on 02/07/24 for the monthly vital signs. Review of Resident #35's vital signs from 02/15/24 to 03/10/24 revealed the resident's blood pressure was taken on 02/27/24 and was 112/73 mmHg and on 03/07/24 was 134/76 mmHg. Interview on 03/12/24 at 9:31 A.M. with the Director of Nursing (DON) verified Resident #35's blood pressure was not monitored as ordered. 365929 Page 16 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and facility policy review, the facility failed to identify and monitor target behaviors for the use of psychotropic medications. This affected one (#73) of six residents reviewed for medications. The facility census was 86. Findings Include: Review of Resident #73's plan of care dated 11/07/22 revealed the resident had trauma related to unwanted sexual contact. Resident #73 had triggers of hearing other people screaming at each other/other people becoming physical with each other. Interventions included consistent staff members, consult with psychiatry/psychology, and include the resident in decision making process. Review of the plan of care dated 02/08/22 revealed Resident #73 was at risk for adverse effects related to psychoactive medication use, dementia with behaviors, depression, and mood disorder. Interventions included give medications as ordered, laboratory values per order, update the physician as indicated, monitor for medication side effects, monitor the pharmacy monthly drug review, reduction in medication doses when indicated, report changes in behavior or mood state, and report to the physician any negative outcomes associated with use of psychoactive drug. Review of Resident #73's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive deficit. Review of mood and behavior assessment revealed the resident displayed no behaviors. The assessment indicated the diagnosis of schizophrenia was an active diagnoses. The assessment indicated Resident #73 received antipsychotic medications on a regular basis, a gradual dose reduction (GDR) was not attempted, and the physician had not documented the GDR was clinically contraindicated. Review of Resident #73's monthly physician orders for March 2023 identified orders dated 07/20/23 the psychotropic medication Lexapro five (5) milligrams (mg) by mouth daily for depression and the antipsychotic Zyprexa 5 mg by mouth daily at bedtime for mood disorder. Review of Resident #73's medical record no revealed identified target behaviors for the use of Zyprexa 5 mg by mouth daily at bedtime and Lexapro 5 mg by mouth daily for depression. On 03/11/24 at 3:27 P.M., interview with the Director of Nursing (DON) verified the the facility had not identified or monitored target behaviors for Resident #73 for the use of the psychotropic medications. Review of the facility policy tilted, Unnecessary Drugs, dated 06/27/15 revealed each resident's drug regimen must be free from unnecessary drugs. Unnecessary drugs are any drugs when used in excessive dose (including duplicate drug therapy) for excessive duration, without adequate monitoring, without adequate indications for its use or in the presence of adverse consequences which indicated the dose should be reduced or discontinued. 365929 Page 17 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of an email correspondence document, staff interview, and policy review, the facility failed to timely complete an order for laboratory values and failed to notify the physician of abnormal laboratory results. This affected one (#78) of two residents reviewed for infections. The facility census was 86. Findings include: Review of Resident #78's medical record revealed an admission date of 01/01/24. Diagnoses included type two diabetes mellitus, chronic heart failure, and stroke. Review of the Minimum Data Set assessment completed on 03/05/24 revealed Resident #78 was severely cognitively impaired and was dependent on personal care. Review of Resident #78's medication administration record for Resident #78 revealed an entry dated 01/14/24 at 6:00 A.M. for collection of a urine analysis with a refusal documented. Review of an order audit report for Resident #78 dated 01/17/24 at 4:25 P.M. revealed an order summary to obtain urine for analysis. Review of an order audit report for Resident #78 dated 01/19/24 at 8:27 A.M. revealed an order summary to obtain a urine for analysis. Review of an email to the Assistant Director of Nursing (ADON) #123 dated 01/17/24 confirmed a staff member from the laboratory was present at the facility on 01/17/24. Review of a laboratory results report for Resident #78 revealed a urine collection date of 01/19/24 at 12:03 P.M. Review of progress notes between 01/15/24 and 01/19/24 for Resident #78 revealed staff did not document an attempt to obtain a urine for analysis. Review of laboratory results for Resident #78 revealed the results were reported to the facility on [DATE] at 10:17 A.M. Further review of the report revealed indication Resident #78 had a urinary tract infection. The report found the urinary tract infection was susceptible to the antibiotic medication Macrobid. Record review of progress notes between 01/23/24 and 01/24/24 for Resident #78 revealed staff did not notify the doctor of Resident #73's abnormal laboratory results. Record review of orders for Resident #78 revealed an order for Macrobid with a start date 01/24/24 and an end date of 01/31/24. The order was to give one capsule by mouth every 12 hours for urinary tract infection. Record review of the medication administration record for Resident #78 revealed an order for Macrobid with a start date of 01/24/24 of 8:00 P.M. 365929 Page 18 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 03/13/24 at 8:04 A.M. with the Director of Nursing (DON) confirmed abnormal laboratory results were received from the laboratory on 01/23/24 at 10:17 A.M. for Resident #78. The DON confirmed the physician was not notified of the abnormal laboratory results on 01/23/24, and confirmed staff should inform the physician immediately of abnormal results. Interview on 03/13/24 at 12:37 P.M. with ADON #123 confirmed the collection of Resident #78's urine for the urinalysis five days and confirmed the urinalysis was not completed in a timely manner. Review of a change in condition policy, dated 10/18/01, revealed the unit supervisor or charge nurse will notify the physician of any change of conditions. 365929 Page 19 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to serve residents therapeutic diets as ordered. This affected one (#42) of seven residents reviewed for nutrition. The facility census was 86. Findings Include: Review of the medical record for Resident #42 revealed an initial admission date of 01/12/24 with diagnoses including senile degeneration of the brain, diabetes mellitus, obstructive sleep apnea, chronic kidney disease, anemia, hyperlipidemia, atrial fibrillation, hypertension, benign prostatic hyperplasia, and altered mental status. Review of the admission assessment and baseline care plan dated 01/12/24 revealed Resident #42's admission weight was 193.4 pounds. The assessment indicated the resident was alert and confused. The assessment indicated the resident was edentulous and was dependent on staff for eating. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had a severe cognitive deficit. Review of the plan of care dated 01/16/24 revealed Resident #42 had a potential for nutrition and hydration risk related to overweight status, diagnoses of diabetes mellitus, chronic kidney disease, anemia, altered mental status, and at risk for skin breakdown. A care plan intervention was initiated to provide diet as ordered. On 03/11/24 at 12:14 P.M., observation of Resident #42's lunch tray revealed the resident was served a puree diet instead of the physician ordered regular diet with sandwiches for the entree. On 03/11/24 at 12:18 PM, interview with Dietary Supervisor #134 verified Resident #42 received a puree diet instead of the physician ordered regular diet with sandwiches for the entree. 365929 Page 20 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on review of monthly infection control surveillance logs, staff interview, and facility policy review, the facility failed to to maintain a complete and accurate tracking system for all infections. This had the potential to affect all 86 residents residing in the facility. The census was 86. Residents Affected - Many Findings Include: Review of the facility infection control monthly surveillance log on 03/13/24 revealed the facility failed to document the results of cultures for residents with suspected or actual infections from May 2023 through February 2024. On 03/13/24 at 10:20 A.M., interview with the Director of Nursing (DON) and the Regional Nurse #200 verified the infection control log was not tracking the bacteria being treated for community acquired and facility acquired infections. Review of the facility policy titled, Infection Surveillance, last revised 11/28/17, revealed data to be used in the surveillance activities may include but are not limited to 24-hour shift reports, laboratory (lab) reports, antibiograms obtained from lab, antibiotic use reports from pharmacy, and documentation of signs and symptoms in clinical record. 365929 Page 21 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 2. On 03/11/24 at 8:53 A.M., observation of Resident #42's room revealed the room had a strong odor of urine. Further observation revealed there was urine under the fall mattress on the floor and under the resident's bed. Interview with Licensed Practical Nurse (LPN) #110 on 03/11/24, at approximately 8:53 A.M. at the time of the observation of Resident #42's room, verified the urine on the floor under the fall mattress and verified the strong smell of urine in the room. Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment. This affected two (#6 and #42) of five residents reviewed for environment. The facility census was 86. Findings include: 1. Observation on 03/10/24 at 10:33 A.M., 11:40 A.M., and 12:33 P.M., and on 03/11/24 at 12:15 P.M. revealed Resident #6 was in her bed which was observed against the wall. Further observation revealed the wall surface from the middle to the head of the Resident #6's bed had brown and red splatters of an unidentifiable substance, and in some areas, the splatters appeared to be dripping down behind the bed. Interview on 03/11/24 at 12:15 P.M. with State Tested Nurse Aide (STNA) #145 verified the brown and red splatter on the wall in Resident #6's room. STNA #145 indicated the wall needed to be cleaned. 365929 Page 22 of 23 365929 03/13/2024 Crown Pointe Care Center 1850 Crown Park Court Columbus, OH 43235

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of facility pest control records, resident family and staff interview, and review of the facility pest control policy, the facility failed to maintain a pest free environment. This affected one (#13) of 24 resident's rooms observed. The census was 86. Residents Affected - Few Findings Include: Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure, emphysema, type II diabetes, unspecified protein-calorie malnutrition, complete traumatic amputation of one lesser toe, muscle weakness, dysphagia, bipolar disorder, and congestive heart failure. Review of Resident #13's Minimum Data Set (MDS) assessment, dated 02/20/24, revealed the resident had a mild cognitive impairment. Interview with Resident #13's family member on 03/10/24 at 2:05 P.M. stated there were ants that crawled all over Resident #13's sink. Resident #13's family member stated the facility was aware of it, but she was not certain what they are doing about it. Observation on 03/12/24 at 8:11 A.M. confirmed ants were on Resident #13's sink. Further observation revealed the ants were cleaned by staff after the observation at 8:11 A.M. Interview with Maintenance Staff #112 and State Tested Nurse Aide (STNA) #250 on 03/12/24 at 8:11 A.M. confirmed there were ants on Resident #13's sink, and verified they would clean them. An additional observation on 03/12/24 at 9:15 A.M. revealed there were more ants present on Resident #13's sink. Review of facility pest control records, dated 02/20/24, revealed the facility had the pest control company treat for ants in their main kitchen with no indication of treatments provided to Resident #13's bedroom. Review of the facility pest control policy, dated 08/17/18, revealed the facility will maintain effective pest control that eradicates and contains common household pests and rodents (e.g. bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats. Comprehensive pest control treatments/services will be used as needed. Chemicals for controlling pests may be used inside the facility if they are safe and will not compromise resident health. A variety of methods for controlling certain season pests may be used as deemed appropriate. The exterior perimeter of the facility and any outlying buildings or structure. 365929 Page 23 of 23