Health inspection·October 10, 2024

F 0610 Level of Harm - Minimal harm or potential for actual harm Interview with the Administrator on 10/10/24 at 10:40 A.M. verified the facility did not have any further information on the SRI investigation including staff interviews/statements. Interview with Assistant Director of Nursing #11 on 10/10/24 at 11:20 A.M. stated she just called the staff and interviewed the staff by telephone but she did not have any documented interviews. Residents Affected - Few Interview with LPN #12 on 10/10/24 at 11:37 A.M. stated Resident #50 would not get out of bed on 09/27/24. LPN #12 stated normally she could walk by herself unassisted sometimes, but usually needed help. LPN #12 stated she was not asked to write a statement about the incident. Interview with STNA #14 on 10/10/24 at 11:49 A.M. stated the morning of 09/27/24, Resident #50 yelled in pain when she put her sock on. STNA #14 went and got the nurse on duty. She thought the nurse told her to write a statement but she was unsure if she wrote a statement or not. 2. Record review of Resident #101 revealed an admission date of 05/05/23 and he passed away in the facility on 09/03/24. Diagnoses included dementia without behaviors, traumatic subdural hemorrhage without loss of consciousness, and age related osteoporosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 was severely cognitively impaired and used a wheelchair to aid in mobility. Review of the progress note dated 08/15/24 at 5:40 P.M. revealed Resident #101 had pain in his right leg starting at right foot radiating up the leg. Slight warmth to the touch minimal swelling. The progress note dated 08/16/24 at 4:56 A.M. revealed right hip two view x-ray stat was ordered. The progress note dated 08/16/24 at 10:47 A.M. revealed Resident #101 was sent to the hospital due to a fracture of the right hip. Review of the facility's self-reported incident (SRI) control number 250845 dated 08/16/24 revealed an injury of unknown origin was reported to the State Survey Agency. On 08/16/24, Resident #101 was found to have a right hip fracture. The facility's investigation did not include staff statements or staff interviews asking if they had seen anything out of the ordinary for Resident #101 except for one. The Director of Nursing (DON)'s statement stated the Nurse Practitioner said it was possible the hip was just dislocated itself since it was replaced 10 years prior. The facility had a basic SRI Investigation form that was evidence of training. The DON stated she spoke with each STNA that worked the night of 08/15/24 into the morning of 08/16/24. Each STNA stated there was nothing out of the ordinary with this resident. There was no documented interview with any of the staff in the investigation. The form was signed by trained employees that asked have you witnessed any staff, resident, or visitor be abusive toward any resident. Have you ever committed abuse, neglect or mistreated a resident? Do you know who to report to? The bottom of the paper stated I acknowledge that my answers are accurate and I understand the inservice provided to me. The facility's SRI investigation revealed there was no evidence of a statement from Licensed Practical Nurse (LPN) #12 or State Tested Nursing Assistant (STNA) #14. Interview with the Administrator on 10/10/24 at 10:40 A.M. verified the facility did not have any further information on the SRI investigation including staff interviews/statements. Interview with LPN #12 on 10/10/24 at 11:37 A.M. revealed Resident #101 could not get up safely out of bed and she was not interviewed about his dislocated femur. LPN #12 stated she was not asked to write a statement about the incident. (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 10/10/2024 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with STNA #14 on 10/10/24 at 11:49 A.M. revealed she was not asked to write a statement about Resident #101's dislocated femur. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Resident Property Policy dated 11/21/16 revealed in response to abuse, neglect, exploitation, or mistreatment, the facility must have evidence that alleged violations are thoroughly investigated. This deficiency represents non-compliance investigated under Complaint Number OH00158297. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 3 of 3