Health inspection·July 28, 2025

F 0558 Level of Harm - Minimal harm or potential for actual harm Observation on 07/23/25 at 2:11 P.M. revealed Resident #1's call light was at the bottom left side of her bed out of resident reach. Interview on 07/23/25 at 2:13 P.M. with Staff Nurse #123 confirmed the call light was located at the bottom left side of her bed out of reach for resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 2 of 12 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 07/28/2025 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 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Potential for minimal harm Based on observation and staff interview, the facility failed to ensure State Agency survey results were maintained, updated, and available for viewing. This had the potential to affect all 89 residents in the facility. Findings include:Observation on 07/24/25 at 2:45 P.M. revealed the survey results binder, located at the front of the building, next to the Administrator's office, revealed the most recent survey results were dated 04/20/24.Review of Enhanced Information Dissemination Collection (EIDC) revealed the facility had surveys completed on 07/31/24 and 10/10/24. Interview on 07/24/25 at 2:48 P.M., the Administrator verified survey results dated 07/31/24 and 10/10/24 were not contained in the survey results binder. The Administrator verified survey results should be placed in the survey results binder following each survey. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 3 of 12 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 07/28/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **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 ensure a resident's responsible party was notified of a new order for a therapy evaluation. This affected one (#97) of one residents reviewed for a change in condition. The facility census was 89. Review of the medical record of Resident #97 revealed an admission date of 10/15/21. The resident discharged from the facility on 07/15/25. Diagnoses included chronic obstructive pulmonary disease, morbid obesity, hemiplegia and hemiparesis following cerebral infarction affecting left-non-dominant side, hyperlipidemia, atrial fibrillation, depression, dementia, anxiety, legal blindness, mood disorder, insomnia, and dysphagia. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had moderately impaired cognition. Review of the medical record revealed an order dated 04/15/25 for the resident to have a physical therapy and occupational therapy evaluation and treatment. The order was signed by Licensed Practical Nurse (LPN) #177. The area on the order for family notification was blank. Further review of the medical record revealed no evidence of Resident #97's responsible party being notified of the new order for therapy evaluation and treatment. Interview on 07/24/25 at 1:17 P.M., LPN #177 verified she was the nurse who signed the order for Resident #97 to receive evaluation and treatments from therapy. LPN #177 stated she assumed she notified Resident #97's responsible party of the new order, however verified there was no documented evidence in the medical record of the responsible party being notified of the new order. Review of the facility policy, dated 04/2013, revealed the unit supervisor or charge nurse will notify the guardian/interested family member of any significant changes in a resident's clinical condition or status, including ADL [activities of daily living] physical functioning and document said notification. This deficiency represents non-compliance investigated under Complaint Number 1327655. Event ID: Facility ID: 365929 If continuation sheet Page 4 of 12 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 07/28/2025 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure admission comprehensive Minimum Data Set (MDS) assessments were completed within the required timeframes. This affected two (#03 and #37) of three residents reviewed for resident assessment. The facility census was 89. 1. Review of the medical record of Resident #37 revealed an admission date of 12/24/24. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included amyotrophic lateral sclerosis and dementia. Review of the medicare 5-day MDS assessment dated [DATE] revealed the resident had severely impaired cognition. Further review of completed MDS assessments revealed the resident's admission MDS assessment dated [DATE] was not completed until 01/10/25. The resident's discharge MDS assessment dated [DATE] was not completed until 02/10/25. The resident's entry MDS assessment dated [DATE] was not completed until 02/10/25. Interview on 07/24/25 at 1:13 P.M., Licensed Practical Nurse (LPN) #144 verified Resident #37's admission MDS assessment was not completed within 14 days of the resident's admission. 2. Review of the medical record of Resident #03 revealed an admission date of 06/23/25. Diagnoses included chronic obstructive pulmonary disease (COPD) and severe protein-calorie malnutrition. Review of the admission MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The assessment was not completed until 07/09/25. Interview on 07/24/25 at 1:06 P.M., LPN #144 verified Resident #03's admission MDS assessment was not completed within 14 days of the resident's admission. Event ID: Facility ID: 365929 If continuation sheet Page 5 of 12 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 07/28/2025 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. 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 entry and discharge Minimum Data Set (MDS) assessments were completed in a timely manner. This affected two (#37 and #40) of three residents reviewed for resident assessment. The facility census was 89.Findings Include:1. Review of the medical record of Resident #37 revealed an admission date of 12/24/24. The resident transferred to the hospital on [DATE] and returned to the facility on [DATE]. Diagnoses included amyotrophic lateral sclerosis and dementia. Review of the Medicare 5-day MDS assessment dated [DATE] revealed the resident had severely impaired cognition. Further review of completed MDS assessments revealed the resident's discharge MDS assessment dated [DATE] was not completed until 02/10/25. The resident's entry MDS assessment dated [DATE] was not completed until 02/10/25. Interview on 07/24/25 at 1:13 P.M., Licensed Practical Nurse (LPN) #144 verified Resident #37's discharge MDS assessment dated [DATE] and entry MDS assessment dated [DATE] were not completed within the required time frames. 2. Review of the medical record of Resident #40 revealed an admission date of 05/27/25. The resident discharged from the facility on 05/31/25. Diagnoses included dementia and cerebral infarction. Review of the admission MDS assessment dated [DATE] revealed the resident had severely impaired cognition. Further review of the medical record revealed there was no discharge MDS completed following the resident's discharge. Interview on 07/24/25 at 1:13 P.M., LPN #144 verified Resident #40 did not have a discharge MDS completed following his discharge on [DATE]. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 6 of 12 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 07/28/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews , medical record review and facility policy review, the facility failed to ensure fall interventions were in place for one, (Resident #76) of one reviewed for falls. The facility census was 89. Review of the medical record for Resident #76 revealed an admission date of 06/08/23. The record revealed the resident had severe cognitive deficits. Resident #76's diagnoses included dementia, chronic obstructive pulmonary disease, heart disease, anemia, depression, and chronic kidney disease. The resident was documented to require one-to-two-person assistance with activities of daily living and ambulation, and the resident had a history of falls.Review of Resident #76's nurse progress notes revealed on 05/29/25 the nurse was called by certified nursing assistant (CNA) at 12:40 P.M. to report he had seen Resident #76 on the floor in bedroom. The nurse went in immediately and found the resident lying on the floor in front of the closet in the bedroom. When the staff asked Resident #76 what happened, the resident told the nurse he fell. Resident #76 was assisted by the nurse and CNA into a wheelchair. A head to toe assessment was completed, and a hematoma was seen on the back of Resident #76's head. Ice was applied and as needed Tylenol (analgesic) was offered. Family, assistant director of nursing (ADON) and the physician were notified. Vitals were documented as stable and neurological checks were documented as in place. Resident had no nausea or vomiting observed at the time.Review of a fall investigation report dated 05/29/25 at 12:45 P.M. revealed Resident #76 was found in his room on the floor in front of his closet. He was alert and orientated to himself and reported he had fallen. A head-to-toe assessment revealed Resident #76 had a hematoma to the back of his head. Neurological checks were established. All parties were notified. The new fall precaution for Resident #76 was to have a safety alarm on while he was in a chair and or in bed. Staff to verify placement every shift.Review of Resident #76's plan of care last updated 6/11/25 revealed the resident had the following fall interventions: physical therapy, occupational therapy, non-skid strips in the bathroom, in front of closet and in front of bathroom entry, and bilateral assist bars to enhance bed mobility. On 07/24/25 Observation of Resident #76 on 07/24/25 at 11:24 A.M. revealed the resident was sitting in the lounge area in a wheelchair without a safety alarm in place. After surveyor intervention CNA #120 verified there was no safety alarm and clipped it on the Resident #76 shirt and wheelchair. On 07/24/25 at 11:37 A.M. observation and interview with Licensed Practical Nurse (LPN) #184 confirmed there is only one alarm for Resident #76, when he is in his bed, he is to have the alarm clipped to the mattress and himself and staff are to check the alarm every shift. Review of facility policy titled Alarms-person monitoring policy, dated 07/15/2003, revealed it is the Licensed Profession Nurse to ensure the residents personal monitoring alarms are in place and ordered.Review of facility policy titled Fall Management, dated 10/17/16 revealed Residents who experience a fall will receive prompt medical attention. Immediate needs will be quickly assessed and responded to. The interdisciplinary team will determine the need for development of additional facility-wide or resident specific interventions, staff, resident and/or family education and training, or other follow up measures that may be needed to reduce the risk of recurrence. Event ID: Facility ID: 365929 If continuation sheet Page 7 of 12 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 07/28/2025 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and facility policy review, the facility failed to ensure staff wore hair nets in the kitchen as required. This had the potential to affect 88 residents in the facility. The facility identified one resident (#03) who did not receive food from the kitchen. The facility census was 89. 1. Observation on 07/23/25 at 7:20 A.M. revealed [NAME] #168 assisting [NAME] #119 with obtaining food temperatures on the steam table. [NAME] #168 was observed with braids which extended approximately 18 inches down her back and was not wearing a hair net. Observation on 07/23/25 at 7:36 A.M., [NAME] #168 was observed briefly leaving the kitchen and returned, wearing a hair net, however her braids still remained hanging outside of the hairnet. [NAME] #168 was then observed tending to food items on the facility stove.Interview on 07/23/25 at the time of the observation., [NAME] #168 verified she had not been wearing a hairnet until she left the kitchen and returned wearing the hair net, which still did not contain all of her hair. 2. Observation on 07/23/25 at 7:47 A.M., Maintenance Director (MD) #213 entered the kitchen without a hair net, walked past the stove and food preparation area, and checked the thermostat above the food preparation area. MD #213 was observed with short hair, approximately one inch in length, and no hair restraint. Interview at the time of the observation, MD #213 verified he was not wearing a hair net upon entering the kitchen and verified he should have applied a hair net prior to entering the kitchen. Review of the facility policy titled, Infection Control-Dietary/Food Handling, dated 02/2016, revealed hair nets or caps must be worn to effectively keep hair from contacting exposed food, clean equipment, utensils, and linens. This deficiency represents non-compliance investigated under Complaint Number 1327653. Event ID: Facility ID: 365929 If continuation sheet Page 8 of 12 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 07/28/2025 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 0826 Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. 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, resident interview, and staff interview, the facility failed to timely provide a physical therapy evaluation. This affected one (#04) of two residents reviewed for abuse. The facility census was 89. Findings include:Review of the medical record of Resident #04 revealed an admission date of 01/30/23. Diagnoses included metabolic encephalopathy, parkinsonism, schizoaffective disorder, bipolar disorder, and hypertension. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was assessed as exhibiting delusions, verbal behavioral symptoms directed towards others during the assessment period. The resident utilized a walker and wheelchair for mobility. The resident required setup/clean-up assistance with eating, partial/moderate assistance for dressing, substantial/maximal assistance for toileting, bed mobility, and transfers, and was dependent for bathing. Review of a self-reported incident (SRI) dated 05/27/25 revealed Resident #04 was involved in an altercation with Resident #48 when Resident #04 was observed running his power scooter into Resident #48's left foot and walker. Resident #04 stated he ran his power scooter into Resident #48 because Resident #48 would not get out of his way. The residents were assessed for injuries and had no negative findings. Resident #04 was moved to a manual wheelchair and was to be reassessed by therapy for the ability to safely use the power scooter. Resident #04 acknowledged understanding and was aware therapy would work with him on the scooter. Review of a social services progress note dated 05/28/25 revealed the resident was being assessed for the use of his electric scooter. At that time, the resident was not authorized to use the scooter. Review of a nursing progress note dated 07/02/25 revealed the nurse talked with therapy and re-educated the resident on proper use of walker and wheelchair. The nurse made a therapy referral to follow-up on the resident's non-compliance. Review of physician orders dated 07/02/25 revealed an order for a Physical Therapy (PT) screen and/or evaluation or treatment for proper transfer/use of adaptive equipment due to non-compliance. Review of therapy documentation revealed Resident #04 was last seen by PT 01/08/25-02/03/25 and Occupational Therapy (OT) 01/03/25-01/31/25. Further review of the medical record revealed no evidence of Resident #04 being assessed by therapy since the incident which occurred on 05/27/25. Observations on 07/24/25 at 4:00 P.M. and 07/28/25 at 10:20 A.M., revealed Resident #04's scooter was parked in the hallway outside of Resident #04's room. Interview on 07/28/25 at 10:20 A.M., the resident stated he had not been able to use his electric scooter in several months. The resident verified his scooter was sitting in the hallway and stated he had not been assessed for its use since it was taken away months prior. Interviews on 07/28/25 at 10:26 A.M. and 11:25 A.M., Director of Rehabilitation (DOR) #162 stated she did not have any evidence of evaluating Resident #04 for the use of his electric scooter following the 05/27/25 incident. DOR #162 verified Resident #04 had an order for a PT evaluation on 07/02/25 and there was no evaluation completed until the morning of 07/28/25. DOR #162 stated she looked at the resident following the order on 07/02/25, however made the determination to wait until the resident's mental status became more stable, as he was having issues with complying with his medication regimen. DOR #162 stated there was no documentation regarding the need to wait to complete the evaluation. DOR #162 stated the expectation, following receiving an order for a therapy evaluation or screen, is to have it completed and documented within a few days but no more than a week. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 9 of 12 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 07/28/2025 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 observation , interview and facility policy review the facility failed to follow proper infection control policies when an outbreak of a contagious skin infection occurred in the facility. This affected two residents (#46 and #87) out of 13 residents who resided in the three hundred unit. The facility also failed to follow appropriate infection control practices by not performing proper hand hygiene after performing catheter care for one resident (#6) . The census was 89. 1.Review of the medical record for Resident #87 revealed an admission date of 04/23/24 with a brief interview of mental status (BIMS) score of 99 indicating severe cognitive deficits. Diagnoses included cerebral infarction, malignant neoplasm, paroxysmal atrial fibrillation, anxiety, hyperlipidemia , dementia, gastro esophageal reflux disease (GERD) and hypertension. The resident was independent with ambulation and wanders throughout the facility. Review of Resident #87's physician orders revealed a rash appeared on his body around 12/27/24 on his upper chest, back, bilateral forearms, abdomen and left side. The rash was treated with multiple medications until it was diagnosed as scabies (an infestation of the human skin by an itch mite) on 01/23/25. The scabies treatment started on 01/24/25 . Resident #87 was placed in contact isolation from 01/27/25 to 02/08/25 . Review of the Dermatologist progress note on 1/23/25 revealed the resident was diagnosed with scabies. Assessment and Plan included scabies located on his trunk, extremities, umbilicus and genitals: Patient informed of etiology and contagious nature of condition. Treatment options discussed. Start Ivermectin 3 milligrams (mg) tablets take five tablets on day 0, repeat in one week. Risk/ benefit/Side Effect (R/B/SE) and proper use of medication disc. Start TAC 0.1% ointment two times a day to itchy areas. R/B/SE and proper use of medication disc. Return to office in four weeks for rash follow up. Family was present and verbalized understanding and agreed with plan. Review of Resident #87's nurses progress notes from 01/20/25 to 01/31/25 revealed on 01/23/25 he was observed walking throughout the facility with no pants on . After several minutes the resident allowed staff to put his pants on. There was no indication staff were notified to follow contact isolation when treating Resident #87 at this time.Review of the Infection Control Surveillance Log from 01/01/25 to 03/31/25 revealed Resident #87 was not listed on the log for the scabies diagnosis.On 07/24/25 at 9:49 A.M. an interview with the Assistant Director of Nursing (ADON) #177 confirmed only one resident in the facility was diagnosed and treated for scabies. She could not confirm the facility completed skin sweeps on residents in Unit 300 or in the facility when Resident #87 was diagnosed with scabies.On 07/24/25 at 3:30 P.M. an interview with a Former Employee #510 confirmed there were two residents diagnosed with scabies. The Former Employee stated there was no staff education regarding scabies or infectious skin conditions. Resident #87 was allowed to wander throughout the facility going into the dining room for meals, lounge area and congregate with fellow residents and staff, while being on contact isolation. On 07/28/25 at 8:38 A.M. an interview with Licensed Practical Nurse # 184 confirmed Resident #87 would not stay in his room when he had scabies. The nurse verified the resident continued to walk throughout the facility while being treated for scabies. 2. Review of the medical record of Resident #46 revealed an admission date of 01/28/22 with a BIMS score of 15 indicating the resident was cognitively intact. Diagnoses included chronic obstructive pulmonary disease, cerebral infarction, schizoaffective disorder, depression, and anxiety. Resident #46 used a walker for mobility and required one person to assist with activities of daily living. Review of Resident #46's nurses progress notes from 01/20/25 to 01/29/25 revealed the nurses reported to Nurse Practitioner (NP) #500 Resident #46 was complaining of itching all over her body. NP #500 visited Resident #46 on 01/24/25 and determined she had crusted scabies since she did not respond to prednisone taper through 01/23/25. Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 10 of 12 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 07/28/2025 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 Residents Affected - Few Review of Resident #46's physician orders for 01/01/25 to 01/31/25 revealed she started treatment for scabies on 01/24/25 and was in contact isolation until 02/08/25. Review of the Infection Control Surveillance Log from 01/01/25 to 03/31/25 revealed Resident #46 was not listed on the log for the scabies diagnosis. The infection log had no indication of any residents in the facility being diagnosed and treated for scabies. With surveyor intervention , the Regional Clinical Director #400 submitted additional surveillance log for 01/01/25 to 01/31/25 indicating one resident was treated for scabies.On 07/24/25 at 9:49 A.M. an interview with the Assistant Director of Nursing (ADON) #177 confirmed only one resident in the facility was diagnosed and treated for scabies. She could not confirm the facility completed skin sweeps on the residents in Unit 300 or in the facility when scabies was identified in the facility. On 07/24/25 at 2:00 P.M. the interview with the Regional Clinical Director #400 confirmed the facility had one resident who was diagnosed and treated for scabies. Regional Clinical Director #400 confirmed the facility had no documentation indicating the local health department was notified of a scabies outbreak at the facility or documentation indicating if all residents in the facility or residents on Unit 300 had a skin sweeps completed to check for scabies after Resident #87 was diagnosed with scabies. On 07/24/25 at 2:25 P.M. interview with Laundry Representative #109 confirmed he recalls washing contaminated linen in January for two residents who were diagnosed with scabies. He denied being educated about scabies or being questioned if he had any rashes. On 07/28/25 at 8:33 A.M. an interview with Resident #47 revealed she was treated for scabies; it was awful and finally it went away. On 07/28/25 at 8:49 A.M. interview with the City of Columbus Health Department Representative #600 confirmed there was no documentation of the facility providing notification to their office of having two residents diagnosed with scabies. Representative #600 stated it is required to report to the local health department when two or more residents in a long-term care facility are diagnosed with scabies. Representative #600 stated then information is sent to the facility with instructions to treat and the health department follows the outbreak for six weeks.Review of the City of Columbus Health Department resource titled: Michigan Department of Community Health Scabies Prevention and Control Manual dated 2005 provided to the surveyor by Representative #600 as the information that would have been issued to the facility had the outbreak of scabies been reported to the local health department. The resource revealed the need for standard precautions stating gowns and gloves should be worn by all facility personnel who have direct contact with suspected or confirmed scabies patients, until completion of treatment, or until scabies has been ruled out. Restrict both patient and roommate(s) to their room for duration of therapy. Do not restrict patient to his/her room if the entire unit is undergoing treatment, but do restrict movement within the nursing unit. Post signs to alert health care workers, visitors, and volunteers of precautions being observed. Any specific isolation precautions beyond standard precautions should be discontinued after treatment has been completedReview of facility policy titled Scabies, dated 07/2018, revealed Staff will implement based on the CDC recommendations to prevent, eradicate, and contain Sarcoptes scabiei (Scabies). The facility should take a systemic approach, including detection and treatment of affected residents. Appropriate transmission-based precautions and infection control practices should be used. Measures to control scabies depend on factors such as how many cases are diagnosed or suspected, how long infested persons have been at the facility while undiagnosed and /or unsuccessfully treated. The local health department may be consulted for any outbreak that may have community implications, including possible spread by patients or staff to other institutions. Control measures for an outbreak involving one or more confirmed crusted scabies may include additional measures for detection , diagnosis, infection control, and treatment measures dependent on community factors . A facility (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365929 If continuation sheet Page 11 of 12 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 07/28/2025 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 Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete information program may be implemented to instruct all management, medical, nursing, and support staff about scabies, the scabies mite, and how scabies is and is not spread.3. Review of the medical record for Resident #6 revealed a readmission date of 01/13/25. Diagnoses included Diabetes Mellitus type 2, neuromuscular dysfunction of the bladder, benign prostatic hyperplasia with lower urinary tract symptoms, history of urinary tract infections (UTI), extended spectrum beta lactamase (ESBL) resistance, dysphagia, and atherosclerotic heart disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact with a Brief Interview for Mental Status (BIMS) of 13. Resident #6 had no impairment with functional limitation of range of motion, utilized a walker and wheelchair for mobility, and required moderate assistance with toileting and showering. Resident #6 was frequently incontinent of bowel.Review of the plan of care dated 06/11/25 revealed a risk for infection with a goal that resident will remain free of signs and symptoms of infection with interventions for foley catheter care and monitor for signs and symptoms of urinary tract infection (UTI): foul smelling urine, cloudy urine, sediment, and decreased output.Review of physician orders for 01/14/25 for Resident #6 revealed orders for enhanced barrier precautions due to foley catheter and to perform catheter care every shift.Observation of catheter care on 7/23/25 at 10:03 A.M. revealed certified nurse aide (CNA) #158 did not remove her soiled gloves and perform hand hygiene after she provided catheter care to Resident #6. CNA #158 assisted resident with dressing, straightened his linens, assisted him to his wheelchair, and placed his call light back on the bed with soiled gloves.Interview with Assistant Director of Nursing (ADON) #177 confirmed CNA #158 should have removed soiled gloves and performed hand hygiene before assisting Resident #6 with dressing, transferring, and handling linen and call light.Facility policy dated October 18, 2001, titled Catheter Care/Urinary stated Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Reposition the bed covers. Make resident comfortable. Place call light within easy reach of resident.This deficiency represents non-compliance investigated under Complaint Number 1327647. Event ID: Facility ID: 365929 If continuation sheet Page 12 of 12