Health inspection·March 4, 2025

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, resident, resident family, and staff interview, medical record review, and policy review, the facility failed to ensure residents received assistance with bathing and nail care. This affected three (#13, #21, and #102) of four residents reviewed for activities of daily living (ADLs) for dependent residents. The facility census was 99. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #102 revealed an admission date of 11/04/24 and discharge date of 01/19/25. Diagnoses included amputation of the right foot, diabetes, muscle disorder, end stage renal disease, epilepsy, and heart failure. Review of the plan of care dated 11/04/24 revealed Resident #102 had a self-care deficit with interventions to assist with bathing and shower as needed, and assist with hygiene, grooming, dressing as needed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #102 was cognitively intact and required substantial maximum assistance for toileting, bathing, and personal hygiene. Resident #102 was dependent for transfers from a bed to a chair, required substantial maximum assistance for toilet transfers, and tub/shower transfers were not attempted during the MDS assessment review period. Review of Resident #102's medical record revealed no evidence of showers from November or December 2024. Review of shower documentation in January 2025 revealed the resident was bathed on 01/16/25 and 01/19/25. On 01/19/25, the resident was transferred out of the facility to the hospital and did not return. Interview on 02/27/25 at 10:30 A.M. with Regional Nurse #200 confirmed showers were only documented twice out of 19 days of Resident #102's stay in January 2025, and confirmed the facility had no documentation of the resident being bathed in November or December 2024. 2. Review of the medical record for Resident #13 revealed an admission date of 10/17/24. Diagnoses included dysphasia, muscle disorder, mobility abnormalities, diabetes with a foot ulcer, respiratory failure, and dependence on renal dialysis. Review of the plan of care dated 10/18/24 revealed Resident #13 had a self-care deficit with interventions to assist with baths and showers as needed, and assist with daily hygiene, grooming, dressing, and oral care as needed. Review of the MDS assessment dated [DATE] revealed Resident #13's cognition was not assessed and resident required substantial maximum assist for toileting and bathing, lower body dressing, partial moderate assistance for upper body dressing, and supervision touching assistance with personal hygiene. Resident #13 required substantial maximum assistance for transfers from a bed to a chair, toilet transfers, and tub/shower transfers. Review of cognitive assessment dated [DATE] revealed Resident #13 had intact cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365950 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sapphire Rehabilitation and Care Center 1605 Northwest Professional Plaza Columbus, OH 43220 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #13's medical record revealed the facility provided showers on 02/01/25, 02/03/25, 02/05/25, 02/18/25, 02/22/25 with no refusals documented. Further review of the documentation revealed no indication nail care was completed on any bathing date. Interview and observation on 02/26/25 at 1:35 P.M. with Resident #13 and Resident #13's family member revealed Resident #13 would like her nails trimmed. Both Resident #13 and Resident #13's family member stated the resident had asked facility staff for assistance with trimming her finger nails, but staff have not assisted her. Resident #13's family member reported the facility had a nail activity each month, but it was during the resident's dialysis appointments, so the resident missed the activity every time. Observation during the interview revealed Resident #13's finger nails were untrimmed. Observation and interview on 02/27/25 at 9:15 A.M. with Resident #13 and Certified Nurse Aide (CNA) #55 confirmed Resident #13's finger nails were long and extended about one to two inches past the nail beds. Resident #13 was observed telling CNA #55 she wanted her nails trimmed and had trouble getting staff to assist her. Interview on 02/27/25 at approximately 10:30 A.M. with Regional Nurse #200 confirmed resident finger nail care should be offered to residents as needed and on shower days. 3. Review of the medical record for Resident #21 revealed an admission date of 01/16/25. Diagnoses included chronic respiratory failure, heart disease, anxiety, heart failure, anemia, and dependence on renal dialysis. Review of the plan of care dated 01/17/25 revealed Resident #21 had a self-care deficit with interventions to allow time for the resident to express feelings, and assist with activities of daily living. Review of the MDS assessment dated [DATE] revealed Resident #21 was cognitively intact, was dependent for toileting, bathing, upper and lower body dressing, and required partial moderate assistance with personal hygiene. Resident #21 was dependent for transfers from a bed to a chair, toilet transfers, and tub/shower transfers. Review of Resident #21's medical record revealed the facility provided showers on 01/29/25, 01/30/25, 02/13/25, and 02/24/25 with one refusal documented earlier in the day on 01/29/25. Interview on 02/26/25 at 1:12 P.M. with Resident #21 revealed she was not provided bathing assistance consistently. Interview on 02/26/25 at 4:40 P.M. with Regional Nurse #200 confirmed Resident #21's showers were only documented four times in the past two months. She confirmed staff should be documenting each shower or bath offered and good hygiene should be maintained. Review of facility policy titled, Activity of Daily Living, dated 08/2023, revealed residents shall be provided with care and services to maintain activities of daily living. Residents unable to carry out tasks independently shall receive assistance to maintain good grooming and hygiene including bathing care. This deficiency represents non-compliance investigated under Complaint Number OH00162784. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365950 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sapphire Rehabilitation and Care Center 1605 Northwest Professional Plaza Columbus, OH 43220 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 0825 Provide or get specialized rehabilitative services as required for a resident. 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, resident family, and staff interview, policy review, the facility failed to ensure physical therapy was provided as ordered. This affected two (#13 and #102) of three residents reviewed for therapy services. The facility census was 99. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 10/17/24. Diagnoses included dysphasia, muscle disorder, mobility abnormalities, diabetes with a foot ulcer, respiratory failure, and dependence on renal dialysis. Review of Resident #13's physician orders dated 11/07/24 to 02/10/25 revealed physical therapy was recommended for skilled treatment five times weekly until 12/11/24. Resident #13 had an order dated 12/06/24 to 02/10/25 for physical therapy recommended for skilled treatment five times weekly until 01/04/25. Further review reveled a third order for 02/19/25 with no end date for a physical therapy recommended for skilled treatment five times weekly. Review of Resident #13's therapy notes dated 12/06/24 to 01/04/25 revealed no evidence of treatment notes or therapy assessments. Review Resident #13's progress notes dated 01/27/25 revealed the resident's daughter requested the resident be screened by therapy to get back in services. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13's cognition was not assessed. The resident required substantial maximum assistance for toileting, bathing, and lower body dressing, and partial moderate assistance for upper body dressing and supervision touching assistance with personal hygiene. Resident #13 also required substantial maximum assistance for transfers from a bed to a chair, toilet transfers, and tub/shower transfers. Review of a cognition assessment dated [DATE] revealed Resident #13 was cognitively intact. Review of the physical therapy assessment dated [DATE] revealed a recommendation for Resident #13 to receive therapy five times weekly. Review of therapy notes revealed Resident #13 was offered or seen by therapy on 02/18/25, 02/21/25, 02/22/25, 02/24/25, and 02/25/25, which equated to two to three times weekly. Interview on 02/26/25 at 1:35 P.M. with Resident #13 and Resident #13's family member stated the resident had not received much therapy until recently. Resident #13 had been admitted for rehabilitation, but the first few months therapy services were not consistent. Interview on 02/27/25 at 10:30 A.M. with Regional Nurse #200 confirmed all of Resident #13's therapy notes the facility had were provided for review and acknowledged Resident #13 had no physical therapy notes from November 2024, December 2024, and January 2025 when the resident was ordered therapy. Interview on 02/07/25 at 11:57 A.M. with Therapy Manager #250 confirmed the therapy department had (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365950 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sapphire Rehabilitation and Care Center 1605 Northwest Professional Plaza Columbus, OH 43220 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 0825 no additional notes or evidence of therapy being provided as ordered for Resident #13. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #102 revealed an admission date of 11/04/24. Diagnoses included amputation of the right foot, diabetes, muscle disorder, end stage renal disease, epilepsy, and heart failure. The resident was discharged on 01/19/25. Residents Affected - Few Review of the MDS assessment dated [DATE] revealed Resident #102 was cognitively intact, and required substantial maximum assistance for toileting, bathing, lower body dressing, and personal hygiene, and partial moderate assistance for upper body dressing. Resident #102 was dependent for transfers from a bed to a chair, required substantial maximum assistance for toilet transfers, and tub/shower transfers were not attempted during the MDS assessment review period. Review of a physician order dated 11/05/24 to 02/10/25 revealed Resident #102 was ordered physical therapy recommended for skilled treatment five times weekly until 12/09/24. Review of an additional order dated 12/10/24 to 01/06/25 for physical therapy recommended for skilled treatment five times weekly was given. Review of a physical therapy evaluation dated 11/05/24 revealed Resident #102 was to be seen five times weekly by physical therapy. Review of therapy notes revealed Resident #102 was offered or seen by therapy on 11/05/24, 11/06/24, 11/07/24, 11/11/24, 11/12/24, 11/13/24, 11/15/24, 11/17/24, 11/18/24, 11/20/24, 11/21/24, 11/22/24, 11/26/24, 11/30/24, 12/02/24, 12/04/24, 12/06/24, 12/07/24, which equated to two to four times weekly. Review of a physical therapy evaluation dated 12/10/24 revealed Resident #102 was to be seen five times weekly by physical therapy. Review of therapy notes revealed Resident #102 was offered or seen by therapy on 12/09/24, 12/11/24, 12/13/24, 12/16/24, 12/17/24, 12/18/24, 12/20/24, 12/26/24, 12/28/24, and 12/30/24, which equated to two to four times weekly. Review of a physical therapy evaluation dated 12/31/24 revealed Resident #102 was to be seen three to five times weekly by physical therapy. Review of therapy notes revealed Resident #102 was offered/seen by therapy on 01/03/25, 01/04/25, 01/08/25, 01/09/25, 01/13/25, 01/16/25, 01/17/25, which equated to two to three times weekly. Interview on 02/26/25 at 11:50 A.M. with Resident #102's family member revealed concerns about the amount of therapy Resident #102 received in the facility. Resident #102's family member also reported concerns were confirmed when talking with therapy staff that the facility did not have enough employees in the therapy department and were unable to keep up with the work load. Interview on 02/27/25 at 11:57 A.M. with Therapy Manager #250 reported when the facility was bought out, all therapy staff left. She revealed facility was then having offsite staff copy and paste therapy assessments and tried to see residents as often as possible but acknowledged facility had one physical therapy assistant (PTA) and 100 residents admitted to the facility. Therapy Manager #250 acknowledged the facility continued to admit new residents for skilled services and verified Resident #102 did not receive therapy as ordered. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365950 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sapphire Rehabilitation and Care Center 1605 Northwest Professional Plaza Columbus, OH 43220 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 0825 Level of Harm - Minimal harm or potential for actual harm Review of facility policy titled, Specialized Rehabilitative Services, from 2024, revealed facility shall provide rehabilitation services to residents upon the written order of the physician until a resident has met their goals. This deficiency represents non-compliance investigated under Complaint Number OH00162784. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365950 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Sapphire Rehabilitation and Care Center 1605 Northwest Professional Plaza Columbus, OH 43220 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 medical record review, staff interview, review of infection control logs, and policy review, the facility failed to ensure COVID-19 infections were adequately monitored. This affected one (#102) of three reviewed for COVID-19 infections. The facility census was 99. Residents Affected - Few Findings include: Review of the medical record for Resident #102 revealed an admission date of 11/04/24. Diagnoses included amputation of the right foot, diabetes, muscle disorder, end stage renal disease, epilepsy, and heart failure. The resident was discharged on 01/19/25. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #102 was cognitively intact. Review progress notes dated 01/08/25 revealed Resident #102 was evaluated for a transfer to an assisted living facility, and a COVID-19 test was requested. Resident #102 tested negative and all parties were updated. Review of a subsequent progress note dated 01/10/25 revealed Resident #102's family was concerned about a change in condition and a COVID-19 test was ordered. Resident #102's test for COVID-19 was positive at that time. Review of Resident #102's physician orders for 01/10/25 revealed an order for a COVID-19 test to be completed. Review of infection logs revealed no evidence of Resident #102's positive COVID-19 test from 01/10/25 being included or reviewed as part of the facility's infection control surveillance program. Interview on 02/27/25 at 10:30 A.M. with Regional Nurse #200 confirmed the facility had no evidence related to monitoring or tracking Resident #102's COVID-19 infection. Review of a facility policy titled, Infection Control Prevention Program, dated 11/2022, revealed the facility shall monitor infections and reports of infections shall be maintained and discussed with infection preventionist and committee. This deficiency represents non-compliance investigated under Complaint Number OH00162784. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365950 If continuation sheet Page 7 of 7