Health inspection·December 11, 2025

F 0576 Ensure residents have reasonable access to and privacy in their use of communication methods. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and policy review, facility failed to ensure residents had privacy when communicating on the phone. This affected one (#35) of three residents reviewed for communication with privacy. Facility census was 108. Review of the medical record for Resident #35 revealed an admission date of 06/06/22. Diagnoses included anxiety, dysphagia, muscle wasting, vascular dementia and Alzheimer's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 00, indicating severe cognitive impairment, and revealed the resident was rarely if ever understood.Review of the medical record for Resident #35 revealed she had a guardian and a family member (son) involved with her care. Observation on 12/10/25 at 2:16 P.M. of the Resident #35's room revealed a corded phone on the nightstand, but not plugged into the wall for service. Resident #35 was unable to be interviewed due to cognitive status. The resident's roommate, Resident #23, had the same type of phone plugged into the wall and the resident stated she had service and confirmed Resident #35's phone jack (outlet) did not have service. Resident #23 reported she knew that the phone jack had not worked for at least several months as she used to stay in that bed on that side of the room and it never worked for her. Interview on 12/10/25 between 5:55 P.M. and 5:57 P.M. revealed mixed answers related to Resident #35's ability to use a phone in private. Licensed Practical Nurse (LPN) #80 stated residents had a private cell phone the facility could provide for a resident to use in their room. LPN #190 and #191 stated every resident had a working phone at their bedside provided by the facility and were unaware of any facility cell phone that could be used for private phone calls by residents. None of staff interviewed could locate the cell phone upon request and reported they had not seen the phone in several months. Interview on 12/10/25 at 6:08 P.M. with the Unit Manager confirmed the room in Resident #35 did not work and stated when the resident would receive calls from her family, about twice a week, Resident #35 would come out to the nurse's station to talk with them. The Unit Manager was unsure whether or not the phone jack worked but confirmed the phone in Resident #35's room did not have a cord to be able to connect to the outlet. Interview on 12/10/25 at 6:20 P.M. with the Regional Nurse and Administrator revealed facility was not required to provide each resident a phone and stated that the resident could request to use the phone in the Social Services Office or the Business Office for privacy. Both the Regional Nurse and the Administrator stated they were not aware staff did not know about the Social Services Office or the Business Office being an option and acknowledged staff will be educated on the option. The Administrator denied knowledge of residents having phones in their rooms without a cord and denied knowing that not all phone [NAME] in the residents' rooms had service. Review of the facility policy titled Phone Usage dated 10/2025, revealed residents shall have reasonable access to phones in a private area. The policy stated designated phones were available to make and receive private phone calls and phones at the nursing station should ordinarily be reserved for staff use. This deficiency represents non-compliance investigated under Complaint Number 2617593. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365950 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 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, review of maintenance repair logs, and review of facility policy, the facility failed to maintain a clean and homelike environment regarding temperature, sanitation and condition of residents rooms. This affected 10 (#8, #16, #21, #26, #79, #83, #87, #96, #97, and #108) of 10 residents reviewed for environment. The facility census was 108. 1. Observation on 12/08/25 at 9:30 A.M. of Resident #83 and Residents #96's room revealed a hole exposing the drywall. 2. Observation on 12/08/25 at 9:36 A.M. of Resident #26 and# 87's room revealed exposed wires hanging from the wall.3. Observation on 12/08/25 at 9:39 A.M. of Resident #21 and #97's room revealed dried feces on the floor and wall and privacy curtain with brown stains and dried feces.4. Observation on 12/08/25 at 9:59 A.M. of Resident #79 and #108's room revealed privacy curtain with brown stains.5. Observation on 12/08/25 at 10:00 A.M. of Resident #16 and #08's room revealed Resident #16 with gloves and a toboggan hat Interview with Resident #16 at the time of the observation stated it was freezing in her room. Observation of the thermostat with Maintenance Director (MD) #133 revealed the temperature was set at 85 degrees Fahrenheit (F), MD #133 checked room with the facility thermometer revealing the room temperature was 68 degrees F.Interview on 12/08/25 at 10:30 A.M. with MD #133 and Housekeeping Supervisor #150 verified the environmental issues.In a follow up interview on 12/09/25 at 12:30 P.M. with MD #133 revealed the furnace in Resident #16 and #08's room was not in working order and the residents will need to be moved until the furnace is repaired.6. Observation on 12/11/25 at 7:40 A.M. revealed the conference room thermostat had a temperature of 74 degrees F and dropped from 74 degrees F to 69 degrees F from 7:40 A.M. to 10:20 A.M. without any adjustment made to the thermostat. 7. Observations and concurrent interview on 12/11/25 at 10:20 A.M. with MD #133 revealed several facility areas were under the required minimum temperature. The sitting area outside the Director of Nursing's office was 71.1 degrees F, recheck of resident room [ROOM NUMBER], the room which Residents #08 and #16 had been moved out of the day prior was at 69.3 degrees F, the 400-hall hallway ranged from 69 to 70 degrees F upon several readings. The Memory Care unit lobby where several residents were sitting at a table was 69.3 degrees F and a Certified Nursing Aide (CNA) was talking with residents and stated, is cold back here. Two residents were observed walking out to the Memory Care Sunroom which had the thermostat set at 77 degrees F, but the wall thermostat read 65 degrees. MD #133 tested the air temperature with the facility thermometer and obtained readings between 58.8 to 62 degrees F. MD #133 verbalized the room was notably colder. The hall by the dialysis unit had a temperature of 71.4 F and the activity room had a temperature of 63.9 degrees F. The Activity Director stated, that explains why it felt so cold in here. The back conference room had a thermostat that read 69 degrees F, the thermostat was set for heat at 66 degrees F, upon MD #133 checking the temperature with the facility thermometer, conference room had a temperature reading of 63.5 degrees F. MD #133 reported the facility required temperature is 71 to 72 degrees F and that is where all the thermostats in common areas should be sent. MD #133 confirmed several common areas were below the minimum required temperatures.Review of the Maintenance repair logs revealed on 11/28/25 the furnace in room [ROOM NUMBER] was not working and signed off by MD #133 as fixed.Review of facility policy titled Homelike Environment dated 10/2025, revealed the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include cleanliness and order, comfortable yet adequate lighting as needed throughout the facility, inviting colors and decor, personalized furniture and room arrangements, pleasant, neutral scents, plants (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365950 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 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm and flowers; where appropriate, comfortable temperatures and comfortable noise levels.This deficiency represents non-compliance investigated under Master Complaint Number 2682354, Complaint Number 2645733, and Complaint Number 2623673. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365950 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 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 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 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, staff interview, and review of the facility policy, the facility failed to ensure residents were assisted and supervised with activities of daily living (ADL), and the facility failed to further ensure the necessary supplies were readily available to staff to ensure residents received timely ADL care. This affected three (#33, #78 and #87) residents received for activities of daily living. The facility census was 108. 1. Review of the medical record for Resident #33 revealed an admission date of 04/17/25, diagnoses including unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, chronic pain, and difficulty in walking.Review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #33 was cognitively intact, required supervision or touching assistance for toileting hygiene, and bed mobility, partial/moderate assistance for shower/bathing, dressing, personal hygiene and transfers, and was frequently incontinent of bowel and bladder.Review of the care plan revealed Resident #33 has an ADL self-care performance deficit related to lumbar compression fracture, pain, visual impairment, asthma, osteoarthritis, with varying self-performance during the time of day, which may require more assistance, as needed, to maintain safety. Interventions included one person assist with bathing/showering.Interview on 12/10/25 at 1:17 P.M. with Resident #33 revealed she had to have her family purchase bath towels and washcloths due to the facility not having enough to be able to provide her a shower or bath when she asked.2. Review of the medical record for Resident #78 revealed an admission date of 10/19/22 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, chronic atrial fibrillation, hypertension and heart failure. Review of the most recent annual MDS assessment dated [DATE] revealed Resident #78 was cognitively intact, required set up or clean up assistance with shower/bathing, toileting hygiene, and bed mobility, required supervision or touching assistance with ambulation and transfers, and was occasionally incontinent of urine and frequently incontinent of bowel.Review of the care plan for Resident #78 revealed an ADL self-care performance deficit related to fatigue, hemiplegia and hemiparesis affecting right side. Interventions included one person assist with bathing and showering and transfers.Interview on 12/10/25 at 1:17 P.M. with Resident #78 revealed showers or baths were not always provided as the facility did not have enough towels. Resident #78 stated his family purchased bath towels and wash cloths to ensure he could receive a shower/bath upon request without having to wait for linens to become available. Observation on 12/04/25 at 2:00 P.M. of clean linen storage room on unit B revealed five washcloths and eight towels and 500 hall clean linen storage room with two towels.Observation on 12/08/25 at 10:00 A.M. of clean linen storage room on unit B revealed five washcloths and zero towels.Interview on 12/04/25 at 1:47 P.M. with Housekeeping Supervisor #50 revealed the laundry deliveries linen three times a day. Housekeeping Supervisor #50 stated there are not enough washcloths and towels to meet the needs of the residents in the facility timely.Interview on 12/04/25 at 1:53 P.M. with Laundry Staff #50 revealed they need more washcloths and towels, stating there is not enough to go around to meet the residents' needs timely.3. Review of Resident #87's medical records revealed an admission date of 02/26/20. Diagnoses included dementia, Alzheimer's disease, and schizoaffective disorder.Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #87 had a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. The resident was assessed to require dependent on staff for activities of daily living including assistance with eating. Observation on 12/08/25 at 1:00 P.M. revealed Resident #87 was in bed with the lunch meal, on the tray was plastic container partially full of juice and a foil lid Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365950 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 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete covering. Further observation revealed Resident #87 chewing on the foil lid.Interview on 12/08/25 at 1:05 P.M. with Certified Nursing Assistant (CNA) #91 verified Resident #87 is confused, should have assistance with feeding and was attempting to eat the foil lid.Interview on 12/09/25 at 2:00 P.M. with the Administrator stated he would provide staff education to remove the foil top for Residents with low cognition or Residents that have difficulty opening the juice themselves.On 12/10/25 review of facility staff education provided by the Administrator revealed, when serving juice, the foil top must be removed for residents with low cognition or residents that have difficulty opening themselves.Further observation of dining on 12/11/25 at 9:10 A.M. revealed Resident #87 in bed with breakfast tray and plastic juice container on tray with foil lid attached to the top.Interview on 12/11/25 at 9:11 A.M. with CNA #138 verified Resident #87 had foil lid on cup and staff received an email sent by the Administrator providing the staff education to remove the foil lid for residents with impaired cognition. CNA #138 verified Resident #87 had impaired cognition. Review of Resident Council Minutes for November 2025 revealed complaints of no washcloths or towels on the weekends.Review of the facility policy titled Resident Rights, dated 10/17/19 stated upon admission and thereafter, residents have the right to adequate medical treatment and nursing care. This deficiency represents non-compliance investigated under Master Complaint Numbers 2682354 and Complaint Number 2623673. Event ID: Facility ID: 365950 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 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure medication error rate was less than five percent. There were three medication errors out of 30 opportunities, resulting in a 10 percent medication error rate. This affected one (#58) out of five residents reviewed for medication administration.Review of the medical record for Resident #58 revealed an admission date 08/22/24 ad diagnoses including rhabdomyolysis, type II diabetes mellitus and hypertension.Observation on 12/09/25 at 9:49 A.M. with Licensed Practical Nurse (LPN) #189 completing medication administration for Resident #58 revealed a physician's order dated 08/23/24 for Mucinex 600 milligrams (mg), one tablet twice daily was not administered per order due to not having any supply on hand. A physician's order dated 04/02/25 for Fluticasone Propionate (treats allergies) nasal spray, two sprays in both nostrils was not administered per order due to not having any supply on hand. A physician's order dated 08/24//24 for glipizide (diabetic medication) 5 mg, give one tablet was not administered per order due to not having any supply in hand. Interview on 12/09/25 at 9:52 A.M. with LPN #189 confirmed Mucinex, Fluticasone Propionate, and glipizide was not administered to Resident #58 as ordered due to the medications being unavailable. LPN #189 stated not having the medications on hand happens often.Review of facility policy titled Administering Medications dated December 2012, revealed The individual administering the medication must check the label against the order to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication.This deficiency represents non-compliance investigated under Master Complaint Number 2682354, Complaint Number 2657879, and Complaint Number 2623673. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365950 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 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation,medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure medications were properly stored. This affected one (#79) of three residents reviewed for medication storage. The facility census was 108.Review of the medical record for Resident #79, revealed an admission date of 11/11/16. Diagnoses included: vascular dementia, cerebral infarction, and hypertension.Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #79 had moderate cognitive impairment. Resident #79 required minimal assistance with activities of daily living and ambulates independently.Observation on 12/08/25 at 9:50 A.M. revealed Resident #79's had several medications in a medicine cup sitting on his bedside table. Resident #79 stated he does not know how long they have been there, adding the nurses often leave his medications on the bedside table for him to take.Review of the physician orders revealed Resident #79 did not have an order to self-administer medications or for medications to be left at bedside.Interview on 12/08/25 at 10:00 A.M. with Licensed Practical Nurse (LPN) # 102 revealed she prepared Resident #79's medications. LPN #102 confirmed she left the medications on the bedside table and further confirmed Resident #79 does not have an order for self-administration or for medications to be left at bedside.Review of the updated facility policy titled Medication Administration stated resident may self administer their own medications only if the attending physician in conjunction with the multidisciplinary care planning team has determined the resident has the decision making capability to do so safely. Event ID: Facility ID: 365950 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 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, resident interview, staff interview, sample of a test tray, and review of Resident Council meeting minutes, the facility failed to ensure food was served at palatable temperatures. This had the potential to affect all 108 residents that received meals from the kitchen. The facility census was 108.Interview on 12/09/25 at 2:00 P.M. with Resident #44 revealed that the food is never served hot.Interview on 12/09/25 at 2:15 P.M. with Resident #18 revealed the food is never hot. Interviews on 12/10/25 at 1:17 P.M. with Residents #33 and #78 revealed the food is always cold.Observation on 12/09/25 from 11:30 A.M. to 12:51 P.M. of the lunch meal service revealed food was above 165 degrees Fahrenheit (F) on the tray line. A food cart left the pantry at 12:51 P.M. and arrived at the unit within a minute. Staff started to serve residents their food trays immediately with the last tray on the food cart was delivered to a resident on 12/09/25 at 12:54 P.M.The Dietary Manager (DM) #24, using a facility thermometer, checked the temperature of the food on the test tray. The turkey was 112 degrees F, the mashed potatoes were 110 degrees F, and the vegetables were 71 degrees F. DM #24 stated that food served to the residents should be hotter, but the facility did not have enough warming food carts. Sample of the food test tray with DM #24 revealed the food was lukewarm.Review of the Resident Council meeting minutes from November 2025 revealed resident food concerns. This deficiency represents non-compliance investigated under Complaint Number 2645018. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365950 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 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 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 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 review of facility policy, the facility failed to maintain a clean and sanitary kitchen area. This had the potential to affect 108 residents who received meals in the facility. The facility census was 108.Observation on 12/09/25 at 10:31 A.M. of the kitchen with Dietary Manager #24 revealed about 15 ceiling tiles covered with a black dusty substance and a thick layer of dust on the ceiling vents covering food preparation and cook areas. Interview on 12/09/25 at 10:35 A.M. with the Dietary Manager #24 revealed the black stuff would not come off, stating they have tried everything, including a microfiber cloth. Dietary Manager #24 verified the black ceiling tiles and the dust on the ceiling vents and stated they do need cleaned or replaced. Dietary Manager #24 stated there is not a set cleaning schedule for the ceiling or vents. Review of the facility policy titled Homelike Environment stated residents are provided with a safe, clean, comfortable and homelike environment. This deficiency represents non-compliance investigated under Master Complaint Number 2682354, Complaint Number 2651115, Complaint Number 2611472, and Complaint Number 2623673. Event ID: Facility ID: 365950 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 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 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 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, resident interview, staff interview, and review of Resident Council meeting minutes, the facility failed to ensure resident call systems were functioning in an appropriate manner. This affected one (#16) of three residents reviewed for call lights, with the potential to affect off residents residing in the facility. The facility census was 108.Review of the medical record for Resident # 16, revealed an admission date of 02/20/20. Diagnoses included chronic respiratory failure with hypoxia, type II diabetes mellitus, need for assistance with personal care, major depressive disorder, and chronic obstructive pulmonary disease. Review of Resident #16's care plan revealed the resident required assistance with activities of daily living (ADL) related to dementia, heart failure, chronic respiratory failure, depression, chronic kidney disease, weakness and cancer. Interview on 12/08/25 at 9:30 A.M. with Resident #16 revealed she has attempted to use her call on various occasions, and the staff do not answer. Resident #16 could not recall a date but stated a staff member provided her with a handheld bell because they were unsure of why the call light was not working. Interview, and observation of demonstration on 12/08/25 at 2:00 P.M. with the Administrator and Maintenance Director # 133 of an empty bathroom, a known malfunction with the call system specific to double rooms with shared a bathroom revealed when a metal lever or switch on the bathroom wall when left part way between the on and off position and not pushed all the up in the off position fail to allow the call light above a resident's bed to function properly. Maintenance Director #133 explained, the call lights beside the residents' beds still illuminate, but no signal is received at the nurses' station or outside the room.Interview on 12/08/25 at 3:00 P.M. with Regional Nurse #30 revealed there is no facility policy related to call lights specifically we expect staff to answer call lights timely.Review of the Resident Council meeting minutes from 09/18/25 and 10/16/25 revealed resident concerns with call light response. This deficiency represents non-compliance investigated under Complaint Number 2651115 and Complaint Number 2645018. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365950 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 365950 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, staff interview, and review of facility policies, the facility failed to ensure outdoor lighting was maintained and failed to ensure the proper storage of hazardous maintenance equipment and supplies. This had the potential to effect 14 residents with orders for unsupervised leave of absence (#2, #9, #10, #15, #23, #31, #44, #60, #67, #69, #83, #96, #104, and #107) and seven Residents (#21, #28, #62, #65, #94, #97, and #102) who were identified as cognitively impaired but independently mobile. Facility census was 108. 1. Observation on 12/09/25 at 6:30 P.M. revealed a dark night sky and no functioning lights to the right side or around the back of the building, and no functioning lights in the employee parking lot. Only two of six lights were working in the middle grassy and visitor parking area. The two lights that were working only had one of the three bulbs illuminated. Observation and interview on 12/10/25 at 8:35 A.M. with MD #133 confirmed all but two of the front lights were not functioning properly and further confirmed that not having exterior lights functioning was a safety issue, especially in the dark.2. Observation on 12/09/25 from 1:30 P.M. to 6:30 P.M. and 12/10/25 from 8:30 A.M. to 2:20 P.M. revealed a sitting room next door to the activity area was being used for storage. The room was unlocked and the door was propped open with furniture. Observation also found maintenance equipment including three tubes of caulk and a box with several cans of painting supplies including paint stripper, labeled as hazardous. The caulk and paint stripper had warning labels to avoid contact with eyes and skin and contact occurs, wash thoroughly with water, if symptoms appear, seek immediate Interview on 12/10/25 at 2:25 P.M. with Activity Staff Member #157 revealed some comfortable chairs were placed in the sitting room for residents to come and relax and or have coffee, however staff started to store beds in the area and ever since it has become more of a storage room. Activity Staff Member #157 verified the door to the room was unlocked and propped open with hazardous materials within reach of the residents. Interview on 12/10/25 at 4:45 P.M. with Regional Nurse #30 confirmed the sitting room had maintenance equipment and supplies with hazard warning labels, confirming the room was unlocked and should not have been as residents could enter the unlocked room when passing by the room to go to the activity area.Review of the facility policy titled Storage Areas dated 10/2025, revealed storage areas shall be maintained in a clean and safe manner with hazardous materials stored in a manner that they are not easily accessible to residents. Review of facility policy titled Homelike Environment dated 10/2025, revealed residents shall be provided with a safe environment. The policy also stated the facility staff, and management should maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include cleanliness and order, comfortable yet adequate lighting as needed throughout the facility, inviting colors and decor, personalized furniture and room arrangements, pleasant, neutral scents, plants and flowers; where appropriate, comfortable temperatures and comfortable noise levels. This deficiency represents non-compliance investigated under Master Complaint Number 2682354, Complaint Number 2651115 and Complaint Number 2611472. Event ID: Facility ID: 365950 If continuation sheet Page 12 of 12