Inspection·August 30, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm The resident stated her blood sugar was high at the time of the interview but was not sure the exact reading. Interview on 08/28/23 at 2:44 P.M. with Regional Nurse (RGN) #210 via email confirmed there was no evidence Resident #6's physician was notified when the resident's BS level was over 400. Residents Affected - Few 2. Review of the medical record for Resident #284, revealed an admission date of 05/23/23. Diagnoses included: chronic obstructive pulmonary disease with acute exacerbation, tracheostomy status, anxiety disorder and chronic pain syndrome with a code status of full code and no known drug allergies. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a BIMS of 13 out of 15 indicating intact cognition. This resident was assessed to require extensive assistance with one person physician assist with bed mobility and transfers, and supervision with one person assist for eating and dressing. Review of Resident #284's progress note dated 07/30/23 at 8:13 P.M. revealed the resident was transferred to the Ohio State University East emergency room due to shortness of breath and the resident stated, that he cannot breathe. Interview with the Regional Nurse on 08/28/23 at 1:25 P.M. revealed there was not a change of condition interact Situation Background Assessment Recommendation (SBAR) communication form, notification to the physician and the resident's representative for the 07/30/23 transfer to Ohio State University East Emergency Room. Review of the policy titled Change in a Resident's Condition or Status dated May 2017 revealed prior to notifying the physician the nurse will make detailed observations and gather relevant information on the interact SBAR Communication Form. The nurse will notify the resident's attending physician of the significant change and the need of transfer to the hospital and will notify the resident's representative of the transfer to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 2 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to timely complete and provide written transfer notices for Resident #47 and Resident #284 who were hospitalized . This affected two (Resident #47 and #284) of three residents reviewed for transfers. The facility census was 82. Findings include: 1. Review of the medical record for Resident #47 revealed an admission date of 07/05/23 with diagnoses including Parkinson's disease, unspecified dementia, heart failure, depression, type two diabetes mellitus, and chronic kidney disease stage three. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had severely impaired cognition. Review of the hospital documentation dated 07/29/23 revealed Resident #47 was admitted to the hospital on [DATE] and discharged on 07/30/23. Review of the transfer to the hospital form dated 08/02/23, revealed it was not completed until after Resident #47's return from the hospital. Interview on 08/23/23 at 4:30 P.M. with Regional Nurse #210 verified Resident #47's transfer assessment was not completed in a timely manner and should have been completed at the time of transfer. 2. Review of the medical record for Resident #284, revealed an admission date of 05/23/23. Diagnoses included: chronic obstructive pulmonary disease with acute exacerbation, tracheostomy status, anxiety disorder and chronic pain syndrome with a code status of full code and no known drug allergies. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15 indicating intact cognition. This resident was assessed to require extensive assistance with one person physician assist with bed mobility and transfers, and supervision with one person assist for eating and dressing. Review of Resident #284's progress note dated 07/30/23 at 8:13 P.M. revealed the resident was transferred to the Ohio State University East emergency room due to shortness of breath and the resident stated, that he cannot breathe. Interview with the Regional Nurse on 08/28/23 at 1:25 P.M. revealed there was not a written transfer notice for the 07/30/23 transfer to Ohio State University East Emergency Room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 3 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #59 revealed an admission date on 02/02/22. Medical diagnoses included depression (01/14/23), post-traumatic stress disorder (PTSD) (01/14/23), borderline personality disorder (01/14/23), and anxiety disorder (02/02/22). Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #59 had intact cognition and scored 15 out of 15 on the BIMS assessment. Resident #59 required supervision to limited assistance from one staff to complete Activities of Daily Living (ADLs). Review of the PASARR dated 07/08/22 submitted for Resident #59 revealed there were no mental health diagnoses included on the screening. Interview on 08/22/23 at 3:54 P.M. with the Administrator confirmed an updated PASARR screening was not submitted when Resident #59 received additional mental health diagnoses. Based on medical record review, staff interview, and review of facility policy, the facility failed to update Preadmission Screening and Resident Review (PASARR)'s for residents with new mental health diagnoses. This affected four (Residents #50, #52, #59, and #65) of the four residents reviewed for accurate PASARRs. The facility census was 82. Findings include: 1. Review of the medical record for Resident #52 revealed an admission date of 07/03/21. Diagnoses included delusional disorder, mood disorder, restlessness and agitation, and encephalopathy. Review of the PASARR for Resident #52 with the file date of 08/04/21 indicated under section D that resident did not have a mental health diagnosis. Review of the care plan dated revised 07/07/23 revealed Resident #52 has a behavior problem related to threatening self harm, picks things up from around the facility and puts them in own room, makes written signs on door saying No One to Enter. Interventions include to administer medication as ordered and monitor for side effects, anticipate and meet the residents needs, initiate every 15 minute checks when indicated, notify the physician of all threats of self harm, when threatens self harm, ensure room is secure and that there are no means for self harm. Review of Resident #52's annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating a moderately impaired cognition for daily decision making abilities. Resident #52 was noted to display disorganized thinking and delusions. Interview on 08/24/23 at 10:49 A.M. with the Administrator confirmed the reviewed PASARR was the most recent and up to date assessment the facility had and confirmed a new PASARR should have been completed with each new mental health diagnosis. 2. Review of the medical record for Resident #65 revealed an initial admission of 06/03/23 and a re-entry date of 11/22/22. Diagnoses included dementia, adult failure to thrive, and psychosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 4 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the PASARR dated 07/11/22 indicated Resident #65 did not have a mental health diagnosis nor was this resident receiving a antipsychotic medication. Review of Resident #65's quarterly MDS dated [DATE] revealed a BIMS score of 08 out of 15 indicating a moderately impaired cognition for daily decision making abilities. Resident #65 noted to experience inattention, disorganized thinking, and rejection of care or evaluation. Resident #65 was noted to receive antipsychotic medication daily. Review of the plan of care dated 03/06/23 and revised 05/08/23 revealed Resident #65 was provided psychotropic medication related to behavior management, and psychotic disorder. Interventions include to administer medication as ordered and monitor for side effects. Review of the plan of care dated 05/08/23 revealed Resident #65 had a mood problem related to dementia and psychosis. Interventions included to administer medication as ordered and monitor and document side effects, provide a behavioral health consults as needed, monitor and record mood to determine if problems seems to be related to external causes. Review of Resident #65's physician orders for August 2023 revealed a order for Olanzapine (antipsychotic) 5 milligram (mg) tablet, give one tablet at bedtime for psychosis and a order for Olanzapine 2.5 mg, give one tablet twice a day for psychosis. Interview on 08/23/23 10:35 A.M. with the Administrator confirmed the reviewed PASARR was the most up to date assessment they have and confirmed the resident's PASARR should have been updated with any new mental health diagnosis and updated to reflect the use of antipsychotic medication. 4. Review of medical record for Resident #50 revealed admission date of 05/15/21 with diagnoses including schizoaffective disorder bipolar type, psychoactive substance abuse, chronic pain syndrome, major depressive disorder, and added 10/22/22 was post-traumatic stress disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #50 had intact cognition. Review of the PASARR completed 06/19/21 revealed Resident #50 was marked as having schizophrenia; however, no other diagnoses were listed. Interview on 08/23/23 at 3:00 P.M. with the Administrator verified Resident #50's PASARR did not address all of Resident #50's diagnoses or one's he had developed following admission. Review of the facility policy, admission Criteria, revised 12/2016, revealed the policy stated, nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program (PASARR) to the extent practicable. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined (through the pre-admission screening program) that the individual has a physical or mental condition that requires the level of services provided by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 5 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the medial record for Resident #67 revealed an admission date of 09/22/22. Diagnoses included anxiety disorder, chronic pain syndrome, and psychoactive substance abuse. Review of Resident #67's Psychiatric Diagnostic Eval with Medical assessment dated [DATE] revealed Resident #67 reports feeling anxious at times and states this stems from past trauma. Resident tells the provider about history of molestation. Resident #67 reports having often nightmares from this incident and has experienced some auditory hallucinations in the past month due to this past experience. Noted under medical and psychiatric history was post traumatic stress disorder (PTSD). Review of Resident #67's quarterly MDS 3.0 assessment dated [DATE] revealed a BIMS score of 14 out of 15 indicating an intact cognition for daily decision making abilities with no behaviors noted. Resident #67 was noted to require supervision only for mobility around the facility and was a unsupervised smoker and was noted to receive opioids daily. Review of Resident #67's care plans revealed no evidence of a care plan related to the diagnosis of PTSD or related triggers. Interview on 08/24/23 3:56 P.M. with Regional Nurse #210 confirmed the PTSD diagnosis should have been added to Resident #67's diagnosis list as well as a care plan related to PTSD should have been developed for this resident. 3. Review of the medical record for Resident #47 revealed an admission date of 07/05/23 with diagnoses including Parkinson's disease, unspecified dementia, heart failure, depression, type two diabetes mellitus, and chronic kidney disease stage three. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #47 had severely impaired cognition. Review of the plan of care revealed nothing addressing Resident #47's hydration needs. Additional review revealed no care plan related to activities. Observation on 08/21/23 at 11:16 A.M. and 2:57 P.M. revealed Resident #47 had no fluids in reach. In an email on 08/28/23 at 9:52 A.M. Regional Nurse #210 verified there was no mention of hydration in the care plan but she thought it probably should have been addressed in the nutrition section of the care plan. She additionally verified there was no activities plan of care for Resident #47. 4. Review of the medical record for Resident #19 revealed an admission date of 12/26/22 with diagnoses including Alzheimer's disease, dysphagia, hypertension, anemia, depression, mood disorder, visual hallucinations, osteoarthritis, and muscle weakness. Review of the comprehensive MDS 3.0 dated 06/06/23 revealed Resident #19 had severely impaired cognition. Review of Resident #19's current plan of care revealed nothing addressing Resident #19's activities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 6 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0656 preferences or needs. Level of Harm - Minimal harm or potential for actual harm In an email on 08/28/23 at 9:52 A.M. Regional Nurse #210 verified there was no mention of activities in Resident #19's care plan. Residents Affected - Some Based on record reviews and interviews, the facility failed to develop and/or implement care plans for five (Residents #19, #47, #66, #67, and #284) of the seven residents reviewed. The facility census was 82. Findings include: 1. Review of the medical record for Resident #284, revealed an admission date of 05/23/23. Diagnoses included: chronic obstructive pulmonary disease with acute exacerbation, tracheostomy status, anxiety disorder and chronic pain syndrome with a code status of full code and no known drug allergies. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 out of 15 indicating intact cognition. This resident was assessed to require extensive assistance with one person physician assist with bed mobility and transfers, and supervision with one person assist for eating and dressing. Review of physician orders dated for 08/10/23 revealed this resident was receiving the following medication: Haloperidol 5 milligram (mg) one tablet by mouth every eight hours for mental disorder. Review of the care plan dated for 07/24/23 revealed none for the monitoring of targeted behaviors due to being administered an antipsychotic medication. Review of the physician's orders dated 08/02/23 revealed Resident #284 had an order to monitor to monitor behaviors and document per behavioral chart but did not specify target behaviors for adverse reactions and side effects, that was discontinued on 08/02/23 with no new order. Interview with Licensed Practical Nurse (LPN) #114 on 08/24/23 at 11:41 A.M. revealed Resident #284 does not have a care plan and a physician order to monitor for specific targeted behaviors for being administered an antipsychotic medication and stated No, we do not have a care plan and an order, but we just know the residents and know what to look for. Interview with the Regional Nurse #210 on 08/28/23 at 2:39 P.M. confirmed Resident #284 did not have a care plan and physician order to monitor for specific targeted behaviors adverse reactions and side effects as well as the order on 08/02/23 being discontinued with no new order placed. 2. Review of the medical record for Resident #66, revealed an admission date of 06/07/22. Diagnoses included: fusion of the spine in the cervical region, cord compression, alcohol abuse with intoxication, nicotine dependence with cigarettes and unspecified mood affective disorder with a code status of full code with no known allergies. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. This resident was assessed to require supervision with one-person physical assist with bed mobility, transfers, dressing and toileting with independent with set up help only for eating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 7 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0656 Level of Harm - Minimal harm or potential for actual harm Review of physician orders dated for 08/04/23 revealed this resident was receiving the following medication: Quetiapine Fumarate 25 mg one tablet by mouth every afternoon for major depressive disorder (MDD). Review of the care plan dated for 08/07/23 revealed none for the monitoring of targeted behaviors due to being administered an antipsychotic medication. Residents Affected - Some Review of the physician's orders dated 06/08/22 revealed Resident #66 had an order to monitor behaviors and document per behavioral chart but did not specify target behaviors for antipsychotic medication adverse reactions and side effects. Interview with the Director of Nursing on 08/24/23 at 12:55 P.M. confirmed Resident #66 did not have a care plan and physician order to monitor for specific targeted behaviors adverse reactions and side effects for antipsychotic medication use. Interview with LPN #114 on 08/24/23 at 11:42 A.M. revealed Resident #66 does not have a care plan and a physician order to monitor for specific targeted behaviors for being administered an antipsychotic medication and stated No, we do not have a care plan and an order, but we just know the residents and know what to look for. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 8 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #20 revealed an admission date of 06/08/21 with diagnoses including senile degeneration of brain, type one diabetes mellitus, unspecified dementia, cognitive communication deficit, epilepsy, and alcohol abuse. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #20 had severely impaired cognition. Review of the plan of care dated 01/14/23 revealed Resident #20 was at risk for skin impairment related to dementia, reduced independent mobility, incontinence, anemia, diabetes, and history of pemphigoid. Interventions included air mattress provided by hospice, drying skin after showers, floating heels as tolerated, pressure reducing cushion to wheelchair and bed, preventative treatments as ordered, incontinence care as needed, repositioning with rounds and as needed, and weekly skin check by nurse. Review of the treatment orders dated 07/10/23 to 08/16/23 revealed Resident #20 had wound treatments to the right medial malleolus, right knee, left hip, left medial midfoot, right hallux, right medial foot, and left buttocks. Review of the plan of care revealed nothing related to Resident #20's current wounds. In an email on 08/28/23 at 9:52 A.M. Regional Nurse #210 verified the care plan did not address current skin concerns prior to 08/23/23. Based on medical record reviews and staff interviews, the facility failed to revise comprehensive care plans for four (Residents #20, #66, #284, and #289) out of the five residents reviewed. The facility census was 82. 1. Review of the medical record for Resident #66, revealed an admission date of 06/07/22. Diagnoses included: fusion of the spine in the cervical region, cord compression, alcohol abuse with intoxication, nicotine dependence with cigarettes and unspecified mood affective disorder with a code status of full code with no known allergies. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. This resident was assessed to require supervision with one-person physical assist with bed mobility, transfers, dressing and toileting with independent with set up help only for eating. Review of the MDS also revealed this resident has a pain numeric rating score of a 07 out of a 00-10 scale over the last five days. Review of the care plan dated for 08/07/23 for Resident #66 revealed no updated interventions for pain. Review of the physician order dated 02/17/23 revealed this resident was receiving the following medication: Percocet 5-325 milligram (MG) one tablet by mouth every six hours as needed for pain. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 9 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the progress notes from 07/23/23 to 08/22/23 for this resident revealed no documentation of revision of care plans and no interventions for pain management except the administration of the Percocet 5-325 mg one tablet every 6 hours. Interview with the Director of Nursing (DON) on 08/28/23 at 12:05 P.M. confirmed Resident #66 has no revised care plan for pain management. 2. Review of the medical record for Resident #289, revealed an admission date of 08/09/23. Diagnoses included: radiculopathy of the lumbar region, psychoactive substance abuse, chronic embolism and thrombosis of unspecified deep veins of right lower extremity with a code status of Full Code and amoxicillin allergies. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a BIMS of 15 out of 15 indicating intact cognition. This resident was assessed to require supervision with set up only for bed mobility, transfers, locomotion off and on the unit, dressing and eating. Review of Resident #289's orders revealed the physician had prescribed: Gabapentin 100 milligram (mg) one capsule by mouth three times a day for pain, Methadone HCL 5 mg five tablets by mouth every eight hours for opioid dependence, Methocarbamol 500 mg one tablet by mouth three times a day for muscle spasms and pain and Oxycodone HCL 10 mg one tablet by mouth every six hours as needed for pain. Review of the progress notes from 07/25/23 to 08/28/23 for this resident revealed no documentation of revision of care plans and no interventions for pain management except the administration of the Oxycodone HCL 10 mg one tablet by mouth every six hours as needed for pain. It also revealed this resident had two unwitnessed falls on 08/21/23 and 08/24/23. Review of the care plans dated for 08/10/23 on 08/28/23 for Resident #289 revealed no updated interventions for pain and no updated interventions due to recent falls. Interview with the Director of Nursing on 08/28/23 at 12:08 P.M. verified this resident did not have an updated care plan for his recent falls. Interview with the Regional Nurse on 08/28/23 at 12:56 P.M. confirmed the Resident #289 does not have any interventions for pain except for his Oxycodone HCL 10 mg one tablet by mouth every six hours as needed for pain documented and the care plan has not been updated even with his ongoing pain not being managed. 3. Review of the medical record for Resident #284, revealed an admission date of 05/23/23. Diagnoses included: chronic obstructive pulmonary disease with acute exacerbation, tracheostomy status, anxiety disorder and chronic pain syndrome with a code status of full code and no known drug allergies. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a BIMS of 13 out of 15 indicating intact cognition. This resident was assessed to require extensive assistance with one person physician assist with bed mobility and transfers, and supervision with one person assist for eating and dressing. Review of the progress notes dated 07/19/23 for this resident revealed an unwitnessed fall and no updated interventions after the fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 10 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0657 Level of Harm - Minimal harm or potential for actual harm Review of the care plan dated for 07/24/23 for Resident #284 revealed no updated interventions due to the fall on 07/19/23. Interview with the Regional Nurse on 08/28/23 at 1:25 P.M. verified no updated interventions to this resident's care plan since the fall. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 11 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide timely follow up treatment for Hepatitis C for Resident #49 and failed to ensure timely wound monitoring and care for Resident #47's leg wound. This affected two residents (#47 and #49) of four residents reviewed for quality of care. The facility census was 82. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #49 revealed an initial admission date on 02/06/21 and a readmission date on 06/18/21. Medical diagnoses included end stage renal disease, dependence on renal dialysis, and other specified abnormal findings of blood chemistry. There was not a diagnosis of viral Hepatitis C included in the diagnosis list. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #49 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #49 required supervision from one staff to complete Activities of Daily Living (ADLs). Review of physician orders dated March 2022 revealed Resident #49 had an order for a referral to a local gastrointestinal (GI) clinic for Hepatitis C. The order was dated 03/22/22. Review of the Medication Administration Records (MARs) and Treatment Administration Records (TARs) dated from March 2022 through August 2023 revealed the ordered referral was not listed on any of the MARs or TARs for Resident #30. Review of the progress notes dated from 03/21/22 through 08/23/23 revealed the following: On 03/21/22, untimed, Certified Nurse Practitioner (CNP) #300 visited Resident #49 for a follow up on Hepatitis C. Resident #30 was seen by the GI clinic at the hospital and was supposed to have started on treatment for Hepatitis C but appeared to be lost for the follow up. Will contact the GI CNP. On 01/16/23 and 02/06/23, untimed, CNP #305 visited Resident #49 for a follow up visits and again noted Resident #49 was seen at the GI clinic and was supposed to have started on treatment for Hepatitis C but appeared to be lost for the follow up. Nursing to contact the GI CNP. On 03/09/23, untimed, Physician #213 visited Resident #49 for another follow up visit. Physician #213 also noted Resident #49 was seen at the GI clinic and was supposed to have started on treatment for Hepatitis C but appeared to be lost for the follow up. Will discuss with staff for a follow up GI appointment. There was no evidence of any follow up with the GI clinic or that a follow up appointment for Resident #49 had been scheduled. Review of the care plan for Resident #49, revised on 07/02/23, revealed treatment for Hepatitis C was not addressed in the care plan. Interview on 08/22/23 at 10:00 A.M. with Resident #49 revealed he was supposed to receive treatment for viral Hepatitis C but has not received any treatment yet. Resident #49 stated he was seen by a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 12 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few physician prior to the COVID-19 pandemic but there had not been any follow up since. Resident #49 stated he would still like to receive treatment. Interview on 08/22/23 at 4:41 P.M. with Unit Manager (UM) #175 confirmed Resident #49 was seen at the GI Clinic one time in 2021 but has not had any additional follow up appointments. UM #175 confirmed there was no evidence Resident #49 received any treatment for viral Hepatitis C. Interview on 08/24/23 at 10:58 A.M. with Physician #213 via telephone confirmed Resident #49 did have a current diagnosis of viral Hepatitis C. Physician #213 confirmed Resident #49 had been seen quite a while ago and there was a plan for the resident to start treatment but Resident #49 never went for a follow up appointment or started any treatment. Physician #213 stated he had notified the facility staff of the need to schedule a follow up appointment with the GI clinic and did not know why the facility had not completed any follow up yet. 2. Review of the medical record for Resident #47 revealed an admission date of 07/05/23 with diagnoses including Parkinson's disease, unspecified dementia, heart failure, depression, type two diabetes mellitus, and chronic kidney disease stage three. Resident #47 was readmitted on [DATE]. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #47 had severely impaired cognition. Review of the hospital paperwork dated 07/29/23 revealed Resident #47 had a second degree burn to his left medial thigh while in hospital. Resident #47 was discharged from the hospital on [DATE]. Review of the plan of care dated 08/01/23 revealed Resident #47 had a burn to the left thigh. Interventions included a dietary consult as indicated, lids on cups with straws, monitor for signs of infection, supplement as ordered, treatment as ordered, and weekly monitoring for measurements and wound bed assessment. Review of the physician's order dated 08/01/23 to 08/10/23 revealed an order to apply A and D ointment every shift to the left upper anterior thigh. Review of Resident #47's assessments revealed the first assessment of his left leg wound was on 08/01/23. Interview on 08/23/23 at 4:30 P.M. with Regional Nurse #210 verified Resident #47's skin should have been reassessed upon his admission and had not been, causing a delay in measurements and treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 13 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, review of hospital records, and facility policy review, the facility failed to timely treat and assess a pressure ulcer and prevent the pressure ulcer from worsening for one resident (Resident #234). Residents Affected - Few Actual Harm occurred on 08/01/23 when Resident #234 was admitted to the facility with a Stage II (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising) pressure wound to her left proximal (back) upper thigh that worsened to a Stage III (full-thickness tissue loss into subcutaneous tissue but does not go into the muscle or bone) pressure ulcer without evidence of routine skin assessments or timely treatments. This affected one resident (Resident #234) out of two residents reviewed for pressure ulcers. The facility census was 82. Findings Include: Review of the medical record for Resident #234 revealed an admission date on 08/01/23. Medical diagnoses included cardiomyopathy, morbid obesity, type II diabetes mellitus with diabetic neuropathy, unspecified mood (affective) disorder, hypertension, venous insufficiency (chronic) (peripheral), and hyperlipidemia. There was no evidence of a pressure ulcer being listed as a diagnosis for the resident. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #234 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #234 required limited assistance from one staff to complete bed mobility, transfers, and toileting. Resident #234 was ambulatory but was unsteady and required staff assistance to stabilize. The assessment did not note any skin impairments or wounds for Resident #234. Review of the hospital records dated 07/24/23 revealed Resident #234 was admitted on [DATE] and discharged on 08/01/23 to the facility. A wound to Resident #234's left proximal, posterior, upper leg was noted with a start date of 05/03/23 and had been present for 83 days. The wound was a Stage II decubitus ulcer and was present on admission. The hospital provided wound care and offloading. A picture of the wound dated 07/25/23 at 3:37 P.M. revealed Resident #234 had a Stage II pressure ulcer to the back of her left thigh. The wound measured four centimeters (cm) long by 1.5 cm wide by 0.1 cm deep. The primary dressing was a bordered foam dressing (Mepilex). Review of the Admit/Readmit Screener dated 08/01/23 and completed by Licensed Practical Nurse (LPN) #189 revealed there were no skin areas noted on the skin grid in the assessment. However, LPN #189 indicated pressure ulcer present under the oral/nutritional section of the assessment. Review of the Interim Care Plan dated 08/01/23 revealed Resident #234 had impaired skin integrity at admission. Review of Skilled Charting dated 08/04/23 at 4:05 A.M. revealed Resident #234 had treatable wounds. Review of Skilled Charting dated 08/05/23 at 4:20 A.M. revealed Resident #234 had treatable wounds to the buttock/sacrum area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 14 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0686 Review of progress notes dated from 08/01/23 to 08/22/23 revealed no documentation of Resident #234's pressure ulcer wound until 08/20/23 at 11:17 A.M. Level of Harm - Actual harm Residents Affected - Few Review of the physician's orders dated for August 2023 revealed no evidence the physician was notified of Resident #234's admission or of any wound treatments being implemented for Resident #234 until 08/20/23 (19 days after admission). Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) dated August 2023 revealed Resident #234 did not receive any wound treatments until 08/20/23. Review of the Skin Observation task dated from 08/01/23 to 08/28/23 revealed an open area was noted for Resident #234 on 08/12/23 at 6:53 P.M. Review of the Skin Grid-Pressure assessment dated [DATE] at 4:56 P.M. revealed documentation of an initial assessment of a wound located on Resident #234's left posterior upper thigh. The assessment noted the wound as a Stage III pressure ulcer. The wound measured 4.2 cm long by 2.2 cm wide by 0.1 cm deep. The wound had a moderate amount of serous (clear to yellow fluid that leaks out of a wound) drainage. The physician, resident representative, and dietitian were notified of the presence of the wound on 08/21/23. A new wound treatment was ordered to cleanse with normal saline, pack wound with alginate, and cover with an absorbent dressing. The dressing was to be changed daily and as needed. Interview on 08/22/23 at 9:39 A.M. with Resident #234 revealed the resident had a pressure ulcer wound to the back of her left thigh when she was admitted to the facility. Resident #234 stated the facility staff did not assess or treat the wound until recently (about three times since admission). Resident #234 stated the wound bled sometimes and left soiled areas on the sheets. Resident #234 stated she experienced an increase in pain from that area since admission but is not able to see the area herself. Interviews on 08/23/23 at 10:31 A.M. and 10:55 A.M. with Unit Manager (UM) #175 and Regional Nurse (RGN) #210 revealed staff used the After Visit Summary (AVS) to determine medications and treatment orders and did not review the hospital records upon admission. Staff should contact the physician to reconcile the orders. It is up to the physician to review the hospital records and have knowledge of what the resident was in the hospital for and what treatment was provided. RGN #210 stated the facility initiated a new directive to complete two skin assessments and record reviews upon admission to ensure nothing was missed. Interview on 08/23/23 at 4:48 P.M. with Registered Nurse (RN) #121 revealed she worked on 08/20/23 and assessed Resident #234's pressure wound. RN #121 stated Licensed Practical Nurse (LPN) #192 asked her how a resident could be added to wound rounds. RN #121 and LPN #192 reviewed Resident #234's admission assessment and the skin grid in the assessment noted a wound to the resident's left gluteal area. RN #121 confirmed there was not a wound treatment in place, or any wound measurements completed at the time she assessed Resident #234 on 08/20/23. RN #121 stated Resident #234 reported she had pain in that area when she sat down and had asked LPN #192 to put something on it on 08/19/23 and 08/20/23. RN #121 pulled up the Admit/Readmit Screener assessment dated [DATE] and stated it was the assessment that she had reviewed prior to assessing the resident. RN #121 stated the Skin Integrity section of the assessment noted the area when she reviewed it, however, it was blank when reviewed today, 08/23/23. RN #121 stated, I promise you; it was there. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 15 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0686 Level of Harm - Actual harm Residents Affected - Few Interview on 08/24/23 at 12:23 P.M. with LPN #192 via telephone revealed she worked during night shift on 08/19/23 and 08/20/23 and assessed Resident #234's wound area. LPN #192 confirmed Resident #234 was admitted with a wound to her left gluteal area on 08/01/23 and the area was noted on the skin grid in the Admit/Readmit Screener assessment dated [DATE]. LPN #192 stated she became aware of the wound when Resident #234 told her about it and that the area was draining and was uncomfortable. LPN #192 stated she checked for a treatment order and there was no order in place. LPN #192 placed a dry dressing on the wound on 08/19/23. Resident #234 requested to have the dressing changed again on 08/20/23 and at that time, LPN #192 decided she needed to confirm an appropriate treatment for the wound. LPN #192 notified RN #121 and they assessed the wound together and took measurements. The nurses placed a clean dry dressing on the wound and notified the physician. Resident #234 was also added to the list to be seen by the wound team. LPN #192 confirmed from 08/01/23 to 08/20/23, Resident #234 did not have a wound treatment in place and the pressure ulcer was not monitored appropriately. Interview on 08/25/23 at 5:20 P.M. with LPN #189 via telephone revealed he completed Resident #234's admission on [DATE]. LPN #189 confirmed he did see Resident #234's wound on her buttocks area and noted it in the skin grid of the Admit/Readmit Screener assessment. LPN #189 stated the Unit Manager was supposed to double check the assessment and pass the information on to the wound team to have Resident #234 seen but I guess that didn't happen. LPN #189 stated he also noted the presence of a wound in the dietary section of the admission assessment to ensure Resident #234 received enough protein in her diet. Follow-up interview on 08/28/23 at 2:25 P.M. with Resident #234 in her room confirmed again she had been admitted with an open wound on the back of her left upper thigh/buttock area. Resident #234 stated she informed the staff a couple of times about the wound but the staff wouldn't listen. Resident #234 confirmed she did not receive any treatment to the wound until recently. Review of the facility policy, Prevention of Pressure Ulcers/Injuries, revised 07/2017, revealed the policy instructed staff to assess the resident on admission for existing pressure ulcer/injury risk factors. Repeat as needed and upon any changes in condition. Conduct a comprehensive skin assessment upon admission, including skin integrity-any evidence of existing or developing pressure ulcers or injuries. Evaluate, report, and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 16 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0687 Provide appropriate foot care. 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 medical record review revealed the facility failed to ensure Resident #47 saw podiatry in a timely manner. This affected one resident (#47) of two residents reviewed for activities of daily living. The facility census was 82. Residents Affected - Few Findings include: Review of the medical record for Resident #47 revealed an admission date of 07/05/23 with diagnoses including Parkinson's disease, unspecified dementia, heart failure, depression, type two diabetes mellitus, and chronic kidney disease stage three. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had severely impaired cognition. Review of the medical record for Resident #47 revealed no evidence he had been seen by a podiatrist. Review of the podiatry list revealed the last visit was on 07/17/23 and Resident #47 was not seen. Observation on 08/21/23 at 11:16 A.M., 12:33 P.M., 1:32 P.M., and 4:41 P.M. of Resident #47 revealed he his toenails were observed to be long, extending several centimeters past the end of his toes and were observed to be jagged and light brown. Interview on 08/21/23 at 12:31 P.M. with Social Worker #135 verified the observation, she reported she was unsure when he had last seen the podiatrist. Further interview on 08/22/23 at 5:03 P.M. with Social Worker #135 revealed Resident #47 was too new to have seen the podiatrist. However, she did verify they can fill out triage forms to get residents see in between schedule podiatry visits. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 17 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility accident investigations, review of the facility incident/accident log, review of hospital records, resident and staff interviews, and facility policy review, the facility failed to ensure one resident (Resident #30) was supervised while smoking, the facility failed to complete neurological checks following an unwitnessed fall for one resident (Resident #56), the facility failed to complete a comprehensive investigation when one resident (Resident #67) required the administration of Narcan (a medication to reverse the effects from a drug overdose), the facility failed to ensure fall interventions were in place for one resident (Resident #47), the facility failed to reassess the effectiveness of fall interventions following multiple falls for one resident (Resident #289), and the facility failed to complete a through investigation following a fall for one resident (Resident #284). This affected six residents (Residents #30, 47, 56, 67, 284, and 289) of nine residents reviewed for accidents. The facility census was 82. Findings Include: 1. Review of the medical record for Resident #30 revealed an initial admission date on 07/22/21 and a readmission date on 11/21/22. Medical diagnoses included hemiplegia and hemiparesis affecting right dominant side, aphasia following cerebral infarction (stroke), vascular dementia with other behavioral disturbance, contracture of unspecified joint, asthma, chronic obstructive pulmonary disease (COPD), unspecified glaucoma, and schizoaffective disorder- Bipolar type. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had impaired cognition and scored a 99 (signifying inability to complete the assessment). According to the staff interview, Resident #30 had moderately impaired cognition. Resident #30 required supervision to limited assistance from one staff to complete Activities of Daily Living (ADLs). Review of the Smoking-Safety Screen assessments dated from 07/22/21 through 07/07/23 revealed Resident #30 was safe to smoke with supervision. Review of the Smoking-Safety Screen assessment dated [DATE] revealed Resident #30 had a dexterity problem and was not able to light his own cigarettes. Resident #30 needed supervision and was safe to smoke with supervision. Review of the care plan for Resident #30 revised 07/17/23 revealed Resident #30 was a smoker with the intervention: the resident requires supervision, initiated on 11/11/21. Observation on 08/23/23 at 3:42 P.M. revealed Resident #30 was outside on the smoking patio smoking a cigarette without any staff supervision. Interview and observation on 08/23/23 at 3:45 P.M. with Social Worker (SW) #135 confirmed Resident #30 was outside smoking without staff supervision. Interview on 08/23/23 at 3:50 P.M. with SW #135 confirmed Resident #30's safe smoking evaluations indicated the resident required supervision with smoking. SW #135 also confirmed Resident #30's care plan indicated Resident #30 required supervision with smoking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 18 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 2. Review of the medical record for Resident #56 revealed an admission date on 04/14/22. Resident #56 was hospitalized on [DATE] and discharged from the facility on 08/17/23. Medical diagnoses included chronic obstructive pulmonary disease (COPD), type II diabetes mellitus, congestive heart failure (CHF), hemiplegia/hemiparesis following cerebral infarction affecting right dominant side, difficulty in walking, muscle wasting and atrophy of multiple sites, and unsteadiness on feet. Residents Affected - Some Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #56 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #56 required limited assistance from one staff for bed mobility, transfers, and toileting. The resident required supervision from one person for walking in the room. There was no indication of any previous falls noted in the assessment. Review of the physician orders dated August 2023 revealed Resident #56 had an order for Apixaban (Eliquis) (an anticoagulant medication) 5 milligrams (mg) every 12 hours for blood thinner. The order was dated 05/13/23. Review of the Medication Administration Record (MAR) dated August 2023 revealed Resident #56 received a dose of Eliquis on 08/13/23 at 10:00 P.M. Review of the progress note dated 08/14/23 at 3:48 A.M. revealed Resident #56 was ambulating to the bathroom and slipped on bedside table. A head to toe assessment was completed. Resident #56 was transferred into bed. Vital signs were taken and Tylenol was administered for pain. The physician and Director of Nursing (DON) were notified of the accident. An X-ray of the left hip was ordered. Resident #14 was sent out to the hospital for evaluation due to pain. Review of the fall investigation dated 08/14/23 revealed Resident #56's fall was unwitnessed and the resident was found on the floor in her room. Initial intervention was to send the resident to the emergency room for an X-ray. Review of the hospital records dated 08/14/23 revealed Resident #56 arrived at the emergency department on 08/14/23 at 4:31 A.M. Review of the neurological assessment flow sheet dated 08/14/23 revealed neurological checks were started on 08/14/23 at 5:00 A.M. (after Resident #56 had already arrived at the emergency room). The neurological checks were completed by Licensed Practical Nurse (LPN) #108. An interview via phone with LPN #108 was attempted but was not successful and no return call was received. LPN #108 has been off work due to illness for several weeks per Regional Nurse (RGN) #210. Interview on 08/28/23 at 12:15 P.M. with RGN #210 confirmed neurological checks should have been started immediately after Resident #56 was found on the floor. RGN #210 confirmed the neurological checks were timed at 5:00 A.M., 5:15 A.M., and 5:30 A.M., after Resident #56 had already arrived at the emergency department. 6. Review of the medical record for Resident #67 revealed an admission date of 09/22/22. Diagnoses included anxiety disorder, depression, and psychoactive substance abuse. Review of Resident #67's quarterly MDS 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating an intact cognition for daily decision making abilities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 19 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 - Some Resident #67 required supervision only for bed mobility, transfers, toilet use, and mobility. Resident #67 was noted to be free of impairment to the bilateral upper and lower extremities and required the use of a walker and/or wheelchair for mobility. Resident #67 was noted to receive opioid medication daily. Review of the plan of care dated 01/13/23 revealed Resident #67 had a substance abuse disorder. Interventions included resident will complete all homework, group and individual assignments, will attend all group activities and individual activities during stay and will follow stepping stones protocol. Review of the plan of care dated 05/08/23 revealed Resident #67 could be non-compliant with care and treatment related to resistance to care and medication. Interventions include for staff to document non-compliance and notify physician of noncompliance that occurs frequently. Review of physician orders for Resident #67 revealed the following orders: -Hold all medications for signs of impairment, every shift for illicit drug use. -Methadone Hydrochloride (hcl) (opioid pain medication) 10 milligram (mg) tablet, give 5 tablets by mouth in the morning for chronic pain. Administer a total of 50 mg daily. -Neloxone HCL (Narcan)- Use 2 mg as needed for overdose. -Gabapentin (nerve pain medication) 400 mg caps, give two capsules for a total of 800 mg every eight hours for nerve pain. -May not go out on leave of absence. Review of the nurses note dated 08/07/23 at 8:14 A.M. created by Licensed Practical Nurse (LPN) #188, Resident was found unresponsive in her room. Nurse tried to wake her up three times , resident didn't respond. Nurse administered Narcan and she came back after one try. Blood pressure assessment was refused, temperature was 98.1 degrees Fahrenheit and oxygen saturation at 95% on nasal cannula. Nurse notified physician, Director of Nursing (DON) and unit manager. No family contact info was in the system. Resident was sent out to the emergency room. Review of the nurses note dated 08/09/23 at 11:06 A.M. created by DON revealed, Interdisciplinary team (IDT) note, Resident was found nonresponsive sitting in her chair. Nurse Narcan resident times one and resident became alert but was very agitated. Resident would not allow staff to obtain vitals and begin to swing and hit at staff once aroused. Emergency Medical Technician (EMT) was called to have resident sent out. Resident has a BIMS of 14. Per hospital emergency department note, resident stated that she intentional overdosed. Review of the hospital notes for Resident #67 dated 08/11/23 at 10:40 A.M. revealed Impression and plan was Accidental Drug Overdose with concern for inciting event was possible drug overdose. She admitted to taking three doses of her prescribed Gabapentin for pain relief (had been saving several extra Gabapentin in case pain symptoms weren't controlled) and because she wanted to be brought to the hospital due to her legs, however felt that the staff at her skilled nursing facility (SNF) were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 20 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 not listening to her. Per history and physical, resident was given intramuscular (IM) Narcan x 2 and Zofran before arriving to emergency department alert and oriented. She denied any intention of harming herself, no current thoughts of harming herself or suicidal ideation, she just wanted to be brought to the hospital. Consulted psychiatry and they agree she is low suicide risk, would offer psychotherapy resources/referral at discharge and continue pain management. Residents Affected - Some Interview on 08/24/23 at 2:20 P.M. with Regional Nurse #210 confirmed the facility did not have an official investigation report for the incident regarding Resident #67 being found unresponsive and requiring Narcan and being transported to the hospital. Regional Nurse #210 claimed the facility did complete a brief investigation regarding this incident and she would print this timeline up. Interview on 08/24/23 at 2:30 P.M. with the Director of Nursing revealed staff had meeting where education is provided including making sure all medications have been swallowed. Review of the provided timeline regarding Resident #67's in facility overdose requiring Narcan revealed on 08/07/23 at 8:14 A.M. resident was found unresponsive by nursing, attempted to wake, Narcan x 1 administration, Resident refused blood pressure monitoring. Physician notified, resident sent out to the hospital. Residents room and belongings were searched, no illicit material found. Stepping Stones (a outpatient substance abuse program) notified. Other Stepping Stone resident rooms searched, no illicit items found. Urine testing preformed on in house Stepping Stone resident's no positives for illicit. On 08/12/23, resident returned to facility from hospital. Stepping Stones updated on admission back to facility. Reviewed stepping stones policy and procedure visitation policy. Resident voiced no complaints on new room/floor change. Review of nursing statements provided by Regional Nurse #210 and completed by LPN #126, #114, #157, #189, and #129 indicated medication was not left at the bedside and residents are observed taking all of their medication. Review of the facility policy, Smoking Policy, revised 12/2016, revealed the facility policy stated, the resident will be evaluated on admission to determine if he/she is a smoker or nonsmoker, including ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). Staff shall consult with the Attending Physician and the Director of Nursing (DON) to determine if safety restrictions need to be placed on a resident's smoking privileges based on the Safe Smoking Evaluation. The resident shall be reevaluated quarterly, with significant change, and as determined by staff. Any smoking-related restrictions shall be noted on the care plan and all personnel caring for the resident shall be alerted. Review of facility policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property, dated 11/01/19 revealed under section titled Definitions C. Injury of Unknown Source includes a injury that was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury. Investigation 2. Interview the resident, and all witnesses. If no direct witnesses, then the interviews may be expanded. For injuries of unknown injuries, the investigation may generally involve talking with both the shift on duty when the injury was discovered and prior. Obtain all medical reports and statements from physician and/or hospitals, and review the resident's records. Finally for follow up, evaluate and make necessary changes in resident's care plan to protect against the occurrence of another similar injury. Conduct in-services training for staff as appropriate. Review of the facility policy titled Falls and Fall Risk dated September 2012 revealed the nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 21 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 - Some shall assess: all current medications, especially those with dizziness and lethargy, pain, and frequency and falls since the last physician visit. 5. Review of the medical record for Resident #47 revealed an admission date of 07/05/23 with diagnoses including Parkinson's disease, unspecified dementia, heart failure, depression, type two diabetes mellitus, and chronic kidney disease stage three. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #47 had severely impaired cognition. The resident required extensive assistance of one person for dressing. Review of the plan of care dated 07/19/23 revealed Resident #47 was at high risk for falls related to weakness and debility. Interventions included anticipating and meeting resident needs, fall mat next to side of bed, following fall protocol, nonskid socks while in bed, and therapy to evaluate as needed. Review of the physician order dated 08/08/23 revealed Resident #47 was to wear nonskid socks while in bed at all times. Observation on 08/21/23 at 11:16 A.M., 12:33 P.M., 1:32 P.M., and 4:41 P.M. of Resident #47 revealed he was in bed with his feet exposed, nonskid socks were not in place. Interview on 08/21/23 at 12:33 P.M. with Social Worker #135 verified Resident #47's feet were exposed. 3. Review of the medical record for Resident #284, revealed an admission date of 05/23/23. Diagnoses included: chronic obstructive pulmonary disease with acute exacerbation, tracheostomy status, anxiety disorder and chronic pain syndrome with a code status of full code and no known drug allergies. Review of the most recent MDS 3.0 assessment dated [DATE] revealed resident was cognitively intact. This resident was assessed to require extensive assistance with one person physical assist with bed mobility and transfers, and supervision with one person assist for eating and dressing. Review of the progress note dated 07/19/23 revealed this resident had an unwitnessed fall due to bed height occurring during sleep. Review of the Fall Scene Investigation Report dated 07/20/23 revealed this resident fell out of bed on 07/19/23 at 12:45 A.M. while sleeping and the investigation did not occur until the next day. The report also revealed no documentation of appropriate fall interventions as well as assisted per care plan, residents' pain, frequency and falls since the last physician visit and all current medications. Interview with the RGN #210 on 08/28/23 at 1:25 P.M. verified no updated interventions to this resident's care plan since the fall and the fall report detailed the bed height as the reason for the fall and no interventions were added to Resident #284's care. 4. Review of the medical record for Resident #289, revealed an admission date of 08/09/23. Diagnoses included: radiculopathy of the lumbar region, psychoactive substance abuse, chronic embolism and thrombosis of unspecified deep veins of right lower extremity with a code status of Full Code and amoxicillin allergies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 22 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 - Some Review of the most recent MDS 3.0 assessment dated [DATE] revealed resident was cognitively intact. This resident was assessed to require supervision with set up only for bed mobility, transfers, locomotion off and on the unit, dressing and eating. Review of the progress notes revealed this resident had two unwitnessed falls on 08/21/23 at 8:00 A.M. and 08/24/23 at 7:20 A.M. It also revealed no documentation of reassessing the resident due to the two falls being the same description. Review of the Fall Scene Investigation Reports for both falls revealed unwitnessed falls, both with no documentation of appropriate fall interventions as well as assisted per care plan, residents' pain, frequency and falls since the last physician visit, all current medications and did not reassess for fall interventions due to the same fall occurring. Review of the care plans dated for 08/10/23 on 08/28/23 for Resident #289 revealed no updated interventions for the falls. Interview with the Director of Nursing on 08/28/23 at 12:08 P.M. verified this resident did not have an updated care plan for his recent falls and no reassessment occurred due to the two falls being the same description. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 23 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the medical record for Resident #67 revealed an admission date of 09/22/22. Diagnosis included anxiety disorder, depression, and psychoactive substance abuse. Residents Affected - Some Review of Resident #67's quarterly MDS 3.0 assessment dated [DATE] revealed a BIMS score of 14 out of 15 indicating an intact cognition for daily decision making abilities. Resident #67 required supervision only for bed mobility, transfers, toilet use, and mobility. Resident #67 was noted to be free of impairment to the bilateral upper and lower extremities and required the use of a walker and/or wheelchair for mobility. Resident #67 was noted to receive opioid medication daily. Review of the plan of care dated 09/23/22 revealed Resident #67 had limited physical mobility related to back pain. Interventions included for staff to monitor, document and report as needed any signs and symptoms of immobility, contracture forming or worsening, thrombus formation, skin breakdown, fall related injury, physician and occupational therapy referrals as ordered and needed. Review of the plan of care dated 09/23/22 and revised on 01/25/23 Resident #67 had pain related to depression, back pain, chronic pain, and neuropathy. Interventions include for staff to anticipate the residents needs for pain relief and respond immediately to any complaint of pain, monitor and document for probable cause of each pain episode, monitor effects for side effects, notify if interventions are unsuccessful or if current complaint is a significant change form past experience. Review of physician orders for Resident #67 revealed the following orders: -Hold all medications for signs of impairment, every shift for illicit drug use. -Methadone Hydrochloride (hcl) (opioid pain medication) 10 milligram (mg) tablet, give 5 tablets by mouth in the morning for chronic pain. Administer a total of 50 mg daily. -Neloxone HCL (Narcan)- Use 2 mg as needed for overdose. -Gabapentin (nerve pain medication) 400 mg caps, give two capsules for a total of 800 mg every eight hours for nerve pain. -Lidocaine 5% patch- apply to affected region topically as needed for pain. -Cyclobenzapine hcl 5 mg tablet bid for muscle spasms -Assess for pain every shift Interview on 08/24/23 at 3:00 P.M. with Regional Nurse #210 confirmed Resident #67's care plan did not include for staff to provide non-pharmacological interventions prior to the administration of pain medication nor did Resident #67's physician orders. Review of the facility policy titled Pain Assessment and Management, dated 03/2015 revealed Non-pharmacological interventions may be appropriate alone or in conjunction with medication. Review of the policy Administering Pain Medications revealed evaluate and document the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 24 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some effectiveness of non-pharmacological interventions. Documentation should include the results of the pain assessment, medication, dosage, route of administration, and results of the medication. 3. Review of medical record for Resident #50 revealed admission date of 01/03/23 with diagnoses including schizoaffective disorder bipolar type, psychoactive substance abuse, chronic pain syndrome, major depressive disorder, and post-traumatic stress disorder. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #50 had intact cognition. He received opioids during all seven days of the look back period. Review of the plan of care dated 01/06/23 revealed Resident #50 had the potential for pain related to history of left index finger amputation. Interventions included administering analgesics as ordered, monitoring for side effects of pain medication, monitoring signs of non-verbal pain, monitoring and recording complaints of pain or requests for pain treatment, and reporting any changes in activity patterns. Review of the plan of care dated 06/30/23 revealed Resident #50 was on pain medication therapy related to his disease process. Interventions included administering analgesic medications as ordered, monitoring for increased risk for falls, and monitoring for adverse reactions. Review of Resident #50's physician order dated 02/10/22 revealed an order for Acetaminophen 650 milligrams (mg) by mouth every six hours as needed for mild pain. Review of Resident #50's physician order dated 01/03/23 revealed an order for Ibuprofen 600 mg one tablet by mouth every six hours as needed for pain. Review of Resident #50's physician order dated 05/28/23 revealed an order for Percocet oral tablet 5-325 mg one tablet by mouth every six hours as needed for pain. Review of the Medication Administration Record (MAR) for August 2023 revealed Acetaminophen was not provided, Ibuprofen was administered on 08/10/23 for a pain of eight and on 08/18/23 for a pain of eight. Percocet was administered on 08/01/23 for a pain of seven, on 08/02/23 for a pain of eight, on 08/03/23 for a pain of eight, twice on 08/04/23 for pains of seven and eight, twice on 08/06/23 for pains of eight and seven, on 08/07/23 for pains of eight and eight, on 08/10/23 for pains of six and eight, on 08/11/23 for a pain of eight, on 08/16/23 for a pain of 10, on 08/17/23 for a pain of eight, twice on 08/18/23 for pains of eight and eight, on 08/19/23 for a pain of eight, on 08/20/23 for a pain of six, on 08/21/23 for a pain of eight, twice on 08/22/23 for pains of seven and eight, twice on 08/23/23 for pains of eight and eight, twice on 08/24/23 for pains of eight and eight, and on 08/25/23 for a pain of eight. No non-pharmacological interventions (NPI) were indicated in the MAR. Review of the progress notes revealed there was no description of pain or NPI's indicated for Percocet administered on 08/03/23, one of two doses on 08/06/23, 08/07/23, 08/11/23, 08/17/23, 08/18/23, 08/19/23, 08/21/23, one of two doses on 08/22/23, one of two doses on 08/23/23, and 08/24/23. No NPI's were indicated for Percocet administration on 08/04/23, both doses on 08/10/23, or on 08/20/23. In an email on 08/28/23 at 11:34 A.M., Regional Nurse #210 revealed NPI's should have been linked to medication administration in the MAR's. She verified this was not the case for Resident #50. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 25 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. Review of the medical record for Resident #71 revealed an admission date of 12/1/22 with diagnoses including hemiplegia and hemiparesis affecting right dominant side, metabolic encephalopathy, dysphagia, aphasia, other psychoactive substance abuse, and anxiety. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had intact cognition. Resident #71 received opioids during four days of the lookback period. Review of the plan of care dated 12/02/22 revealed Resident #71 had the potential for pain related to a recent intracerebral hemorrhage and multiple medical problems. Interventions included administering analgesia as ordered, monitoring for side effects of pain medications, monitoring for signs of nonverbal pain medications, monitoring and reporting loss of appetite, monitoring and recording nurse resident complaints of pain and requests for pain treatment, and observing for changes in routine. Review of the physician order dated 06/01/23 revealed Resident #71 was to receive Percocet 5-325 milligrams (mg) one tablet every hour hours as needed for pain. Review of the August 2023 Medication Administration Record (MAR) revealed Percocet was administered three times on 08/02/23, twice on 08/03/23, four times on 08/04/23, three times on 08/05/23, four times on 08/06/23, twice on 08/07/23, once on 08/08/23, twice on 08/10/23, twice on 08/12/23, once on 08/13/23, once on 08/14/23, twice on 08/16/23, once on 08/17/23, three times on 08/18/23, twice on 08/19/23, three times on 08/20/23, once on 08/21/23, four times on 08/22/23, and three times on 08/23/23. Non-pharmacological interventions (NPI's) were not indicated as having been attempted once on 08/04/23, once on 08/04/23, twice on 08/07/23, on 08/08/23, twice on 08/12/23, on 08/13/23, on 08/14/23, three times on 08/18/23, once on 08/19/23, twice on 08/22/23, and once on 08/23/23. Review of the progress notes from 08/02/23 to 08/23/23 revealed there was no description of the pain or location of pain on two of three Percocet administrations on 08/02/23, 08/03/23, one of three Percocet administrations on 08/04/23, one of three Percocet administrations on 08/05/23, one of four Percocet administrations on 08/06/23, 08/07/23, 08/08/23, 08/12/23, 08/13/23, 08/14/23, one out of two Percocet administrations on 08/16/23, 08/17/23, 08/18/23, one out of two Percocet administrations on 08/19/23, 08/21/23, 08/22/23, and one of three Percocet administrations on 08/23/23. Interview on 08/23/23 at 3:42 P.M. with LPN #171 revealed when administering pain medications, the nurse should be assessing and documenting pain scale and location. She reported NPI's were to be coded in the MAR. LPN #171 reported there were residents who did not want to try NPI's, but it should be documented. Based on staff interviews, medical record reviews, and the facility policy, the facility failed to offer non-pharmacological interventions and/or pain descriptions prior to administration of pain medications. This affected five residents (#50, #66, #67, #71, and #289) out of the five residents receiving pain medication reviewed. The facility census was 82. Findings include: 1. Review of the medical record for Resident #289, revealed an admission date of 08/09/23. Diagnoses included: radiculopathy of the lumbar region, psychoactive substance abuse, chronic embolism and thrombosis of unspecified deep veins of right lower extremity with a code status of Full Code and amoxicillin allergies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 26 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0697 Level of Harm - Minimal harm or potential for actual harm Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating intact cognition. This resident was assessed to require supervision with set up only for bed mobility, transfers, locomotion off and on the unit, dressing and eating. Residents Affected - Some Review of the MDS also revealed resident did not receive non-medication intervention for pain. Review of the physician's orders for this resident revealed no orders for non-pharmacological interventions for pain. Review of the care plan for pain dated 08/10/23 for this resident revealed no interventions for non-pharmacological interventions. Interview with Licensed Practical Nurse (LPN) #14 on 08/24/23 at 11:38 A.M. revealed no nonpharmacological interventions for pain are in place for Resident #289. LPN#14 stated, He specifically asks for the Oxycodone HCL so we give it to him. Interview with Resident #289 on 08/24/23 at 12:11 P.M. revealed the resident does not get nonpharmacological interventions for pain and stated, My pain is fine, they don't try like pillows or anything. I get my pills when I need them and that works fine. Interview with the Director of Nursing (DON) on 08/28/23 at 12:02 P.M. confirmed Resident #289 has no order and care plan for non-pharmacological interventions for pain. 2. Review of the medical record for Resident #66, revealed an admission date of 06/07/22. Diagnoses included: fusion of the spine in the cervical region, cord compression, alcohol abuse with intoxication, nicotine dependence with cigarettes and unspecified mood affective disorder with a code status of full code with no known allergies. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a BIMS of 15 out 15 indicating intact cognition. This resident was assessed to require supervision with one-person physical assist with bed mobility, transfers, dressing and toileting with independent with set up help only for eating. Review of the physician's orders for resident revealed no orders for non-pharmacological interventions for pain. Review of the care plan for pain dated 08/07/23 for resident revealed no interventions for non-pharmacological interventions. Interview with LPN #14 on 08/24/23 at 11:40 A.M. revealed no nonpharmacological interventions for pain are in place for Resident #66. Interview with the DON on 08/28/23 at 12:05 P.M. confirmed Resident #66 has no order and care plan for non-pharmacological interventions for pain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 27 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of dialysis communication forms, and review of facility policy, this facility failed to ensure post dialysis weights were obtained as per order. This affected one (Resident #15) of one residents reviewed for dialysis services. Facility census was 82. Residents Affected - Few Findings include: Review of the medical record for Resident #15 revealed an admission date of 08/25/22. Diagnoses included chronic kidney disease and neuropathy, chronic viral Hepatitis C, and end stage renal disease with dependence on renal dialysis. Review of Resident #15's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating a moderately impaired cognition for daily decision making abilities. Resident #15 was noted to be receiving dialysis services. Review of Resident #15's physician orders revealed a order for staff to log post dialysis weights every day shift on Tuesdays, Thursdays, and Saturdays. Review of the medication administration record (MAR) and treatment administration record (TAR) for August 2023 revealed the only post dialysis weight obtained were on on 08/17/23 on 146.7 pounds, 08/19/23 on 152.5 pounds, and on 08/22/23 for 152.5 pounds. Review of Resident #15's dialysis communication forms from 07/2023 through 08/2023 revealed multiple communication forms did not have the residents pre-dialysis weight nor did they have the resident post-dialysis weight noted. Interview on 08/28/23 at 11:29 A.M. with Unit Manager #320 confirmed Resident #15 did have a order to log his post dialysis weight and confirmed this was not being completed. After looking at the dialysis communication form claimed the facility fills out a dialysis communication form that is sent with the patient to dialysis. While there, the center will completed their section including pre and post dialysis weight and send that form back with the patient. Unit manager confirmed there were multiple communication forms that had not been completed to include the pre and post weight. Interview 08/28/23 at 12:10 P.M. with Regional Nurse #210 confirmed Resident #15's dialysis communication form did not have the pre or post weights on some of them and she would expect the nurse to call the dialysis center to follow up on that missing weight. Review of facility policy titled Care of a Resident with End-Stage Renal Disease, dated 09/2010 revealed Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed including how the care plan will be developed and implemented. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 28 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview, review of resident medical records and pharmacy recommendations revealed the facility failed to timely address pharmacy recommendations for Resident #19 and #71. This affected two residents (#19 and #71) of seven residents reviewed for unnecessary medications. The facility census was 82. Findings include: 1. Review of the medical record for Resident #71 revealed an admission date of 12/1/22 with diagnoses including hemiplegia and hemiparesis affecting right dominant side, metabolic encephalopathy, dysphagia, aphasia, other psychoactive substance abuse, and anxiety. Review of the pharmacy recommendation dated 01/24/23 revealed the pharmacist recommended discontinuing the 'as needed' medication Quetiapine or reordering for a specific number of days. The physician indicated that this was something psych addressed, however, their comments were undated. Review of the pharmacy recommendation dated 02/17/23 revealed the pharmacist recommended discontinuing the 'as needed' medication Quetiapine or reordering for a specific number of days. The physician did not choose an option, wrote psych in the response section, and did not date when they addressed the recommendation. Review of the pharmacy recommendation dated 02/17/23 revealed the pharmacist recommended obtaining routine labs for valproic acid, ammonia, and liver function tests, due to routinely taking valproic acid. The physician indicated this should be done every six months, they did not date when they addressed the recommendation. Review of Resident #71's physicians orders revealed no orders for routine lab work. Review of the medical record from 02/17/23 to 08/23/23 revealed no evidence labs were obtained for valproic acid, ammonia, or liver function. Review of the Pharmacists medication regimen review list of residents with no recommendations for April 2023 revealed Resident #71 was not on the list. No recommendation was provided for April 2023. Interview on 08/23/23 at 11:14 A.M. with the Director of Nursing (DON) verified the pharmacy recommendations were not dated or were not completed as the physician agreed to. 2. Review of the medical record for Resident #19 revealed an admission date of 12/26/22 with diagnoses including Alzheimer's disease, dysphagia, anemia, depression, mood disorder, visual hallucinations, osteoarthritis, and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) 3.0 dated 06/06/23 revealed Resident #19 had severely impaired cognition. Review of the pharmacist recommendation dated 01/24/23 revealed due to Resident #19's medications the pharmacist recommended monitoring serum valproic acid every six months and serum ammonia level once. The physician agreed with this recommendation on 07/25/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 29 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the pharmacist recommendation dated 02/17/23 revealed due to Resident #19's medications the pharmacist recommended monitoring serum valproic acid every six months and serum ammonia level once. The physician agreed with this recommendation on 07/25/23. Review of the pharmacist recommendation dated 04/20/23 revealed due to Resident #19's medications the pharmacist recommended monitoring serum valproic acid every six months and serum ammonia level once. The physician agreed with this recommendation on 05/07/23. Review of the physician's orders from 01/24/23 to 08/23/23 revealed no evidence the lab work was ever ordered. Review of the pharmacist recommendation dated 05/22/23 revealed Resident #19 had been on Sertaline 100 milligrams (mg) one time a day since December 2022, a gradual dose reduction was recommended. The physician agreed to the recommendation on 06/07/23 and recommended lowering Sertraline to 75 mg once a day. Review of the physician order dated 07/05/23 revealed an order to change Sertraline to 75 mg one time a day. Interview on 08/23/23 at 11:14 A.M. with the Director of Nursing (DON) verified the pharmacy recommendations were not dated or were not completed as the physician agreed to. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 30 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to monitor blood pressure consistently prior to administering medications for Resident #20 and #47 additionally they failed to monitor for side effects of medications for Resident #289. This affected three residents (#20, #47 and #289) of seven residents reviewed for unnecessary medications. The facility census was 82. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #20 revealed an admission date of 06/08/21 with diagnoses including senile degeneration of brain, type one diabetes mellitus, unspecified dementia, cognitive communication deficit, epilepsy, alcohol abuse, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of the plan of care dated 10/26/20 revealed Resident #20 had hypertension. Interventions included avoiding taking blood pressure after physical activity, educating about compliance, giving antihypertensive's as ordered and monitoring for side effects, monitoring for edema, and monitoring for malignant hypertension. Review of the physician order dated 08/14/21 revealed Resident #20 had an order for Lisinopril 10 milligrams (mg) one tablet by mouth one time a day for hypertension. Hold for systolic blood pressure below 115 millimeters of mercury (mmHg). Review of the July 2023 Medication Administration Record (MAR) revealed Lisinopril was scheduled to be administered at 6:00 A.M. every day, the medication was not held. Lisinopril did not have blood pressure parameters attached to it. Review of the daily blood pressure measurements revealed systolic blood pressure was below 115 mmHg on 07/01/23, 07/02/23, 07/05/23, 07/12/23, 07/13/23, 07/16/23, 07/17/23, 07/19/23, 07/20/23, 07/23/23, 07/24/23, 07/26/23, 07/27/23, 07/28/23, 07/29/23, and 07/30/23. Review of the August 2023 MAR revealed Lisinopril was scheduled to be administered at 6:00 A.M. every day, the medication was held on 08/02/23. Lisinopril did not have blood pressure parameters attached to it. Review of the daily blood pressure measurements revealed systolic blood pressure was below 115 mmHg on 08/02/23, 08/06/23, 08/07/23, 08/10/23, 08/11/23, 08/12/23, 08/13/23, 08/16/23, 08/17/23, 08/18/23, 08/19/23, 08/20/23, and 08/21/23. In an email on 08/23/23 at 11:37 A.M. with Regional Nurse #210 she was unable to provide an explanation for why Lisinopril was not held more often. 2. Review of the medical record for Resident #47 revealed an admission date of 07/05/23 with diagnoses including Parkinson's disease, unspecified dementia, heart failure, depression, type two diabetes mellitus, and chronic kidney disease stage three. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #47 had severely impaired cognition. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 31 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0757 Level of Harm - Minimal harm or potential for actual harm Review of the physician order dated 07/05/23 revealed Resident #47 had an order for Carvedilol tablet 25 mg 12.5 mg twice a day for hypertension. Review of the physician order dated 07/06/23 revealed Resident #47 had an order for Furosemide tablet 20 mg by mouth for edema. Residents Affected - Few Review of the physician order dated 07/06/23 for Amlodipine Besylate oral tablet 10 mg by mouth daily for hypertension. Review of Resident #47's Medication Administration Record (MAR) for July 2023 revealed Amlodipine Besylate, Carvedilol, and Furosemide was held on 07/12/23 for a blood pressure of 96 over 45 millimeters of mercury (mmHg). Carvedilol was held on 07/17/23 for a blood pressure of 107 over 44 mmHg. Review of Resident #47's MAR for August 2023 revealed Amlodipine Besylate was held on 08/01/23 and 08/19/23 with no blood pressure indicated. It was held on 08/14/23 for a blood pressure of 99 over 67 mmHg. Review of the progress note dated 08/01/23 revealed Amlodipine and Carvedilol were held for a blood pressure of 96 over 58 mmHg with a heart rate of 61 beats per minute. Review of the progress note dated 08/19/23 revealed Amlodipine and Carvedilol were held for a blood pressure of 115 over 52 mmHg. Review of the medical record revealed no hold parameters for Amlodipine Besylate, Carvedilol, or Furosemide. In an email on 08/23/23 at 11:27 A.M. with Regional Nurse #210 revealed there were no hold parameters for medication unless otherwise indicated by the physician. She reported nurses should not be holding medication without a physician order or notifying the physician. 3. Review of the medical record for Resident #289, revealed an admission date of 08/09/23. Diagnoses included: radiculopathy of the lumbar region, psychoactive substance abuse, chronic embolism and thrombosis of unspecified deep veins of right lower extremity with a code status of Full Code and amoxicillin allergies. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a BIMS of 15 out of 15 indicating intact cognition. This resident was assessed to require supervision with set up only for bed mobility, transfers, locomotion off and on the unit, dressing and eating. Review of Resident #289's orders revealed the physician had prescribed: Gabapentin 100 mg one capsule by mouth three times a day for pain, Methadone HCL 5 mg five tablets by mouth every eight hours for opioid dependence, Methocarbamol 500 mg one tablet by mouth three times a day for muscle spasms and pain and Oxycodone HCL 10 mg one tablet by mouth every six hours as needed for pain. Review of Resident #289's physicians orders revealed no adequate monitoring and adverse consequences for the pain medications prescribed. Review of the care plan for this resident being on pain medication therapy dated 08/10/23 revealed an intervention for monitoring respiratory rate, depth, and effort after administration of pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 32 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0757 Level of Harm - Minimal harm or potential for actual harm medications but revealed no monitoring for specific side effects and behaviors for his multiple pain medications. Interview with the Director of Nursing (DON) on 08/28/23 at 12:04 P.M. verified no orders for adequate monitoring and adverse consequences for the pain medications. Residents Affected - Few Review of the policy titled Pain Assessment and Management dated March 2015 revealed reporting adverse effects to the physician such as: confusion and lethargy. Review of Medscape drug interactions revealed the use of Methadone HCL and Oxycodone HCL together has a significant interaction and to monitor closely for increased sedation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 33 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide appropriate diagnoses or monitoring for the use of psychotropic medications for Resident #19, #47, #66, #71, and #284. This affected five residents (#19, #47, #66, #71, and #284) of seven residents reviewed for unnecessary medications. The facility census was 82. Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 12/26/22 with diagnoses including Alzheimer's disease, dysphagia, hypertension, anemia, depression, mood disorder, visual hallucinations, osteoarthritis, and muscle weakness. Review of the comprehensive Minimum Data Set (MDS) 3.0 dated 06/06/23 revealed Resident #19 had severely impaired cognition. She was noted to have delusions and no other behaviors. Review of the plan of care dated 01/12/23 revealed Resident #19 used antidepressant medication related to depression. Interventions included administering antidepressants as ordered and monitoring for adverse reactions. Review of the plan of care dated 03/21/23 revealed Resident #19 used psychotropic medications related to visual hallucinations. Interventions included administering psychotropic medications as ordered and monitoring for side effects and effectiveness every shift, consulting with pharmacy, monitoring for adverse reactions, and monitoring and recording occurrence of target behavior symptoms and document per facility protocol. Review of the plan of care dated 06/30/23 revealed Resident #19 had depression related to Alzheimer's disease. Interventions included administering med's as ordered, monitoring for any risk for harm to self, monitor for any signs of depression including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness, monitor for risk to harm others. Review of the physician order dated 08/03/23 revealed Resident #19 had an order for Lorazepam 0.5 milligram (mg) one tablet by mouth every two hours as needed for mild anxiety or agitation and two tablets by mouth every two hours as needed for severe anxiety and agitation. There was no end date for the order. Review of the physician order dated 08/03/23 revealed Resident #19 had an order for Sertraline 100 mg by mouth one time a day related to depression. Review of the physician order dated 08/07/23 revealed Resident #19 had an order for Seroquel 50 milligrams (mg) one time a day for hallucinations. Review of the August 2023 Medication Administration Record (MAR) revealed the mild dose of Lorazepam was not administered. The severe dose of Lorazepam was administered on 08/03/23 at 9:00 P.M. and 11:05 P.M., on 08/04/23 at 2:00 A.M., 8:00 P.M., and 10:40 P.M., on 08/05/23 at 3:40 P.M., on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 34 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0758 08/08/23 at 9:00 A.M., on 08/18/23 at 4:13 P.M. and on 08/21/23 at 10:15 P.M. Level of Harm - Minimal harm or potential for actual harm Review of the medical record revealed no indication to monitor for anxiety, agitation, depression, or hallucinations. Residents Affected - Some Review of the progress notes revealed no description of behaviors prior to administering Lorazepam and no description of non-pharmacological interventions. In an email on 08/28/23 at 10:45 A.M. with Regional Nurse #210 revealed when it came to targeted behaviors, they used point of care charting for behaviors every shift unless otherwise indicated. She verified there were no progress notes associated with Resident #19's behaviors. 2. Review of the medical record for Resident #71 revealed an admission date of 12/1/22 with diagnoses including hemiplegia and hemiparesis affecting right dominant side, metabolic encephalopathy, dysphagia, aphasia, other psychoactive substance abuse, and anxiety. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #71 had intact cognition. Review of the plan of care dated 12/02/22 revealed Resident #71 used anti-anxiety medications related to anxiety disorder. Interventions included administering antianxiety medications as ordered and monitoring for any adverse reactions as needed. Review of the plan of care dated 12/02/22 revealed Resident #71 used antidepressant medication related to insomnia. Interventions included administering antidepressants as ordered and monitoring for adverse reactions. Review of the plan of care dated 12/02/22 revealed Resident #71 used psychotropic medications related to psychomotor agitation and impulsiveness. Interventions included administering psychotropics as ordered, consulting with the pharmacy, and monitoring for adverse reactions. Review of the physician order dated 12/02/22 revealed Resident #71 received Seroquel 100 mg one time a day at bedtime for mood. Review of the physician order dated 12/02/22 revealed Resident #71 received Risperidone 0.5 mg three tablets at bedtime for agitated movements. Review of the physician order dated 12/02/22 revealed Resident #71 received Risperidone 1.0 mg one time a day for agitated movements. Review of the physician order dated 12/02/22 revealed Resident #71 received Valproic acid solution 10 milliliters (ml) three times a day for mood. Review of the physician order dated 04/23/23 revealed Resident #71 received Seroquel 50 mg twice a day for mood. Review of the medical record revealed no indication to monitor for agitated movements. In an email on 08/28/23 at 10:45 A.M. with Regional Nurse #210 revealed the 12/02/22 medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 35 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were started in the hospital for the reasons listed in the order. She did not provide a reason for the 04/23/23 Seroquel being used for 'mood'. She reported when it came to targeted behaviors, they used point of care charting for behaviors every shift unless otherwise indicated. 3. Review of the medical record for Resident #47 revealed an admission date of 07/05/23 with diagnoses including Parkinson's disease, unspecified dementia, heart failure, depression, type two diabetes mellitus, and chronic kidney disease stage three. Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #47 had severely impaired cognition. Review of the plan of care dated 07/19/23 revealed Resident #47 used antidepressant medication related to depression. Interventions included administering medications as ordered and monitoring for adverse reactions related to antidepressants. Review of the physician's orders revealed Resident #47 was on four medications for depression including: Seroquel 75 mg at bed time for manic depression starting 07/05/23, Mirtazapine 7.5 mg by mouth at bedtime for depression starting 07/05/23, Seroquel 25 mg twice a day for manic depression starting 07/06/23, and Lexapro 5 mg one time a day for depression starting 07/06/23. Review of the medical record revealed no indication to monitor for signs of depression. In an email on 08/28/23 at 10:45 A.M. with Regional Nurse #210 revealed when it came to targeted behaviors, they used point of care charting for behaviors every shift unless otherwise indicated. 4. Review of the medical record for Resident #284, revealed an admission date of 05/23/23. Diagnoses included: chronic obstructive pulmonary disease with acute exacerbation, tracheostomy status, anxiety disorder and chronic pain syndrome with a code status of full code and no known drug allergies. Review of the most recent MDS 3.0 assessment dated [DATE] revealed BIMS of 13 out of 15 indicating intact cognition. This resident was assessed to require extensive assistance with one person physician assist with bed mobility and transfers, and supervision with one person assist for eating and dressing. Review of physician orders dated for 08/10/23 revealed this resident was receiving the following medication: Haloperidol 5 mg one tablet by mouth every eight hours for mental disorder. Review of current resident diagnoses revealed this resident does not have an active diagnosis of psychosis in the medical chart. Interview with the Regional Nurse on 08/28/23 at 2:39 P.M. verified mental disorder is an unacceptable diagnosis use of Haloperidol. 5. Review of the medical record for Resident #66, revealed an admission date of 06/07/22. Diagnoses included: fusion of the spine in the cervical region, cord compression, alcohol abuse with intoxication, nicotine dependence with cigarettes and unspecified mood affective disorder with a code status of full code with no known allergies. Review of the most recent MDS 3.0 assessment dated [DATE] revealed a Brief Interview for Mental (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 36 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Status (BIMS) of 15 out of 15 indicating intact cognition. This resident was assessed to require supervision with one-person physical assist with bed mobility, transfers, dressing and toileting with independent with set up help only for eating. Review of physician orders revealed this resident was receiving the following medication: Duloxetine HCL 30 mg one capsule by mouth two times a day for pain. Review of current resident diagnoses revealed this resident does not have an active diagnosis of pain disorders in the medical chart. Review of this resident's chart revealed no indication for the use of Duloxetine HCL for pain. Interview with the Director of Nursing on 08/28/23 at 12:55 P.M. verified pain is an unacceptable diagnosis use of Duloxetine HCL. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 37 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, hospital record review, and facility policy review, the facility failed to complete comprehensive blood glucose monitoring for Resident #65 to ensure insulin was administered per physician order and to meet the resident's total care needs. Residents Affected - Few Actual Harm occurred when the lack of blood glucose monitoring (beginning in June 2023 and continuing through August 2023) and evaluation and/or administration of insulin resulted in ongoing episodes of hyperglycemia. On 08/12/23 Resident #65 had a blood glucose reading above 500 milligrams per deciliter (mg/dL) and was admitted to the hospital with hyperglycemia and acute kidney injury. This affected one resident (#65) of four residents reviewed for quality of care. The facility census was 82. Findings include: Review of the medical record for Resident #65 revealed an initial admission date of 06/03/22 and latest re-entry date of 08/15/23. Resident #65 had diagnoses including mild protein-calorie malnutrition, muscle wasting and atrophy, and type two diabetes mellitus. Review of the plan of care for Resident #65 dated 06/13/22 and revised on 05/08/23 revealed Resident #65 had a diagnosis of diabetes mellitus. Interventions included administering medication as ordered, monitor and document for side effects and effectiveness of medications, complete dietary consult for nutritional regimen and ongoing monitoring, complete fasting serum blood sugar as ordered, monitor, document and report as needed any signs or symptoms of hyperglycemia including increased thirst and appetitive, frequent urination, weight loss, fatigue, and dry skin. Review of Resident #65's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08 out of 15 indicating the resident had moderately impaired cognition for daily decision-making. Record review revealed Resident #65 had a hospitalization from 06/05/23 to 06/13/23. Prior to the hospitalization the resident had a physician's order to check blood glucose level in the morning, record in the electronic medical record and notify the physician if the resident's blood glucose was greater than 400. The orders also included to monitor resident for signs or symptoms of hypo/hyperglycemia and notify the physician of blood glucose readings less than 60 or greater than 400 every shift. The resident had an order for insulin medication, Glargine (Lantus) 100 units/milliliter-solution 14 units subcutaneously at bedtime for diabetes mellitus. Review of Resident #65's after hospital visit summary dated 06/13/23 revealed to stop taking the prescribed Insulin Glargine (Lantus)100 units/ml and continue taking Insulin Lispro 100 units/ml solution per sliding scale. The sliding scale revealed for a blood glucose level of 100 to 150 give two units of Lispro, for a blood glucose of 151 to 200 give three units of Lispro, blood glucose of 210 to 300 give four units Lispro, blood glucose of 301 to 400 give six units of Lispro and for a blood glucose reading greater than 400 give 10 units of Lispro and then call the physician. The blood glucose monitoring and sliding scale coverage was ordered to be completed four times a day. Review of the physician's orders for Resident #65 revealed upon re-admission [DATE]) the order for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 38 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0760 Level of Harm - Actual harm Residents Affected - Few the Lantus insulin had been discontinued. However, the new order for the Lispro sliding scale insulin with blood glucose monitoring four times a day had not been written/implemented. There was an order for the resident's blood glucose to be monitored daily in the morning and to notify the physician of any reading less than 60 or greater than 400 (which was the order that had been in place prior to the 06/05/23 hospitalization). Review of Resident #65's medication administration record (MAR) and treatment administration record (TAR) for June 2023 revealed an actual blood glucose reading was only obtained and recorded twice during the month for the resident. On 06/14/23 the resident's blood glucose was elevated at 325.0 mg/dL and on 06/22/23 it was elevated at 325.0 mg/dL. Based on the hospital visit summary, the resident should have received six units of insulin (Lispro) for the blood glucose readings of 325 of these dates. However, there was no evidence of any insulin being administered to the resident. Review of Resident #65's MAR and TAR for July 2023 revealed no evidence staff had checked or documented any blood glucose readings for the resident during the month of July 2023. Review of Resident #65's MAR and TAR for August 2023 revealed staff had only checked the resident's blood glucose levels twice; on 08/04/23 the resident's blood glucose level was 371.0 mg/dL (elevated) and on 08/12/23 the resident's blood glucose level was elevated at 549.0 mg/dL. There was no evidence the resident was administered any insulin on 08/04/23 related to the elevated blood glucose level of 371. Review of a physician note dated 08/10/23 at 1:38 P.M. created by Certified Nurse Practitioner (CNP) #500 revealed the CNP was asked to see the resident by staff due to increased confusion, type two diabetes mellitus, dementia, and chronic kidney disease. The CNP note reflected the resident was seen in the hospital from [DATE] through 06/13/23 for worsening shortness of breath, volume overload and elevated troponin. Hospital course included a left heart catheterization without intervention. The note revealed to monitor blood glucose and adjust regimen as needed, check HgbA1C and basic metabolic panel (BMP) periodically, order to check blood glucose daily in morning in place in electronic record. Accu check (blood glucose results) trends not available for review, will discuss with nursing. A1C ordered next lab day and every six months. Review of the nursing note dated 08/10/23 at 3:38 P.M. created by Licensed Practical Nurse (LPN) #114 revealed, laboratory orders obtained, stat complete blood count (CBC) and basic metabolic panel (BMP). Aspirin to be discontinued per CNP #500. Review of a nursing note dated 08/12/23 at 12:30 P.M. created by LPN #118 revealed received phone call from CNP #500. Resident's glucose level was 550 (critical). Called and spoke with physician concerning resident's lab work. New orders (1) Accu-check done and registers Hi. (2) Give Lispro 10 Units now. Re-check (blood) sugar in an hour. Call back if sugars were in the 400's. (3) collect urine and an A1C/ call lab. Resident says he's tired, did eat breakfast. Refusing lunch (just sleeping). There was no indication why the laboratory testing, ordered on 08/10/23 was not addressed until 08/12/23 (two days later). Review of the nursing note dated 08/12/23 at 2:00 P.M. created by LPN #118 revealed the nurse re-checked resident's blood glucose which was 549 (hyperglycemic). The resident still remained in bed sleeping, did not eat lunch. Called physician and explained the resident's condition and received new orders to send to emergency room due to status change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 39 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0760 Level of Harm - Actual harm Residents Affected - Few Review of Resident #65's hospital after visit summary for the hospitalization from 08/12/23 through 08/15/23 revealed the resident's primary diagnoses included hyperglycemia. The visit summary noted the resident was noted with a glucose reading in the 500's at the extended care facility. Hyperglycemia on admission likely secondary to lack of basal coverage. HgbA1C reading of 13% (elevated) which indicated the resident had an average blood sugar/glucose reading of 326 mg/dL in the last 90 days. Restarted Lantus insulin, titrated up to 24 units daily at bedtime with improvement in glucose in the 200's. Interview on 08/24/23 at 3:00 P.M. with Regional Nurse #210 confirmed Resident #65's blood glucose levels were not being monitored for the month of June 2023, July 2023, or August 2023 as per orders following the resident's re-admission in June 2023. Regional Nurse #210 also verified the hospital discharge instructions from the hospital stay dated 06/05/23 through 06/13/23 indicated for the resident to continue the insulin medication Lispro and if there any questions regarding this order, the admitting nurse should have called for clarification. Review of facility policy titled Obtaining a Fingerstick Glucose Level, dated 10/2011 revealed under Documentation, the person performing this procedure should record the following information in the resident's medical record: The blood sugar results. Follow facility policies and procedures for appropriate nursing interventions needed to adjust insulin or oral medication dosages. No additional policy/procedures were provided for review related to diabetic monitoring and/or diabetic care/treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 40 of 41 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 366207 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/30/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bella Terrace Rehabilitation and Nursing Center 1520 Hawthorne Avenue Columbus, OH 43203 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure current hospice plan of care and documentation was on site. This had the affected one resident (#20) of one resident reviewed for hospice. The facility census was 82. Findings include: Review of the medical record for Resident #20 revealed an admission date of 06/08/21 with diagnoses including senile degeneration of brain, type one diabetes mellitus, unspecified dementia, cognitive communication deficit, epilepsy, alcohol abuse, and hypertension. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed severely impaired cognition. Review of the plan of care dated 12/02/21 revealed Resident #20 was enrolled in hospice services related to senile degeneration of the brain. Interventions included administering medications as ordered, allowing resident to discuss feelings, assisting with activity of daily living care per care plan, honoring advanced directives, and notifying hospice of changes. Interview on 08/22/23 at 3:05 P.M. with Licensed Practical Nurse (LPN) #126 revealed there was a hospice binder for residents on hospice that should have been at the nurse's station. A request was made for hospice documentation; however, she was unable to find it. LPN #126 reported Unit Manager #140 would look for the binder. Review of the hospice binder provided on 08/23/23 at 8:30 A.M. by Social Worker #135 revealed Resident #20's information was not current. The hospice binder contained a plan of care for the certification period of 03/08/23 to 05/06/23 and the last note was dated 06/26/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 41 of 41