Health inspection·April 8, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and resident interview, the facility failed to ensure residents who were dependent on staff assistance received baths/showers as scheduled/requested. This affected two (Residents #68 and #73) of three residents reviewed for bathing. The census was 89. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #68 revealed Resident #68 was admitted to the facility on [DATE]. Resident #68's diagnoses included but were not limited to cerebral infarction, hemiplegia, neurologic neglect syndrome, dysarthria and anarthria, aphasia, dysphagia, and cognitive communication deficit. Review of Resident #68's Minimum Data Set (MDS) assessment, dated 02/02/24, revealed he was cognitively intact and required substantial/maximal assistance with baths/showers. Review of Resident #68's active shower schedule revealed he was to receive a bath or shower on Mondays and Thursdays during the day shift. Review of Resident #68's shower logs and documentation, dated 01/01/24 to 04/07/24, revealed he was scheduled to have a total of 28 baths or showers. Review of the shower documentation provided by the facility revealed Resident #68 had a total of 10 baths/showers from 01/01/24 to 04/08/24 and the baths/showers occurred on 01/08/24, 02/01/24, 02/05/24, 02/12/24, 02/29/24, 03/16/24, 03/18/24, 03/25/24, 03/28/24, and 03/30/24. Interview with Administrator on 04/08/24 at 12:15 P.M. confirmed there was no additional documentation to indicate Residents #68 was offered or received baths/showers as scheduled/requested. 2. Review of the medical record for Resident #73 revealed Resident #73 was admitted to the facility on [DATE]. Resident #73's diagnoses included but were not limited to spinal stenosis, dysphagia, and major depressive disorder. Review of Resident #73's MDS assessment, dated 01/29/24, revealed she was cognitively intact and required partial/moderate assistance with baths/showers. Review of Resident #73's active shower schedule revealed she was to receive a bath or shower on Wednesday and Saturdays during the day shift. Review of Resident #73's shower logs and documentation, dated 01/22/24 to 04/07/24, revealed she (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 366207 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 04/08/2024 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)