Health inspection·July 1, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, review of the facility policy, staff interviews, and review of the health departments' food inspection reports, the facility failed to ensure the kitchen was in a sanitary condition. This had the potential to affect all 95 residents who received food from the kitchen. The facility identified one resident (#32) who received nothing by mouth. The facility census was 96. Findings include: Review of the City of Columbus Inspection Report dated 06/11/24 revealed the inspection was a standard visit. The facility received a violation for food contact services were dirty and noted there were observations of dust hanging from the vents in dish area, specifically above the clean dishes part of dishwasher. Review of the State of Ohio Food Inspection Report dated 06/26/24 revealed it was a follow up visit. The facility received a violation for the presence of insects, rodents, and other pest is not being adequately controlled or minimized. The sanitarian observed roughly 20 to 30 cockroaches of all life stages throughout the kitchen: -under three compartment/ware wash sink-under the prep sink-around and under the cooking equipment-inside of the stand mixer cover-in the ceiling of the dish washer. There were no paper towels at the hand washing sink in dish washing area, there was food debris, dirt, and grease throughout the facility: behind the steam table, ovens, and other cooking equipment, on pipes under all sinks, along walls of kitchen and dish washing area, ceiling of dish washing area, and floor throughout the kitchen and dish washing area. The plumbing system was not maintained in good repair and the concerns were ware wash sink faucet, prep sink pipes under sink, and leaking sanitizer dispenser in dish washing area. The physical facilities were not maintained in good repair and the following issues were observed: water damaged, broken ceiling tiles throughout the kitchen and dish washing room, cracked, damaged flooring under prep sink, cracked damaged flooring throughout kitchen, holes along the walls near door frames, paneling of door to dining room peeling off, and cracks between metal sheets on walls and corner guard near prep sink/dish area. Non-food contact surfaces were dirty and observed food debris, grease, and dirt on the following pieces of equipment: outside, inside, behind and under all cooking equipment (stove, ovens, and steam tables), stand up mixer, plate warmer, and under prep tables. The floor and wall junctures were not covered and closed to no larger than one-thirty second inch and the observations revealed the baseboards throughout the kitchen, dish washing room, and dining room were peeling off of the wall and not sealed. The recommendation was to ensure all baseboards throughout the facility are properly sealed to the wall to prevent food debris, pest, and moisture from getting in. The equipment and/or component were not maintained in good working order and the observations revealed the following pieces of equipment needed sealed/repaired: the opening from bent metal on sink near pass through window in dish washing room and opening of the stove near the ovens, that needs sealed to prevent pest entry. The facility was to comply (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 5 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 07/01/2024 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)