Inspection·August 20, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on medical record review, family interview, staff interview, and facility policy review, the facility failed to timely notify all resident representatives/guardians of a temporary discharge. This affected 61 residents (#83, #84, #85, #82, #87, #86, #62, #51, #55, #56, #6, #88, #29, #12, #63, #50, #73, #3, #28, #20, #75, #89, #61, #46, #90, #24, #32, #34, #35, #52, #15, #22, #23, #68, #91, #2, #76, #16, #36, #69, #39, #33, #7, #78, #60, #4, #5, #17, #13, #11, #79, #19, #14, #43, #41, #42, #8, #57, #92, #40, and #9) of 91 residents residing in the facility at the time of the emergency temporary discharge. Findings Include: Interview with Administrator on 07/30/24 at approximately 10:30 A.M. revealed the facility had an emergency which resulted in the temporary evacuation of all residents beginning on 07/22/24 around 12:30 P.M. due to the electricity to the facility being shut off. The Administrator revealed some of the resident family members/representatives were contact during that time, but the facility was not able to contact all family members/representatives until the next day (07/23/24) due to the facility not having electricity and their inability to charge cell phones and computers. The Administrator revealed staff finished contacting resident representatives and family members the next day after the staff went home and charged all their. The Administrator revealed all residents were transferred to safe places by 11:30 P.M. on 07/22/24. Review of facility medical and notification records revealed the following dates and times the facility first contacted residents/representatives regarding the immediate evacuation of the facility: Resident #83 representative was contacted on 07/23/24 at 9:00 A.M., a voicemail message was left. Resident #84 family was contacted on 07/23/24 at 9:15 A.M., was not able to leave a voicemail message. Resident #85 representative was contacted on 07/23/24 at 10:00 A.M., the phone was disconnected. Resident #82 representative was contacted on 07/23/24 at 10:00 A.M., spoke with the representative. Resident #87 representative was contacted on 07/23/24 at 10:30 A.M., phone was disconnected. Resident #86 emergency contact was contacted on 07/23/24 at 11:00 A.M., phone was disconnected, but her friend was called on 07/23/24 at 11:00 A.M. also and spoke with her. (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 4 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 08/20/2024 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)