Health inspection·July 2, 2025

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few filed in her office. She indicated she would call and leave messages with the family or guardian to inform them of the care conference. Families and guardians do not answer when she calls. She never received calls back. She said she would document if she called the family or guardian. She never sent a letter to families. Social Services Staff #355 indicated there was a message we send out to the staff to tell them when the meetings are. Social Services Staff #355 verified there was no evidence of families and guardians being invited or at the meetings. Interview on 06/25/25 at 1:49 P.M. with Admissions Staff #385 revealed she gets with Social Services Staff #355 in the morning meeting and learns what care conferences are coming up. If they have a family or a guardian she sends them a letter. Admissions Staff #385 presented letters with Resident #56's name and the time and date of the care conference. There was not a name or address on the letter of who the letter was sent to. Admissions Staff #385 said the name and address would be on the envelope. Admissions Staff #385 verified she had no evidence of care conference letters being sent. She verified they were not sent certified or with a signature page to respond to the letter. Admissions Staff #385 had no explanation as to why family and guardians did not receive the letter. Review of the facility policy Resident Participation- Assessment/Care Plans (revised December 2016) included spouses and other members of the family may participate in the resident assessment and development of the person centered care plan with the residents permission. For the purposes of this and other policies family includes spouse which is defined as an individual has been lawfully married to the resident regardless of the state or local laws of the jurisdiction of the facility. The resident resident representatives right to participate in the development and implementation of his or her plan of care. The care planning process will facilitate the inclusion of the resident and/or representative. The resident has the right to be fully informed in a language that he or she can understand of his or her total health status including but not limited to his or her medical condition the right to be informed in advance of changes to the plan of care the facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. An advance notice of the care planning conference is provided to the resident and his or her representative. Such notice is made by mail and/or telephone. The Social Service Director or designee is responsible for notifying the resident/representative. Notices include: the date, time and location of the conference. The method of contact (e.g., mail, telephone, email, etc.) 2. Review of Resident #61's medical record revealed a 02/09/23 admission with diagnoses including dementia, alcohol induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Review of the care conferences included a 06/11/25 electronic care conference entry by Social Services documented in the electronic record. There was no one listed in attendance. The nursing section was not signed by a nurse from any shift when the form indicated input from all shifts was required. The dietary section did not include oral intake, current weight, BMI, weight history, bowel pattern, relevant medication, laboratory reports, or nutritional risk. The section was not signed by dietary staff. The pharmacy section was not completed. The code status was not marked. Social Services was the only department to sign the care conference. There was no evidence of the guardian being notified of the conference. There was a 04/14/25 and 01/16/25 care conference documented on paper. There was no evidence of the resident's guardian attending the care conferences. There was no evidence the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 2 of 47 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 07/02/2025 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 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few guardian was invited to the care conferences. There was no documentation of the guardian being invited by phone. Interview 06/24/25 at 10:31 A.M. with Resident #61's guardian, Guardian #700 revealed they do not have care conferences including her. She indicated she has asked for care conferences and the staff does not arrange them. She does not get notified of meetings. The resident's guardian was not listed in the resident's medical record. There was a different name listed as the resident's guardian. Guardian #700 who answered the phone at the number listed for the guardian said she had been the resident's guardian for about two and a half years. Guardian #700 verified the name listed in the medical record was not correct. Interview on 06/24/25 at 5:24 P.M. of Social Services Staff #355 verified there was no evidence of Resident #61's guardian being invited or at the meetings. Interview on 06/26/25 at 12:47 P.M. with the Regional Director of Operations #602 verified there was no evidence of the guardians/families being notified of upcoming care conferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 3 of 47 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 07/02/2025 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 0558 Reasonably accommodate the needs and preferences of each resident. 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 record review, the facility failed to provide barber services for Resident #38. This affected one resident (#38) of four residents reviewed for activities of daily living. Facility census was 90. Residents Affected - Few Findings include: Review of the medical record revealed Resident #38 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis, depression, and adjustment disorder with anxiety. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #38 was cognitively intact. An interview on 06/23/25 at 10:59 A.M. Resident #38 stated he had not had a haircut since he was admitted to the facility, and he wanted his hair cut. Observation of Resident #38 revealed his hair was below his shoulders. An interview on 06/26/25 at 9:11 A.M. Licensed Nursing Home Administrator (LNHA) verified the facility had not had a beauty shop license since 2021. LNHA verified residents could not receive haircuts or beauty salon services at the facility. The LNHA stated he was currently looking into possibly taking residents to a local barber school and/or cosmetology school to receive haircuts. This deficiency represents non-compliance investigated under Complaint Number OH00165933. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 4 of 47 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 07/02/2025 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure medical records contained accurate advance directives. This affected two residents (#39, #61) of 24 residents reviewed. Findings include: 1. Review of Resident #39's medical record revealed a [DATE] admission and [DATE] readmission with diagnoses including Alzheimer's disease, diabetes, dementia, delusional disorders, anxiety disorder, hyperlipidemia, chronic stage three kidney disease, morbid obesity, hypertension, and atherosclerotic heart disease. Review of the paper chart revealed there was a Do-Not-Resuscitate Comfort Care (DNRCC) advanced directive (a medical order that instructs healthcare professionals to not perform cardiopulmonary resuscitation (CPR) if a resident's heart or breathing stops, but to focus on providing comfort care) page. On the next page in the paper medical record, there was a signed advanced directive for a DNRCC-A (Do-Not-Resuscitate Comfort Care-Arrest, a type of Do-Not-Resuscitate (DNR) order that specifies that resuscitation efforts (like CPR) should not be initiated if a person experiences cardiac or respiratory arrest. However, until that point, the individual will receive standard medical care for any other illnesses or injuries). The electronic medical record contained an order for the resident to be a DNRCC-A. Interview on [DATE] at 3:46 P.M. with Licensed Practical Nurse (LPN) #230 verified it would be confusing as to what code status the resident was when the chart was opened. A yellow DNRCC page was the first advanced directive seen with the resident's name on the name line at the bottom and on the next page of the paper medical record, a DNRCC-A signed [DATE]. 2. Review of Resident #61's medical record revealed a [DATE] admission with diagnoses including dementia, alcohol induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Review of the resident's code status revealed when the hard chart was opened there was a blank full code sheet and a blank DNRCC sheet. The electronic record had an order for the resident to be a full code. Interview on [DATE] at 3:46 P.M. with LPN #230 verified the resident had a blank Full Code sheet followed by a blank DNRCC directive. LPN #230 verified it would be confusing as to what code status the resident was when the chart was opened. Interview on [DATE] at 4:52 P.M. with the Director of Nursing revealed they get the signed code status and upload them on the electric chart. They removed them all from the hard chart. The DON acknowledged the code status sheets were found on the hard chart and had not been removed from the hard chart. She indicated they did not have a policy that said the code status was in the electronic record not the hard chart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 5 of 47 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 07/02/2025 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 0578 The advanced directive policy included information about whether or not the resident had executed an advance directive and shall be displayed prominently in the medical record. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 6 of 47 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 07/02/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interviews, work orders, and policy review, the facility failed to ensure temperatures in the facility were at a comfortable level. This had the potential to affect all 90 residents. Facility census was 90. Finding include: Review of quote dated 04/22/25 from heating, ventilation, and air conditioning (HVAC) company revealed cooling tower repairs due to coil froze and burst due to being shut off over the winter. The coil would need replaced for a total of $79,990. A quote dated 04/24/25 was received from the same HVAC company for temporary cooling tower, temporary pump, piping, electric, and breakers as needed for a total of $48,659.00. The work was completed and paid for sometime in May. Review of temperature logs from 04/28/25 to 06/12/25 revealed temperatures from 74 degrees to 82 degrees. The temperatures for resident rooms at 80 degrees or above had notation of air conditioner unit being off and/or windows open. A work order dated 06/06/25 revealed the air unit on the second floor (Blue) was not working. On 06/11/25 a work order was placed for a problem with air conditioning in Resident #57's room. On 06/13/25 a work order was placed for air conditioning not working for Resident #60. A timeline of events revealed on 06/22/25 maintenance reported to the facility to assist with elevated temperatures. HVAC company was contacted when complaints were received on increased temperatures. Residents were offered extra fans and portable air conditioning units. Observations and interviews on 06/23/25 from 10:25 A.M. to 1:22 P.M. Residents #26, #28, #38, #60, #73, and #75 stated it was hot in the facility. Resident rooms and common areas were warm and multiple fans and portable air conditioners were noted. An observation on 06/23/25 at 1:11 P.M. of the thermostat at the nurses station on the third floor near the elevator showed 84 degrees. An observation on 06/23/25 at 1:12 P.M. of the nurses station on the back unit on the third floor had an electronic thermometer that showed 85 degrees. On 06/23/25 at 1:47 P.M. weather.com revealed the temperature in Columbus, Ohio, was 94 degrees. On 06/23/25 room temperatures were conducted with [NAME] President of Plant Operations #600 revealed the following temperatures: At 1:50 P.M. Resident #78's room was 81.8 degrees At 1:51 P.M. Resident #76's room was 82.9 degrees At 1:52 P.M. Resident #59's room was 82.2 degrees At 1:52 P.M. Resident #40's room was 82 degrees At 1:56 P.M. Resident #52's room was 81.1 degrees (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 7 of 47 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 07/02/2025 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 0584 At 1:57 P.M. the common area on the locked unit was 81.8 degrees Level of Harm - Minimal harm or potential for actual harm At 2:14 P.M. Resident #68's room was 83.3 degrees At 2:15 P.M. Resident #75's room was 84.2 degrees Residents Affected - Some At 2:16 P.M. Resident #38's room was 84 degrees At 2:17 P.M. Resident #73's room was 81.1 degrees At 2:23 P.M. the nurses station on the third floor near the elevators was 85 degrees At 2:24 P.M. Resident #57's room was 85 degrees At 2:31 P.M. the therapy room was 84 degrees An interview on 06/23/25 at 3:50 P.M. [NAME] President of Plant Operations #600 revealed the cooling tower fan was running backwards and caused breakers to trip which resulted in the air conditioning not working properly. An interview on 06/24/24 at 10:19 A.M. Occupational Therapist #501 verified therapy was being completed in resident rooms because the therapy room was hot. An interview on 06/24/24 at 10:22 A.M. Therapy Director #505 verified therapy was only done in the therapy room if residents wanted therapy done there because the therapy room was hot. Therapy Director #505 stated a portable air conditioner and two fan were placed in the therapy room to help with the heat. An additional interview on 06/30/25 at 8:47 A.M. [NAME] President of Plant Operations #600 verified in April a temporary chiller was used until a part could be made. The end of May the part was available and the cooling tower was fixed. On 06/22/25 there were complaints of the air conditioning not working properly. The HVAC company was called and it was discovered the high voltage was wired wrong and caused the units to trip and an air bleeder was found. Excessive heat policy dated 11/30/14 revealed air conditioning will be utilized. If air conditioning was not appropriate or feasible, fans would be utilized to provide air circulation. Fluid hydration would be encouraged and cool fluids would be passed to residents on a regular basis. Window treatments would be closed to block out the sun where appropriate, residents would be encouraged to relocate and spend time in the cooler sections of the building, residents would be monitored closely for signs of dehydration, respiratory difficulties, and transferred to appropriate facilities if indicated. The facility must maintain temperature range of 71 to 81 degrees. This deficiency represents non-compliance investigated under Master Complaint Number OH00166971 and Complaint Number OH00165933 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 8 of 47 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 07/02/2025 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 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an accurate assessment was completed for Resident #68. This affected one (Resident #68) out of 28 resident record reviews. Facility census was 90. Findings include: Review of the medical record revealed Resident #68 was admitted on [DATE] with diagnoses that included encephalopathy, disseminated mycobacterium avium-intracellulare complex, human immunodeficiency viruses, severe protein-calorie malnutrition, dysphagia, congenital cytomegalovirus, pressure ulcer of sacral region, dementia, and sensorineural hearing loss. The admission/readmit form dated 03/12/25 revealed Resident #68 had impaired vision, wore glasses, and was deaf. The admission Minimum Data Set (MDS) date 03/15/25 revealed Resident #68 had cognitive impairment, had highly impaired hearing, impaired vision, and did not wear glasses. The quarterly MDS dated [DATE] revealed Resident #68 had adequate hearing, impaired vision, and did not wear glasses. An observation on 06/23/25 at 1:15 P.M. revealed Resident #68 had glasses with one lens on the right and tape on the right side of the glasses and the nose area. An interview on 06/24/25 at 9:07 A.M. with Resident #68's family member revealed Resident #68 was deaf and read lips or read what was written on paper to communicate. An interview on 06/25/25 at 8:51 A.M. Licensed Practical Nurse (LPN) #353 verified Resident #68 was deaf and read lips or used a communication board. An interview on 06/26/25 at 8:10 A.M. Regional Nurse #601 verified Resident #68 was admitted to the facility with broken glasses. An additional interview on 06/26/25 at 9:35 A.M. Regional Nurse #601 verified the MDS's completed on 03/15/25 and 06/14/25 were incorrectly coded to reveal Resident #68 did not wear glasses. Regional Nurse #601 also verified the 06/14/25 MDS was incorrectly coded to reveal Resident #68 had adequate hearing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 9 of 47 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 07/02/2025 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 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on medical record review, staff interview and review of the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) manual the facility failed to complete a significant change MDS required for a resident admitted to hospice services. This affected one resident (Resident #2) of two residents reviewed for hospice services. The facility census was 90. Residents Affected - Few Findings Include: A review of Resident #2's medical record revealed admission date 12/05/23 with the following diagnoses including but not limited to depression, high blood pressure, heart failure, anxiety, and schizoaffective disorder. Resident #2 had impaired cognition and required assistance from staff to complete activities of daily living (ADL) tasks. A review of Resident #2's physician orders revealed a revised order dated 03/13/25 to be admitted to Hospice with the diagnosis of metabolic encephalopathy. A review of Resident #2's hospice admission paperwork revealed an admission date of 01/30/25 to Hospice for metabolic encephalopathy. A review of Resident #2's completed MDS listing revealed an entry MDS was completed on 01/12/25, a quarterly MDS was completed on 01/15/25, and a quarterly MDS was completed on 04/14/25. A review of the MDS RAI manual dated 10/01/24 revealed in Chapter 2 - Assessments for the Resident Assessment Instrument (RAI) section 2.6 - Required Assessments for the MDS, A significant change in status assessment (SCSA) is required to be performed when a terminally ill resident enrolls in hospice program or changes hospice providers and remains in the nursing home. The assessment reference date (ARD) must be within 14 days from the effective date of the hospice election. An interview on 06/26/25 at 2:39 P.M. with Regional MDS Nurse #703 confirmed Resident #2 did not have a significant change MDS completed when hospice services were initiated on 01/15/25. Regional MDS Nurse #703 stated there should have been a significant change MDS completed within 14 days of Resident #2 being admitted to hospice on 01/15/25. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 10 of 47 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 07/02/2025 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 0641 Ensure each resident receives an accurate assessment. 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 ensure assessments were accurately completed. This affected two (Resident #5 and Residents #40 ) of twenty eight residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 90. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #5 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included generalized idiopathic epilepsy and epileptic syndromes, schizophrenia, hypertension, anxiety disorder, disruptive mood dysregulation disorder, repeated falls, restlessness and agitation, senile degeneration of brain and glaucoma. Review of the Annual MDS 3.0 assessment dated [DATE] for Section J1800 revealed Resident #5 did not have any falls since admission/entry or prior assessment. Review of facility fall investigations revealed Resident #5 had falls on 12/16/24, 12/21/24, 03/11/25, 03/21/25, and 03/26/25. Interview on 06/30/25 at 01:52 PM with Regional MDS #703 verified MDS did not reflect the residents falls and it was coded incorrectly. 2. Review of the medical record for Resident #40 revealed an admission date of 10/18/23 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, sickle-cell disease, pain, anxiety disorder, dysphagia and hypertension. Review of the medial record revealed an oral assessment indicating Resident #40 had his own teeth and broken or carious teeth. Review of the Annual MDS 3.0 assessment dated [DATE] for section L0200 revealed No for natural teeth and No for broken natural teeth. Interview on 07/01/25 at 4:25 P.M. with Regional MDS #703 verified the MDS was coded incorrectly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 11 of 47 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 07/02/2025 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 - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on record review, policy review and interview, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) review was completed with a new psychiatric diagnosis. This affected one (Resident #61) of two residents reviewed for PASARR. The census was 90. Findings include: Review of Resident #61's medical record revealed a 02/09/23 admission with diagnoses including dementia, alcohol induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Review revealed the last PASARR submitted for the resident was a 01/13/24 Significant Change for the addition of Post Traumatic Stress Disorder (PTSD) diagnosis. Record review revealed on 08/12/24 Resident #61 had a diagnosis of psychosis not due to a substance or known pathological condition added to her list of diagnoses. Review revealed there was no evidence of a subsequent PASARR submission, for a Level II consideration, to the state agency that included the new psychiatric diagnosis. Interview 06/26/25 at 5:03 P.M. with the Director of Nursing verified there was not a PASARR submitted to the state agency for Level II consideration after the addition of the psychosis diagnosis. Review of the facility's admission Criteria policy revised 12/2016 included 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 12 of 47 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 07/02/2025 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, record review and interview, the facility failed to develop a dental plan of care and identify triggers for Post Traumatic Stress Disorder (PTSD). This affected two (Resident #10 and #40) of 27 residents reviewed. The census was 90. Findings include: 1. Review of Resident #10's medical record revealed a 05/21/24 admission with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, asthma, epileptic seizures, mood disorder, dysthymic disorder, post-traumatic stress disorder, major depressive disorder, malignant neoplasm of lung and bronchus, history of malignant neoplasm of pancreas, insomnia, and nicotine dependence. Review of the 05/23/25 Quarterly Minimum Data Set (MDS) Assessment revealed the resident was independent for daily decision making. Review of the residents' plans of care revealed two plans of care related to Post Traumatic Stress Disorder. A 06/23/25 plan of care revealed the resident had a past traumatic event of transportation accident (car accident/boat accident/train wreck/plane crash) related to a transportation accident. The problem did not include what type of transportation accident traumatized the resident. The problem did not include what triggers would elicit a PTSD reaction. Further review revealed a 06/23/25 plan of care revealed the resident had a past traumatic event of abuse from step father. The problem did not include what type of abuse the resident endured from her step father. The problem did not include what triggers would elicit a PTSD reaction. Interview on 07/02/25 at 9:48 A.M. with Resident #10 revealed her triggers for PTSD were yelling, slamming doors, and loud pops. She revealed her Mom and step-dad would shoot at her, put guns to her head, and break her favorite things. She went to live with an uncle when she was nine trying to get away from her parents. She shared she was molested by her uncle. He was also abusive and would drag her by her hair. Lastly, the resident shared she had a couple car accidents where she was hit in the front and back of the vehicle and totaled (wrecked beyond repair) two cars. Interview 07/02/25 at 2:20 P.M. with the Director of Nursing verified the plan of care needed to include what triggers would elicit a PTSD response so staff were aware to avoid triggers. 2. Review of the medical record for Resident #40 revealed an admission date of 10/18/23 with diagnosis that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, sickle-cell disease, pain, anxiety disorder, dysphagia and hypertension. Review of the medial record for Resident #40 revealed an oral assessment indicating Resident #40 had their own teeth and broken or carious teeth. Review of the medical revealed no dental/oral care plan was implemented. Interview on 07/01/25 at 4:25 P.M. with Regional MDS #703 verified no dental/oral care plan was implemented for Resident #40. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 13 of 47 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 07/02/2025 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 facility policy titled Care Plans, Comprehensive Person- Centered Revised December 2016 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 14 of 47 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 07/02/2025 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 - Few 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** Based on record review, observation, interview, and policy review, the facility failed to ensure Resident #60, #68, and #72 had comprehensive care plans addressing preferences. This affected three (Residents #60, #68, and #72) out of 28 records reviewed. Facility census was 90. Findings include: 1. Review of the medical record revealed Resident #60 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included tracheostomy, paralysis of vocal cords and larynx, and anxiety. A care plan dated 05/24/23 revealed Resident #60 had a tracheostomy. Interventions included tracheostomy care as ordered. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #60 was cognitively intact. An interview on 06/23/25 at 1:20 P.M. Resident #60 stated he did his own tracheostomy care except for suctioning. An observation on 06/25/25 at 3:32 P.M. tracheostomy care was provided by Registered Nurse #228. The Director of Nursing was present and stated Resident #60 had been educated and provided his own tracheostomy care. Resident #60 declined to do tracheostomy care for the surveyor. A revised care plan dated 06/25/25 revealed Resident #60 had a tracheostomy. Interventions included tracheostomy care as ordered and Resident #60 preferred to complete tracheostomy care himself. Resident #60 had been educated on completing tracheostomy care. An interview on 06/26/25 at 2:30 P.M. Director of Nursing verified Resident #60's care plan had been updated with an intervention for Resident #60 to provide his own tracheostomy care. Director of Nursing also verified there was no documentation of Resident #60 being educated on how to complete tracheostomy care prior to 06/25/25. Review of Care Plans, Comprehensive Person-Centered policy (no date) revealed care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The resident will be informed of his or her right to participate in his or her treatment. The care planning process will facilitate resident and/or representative involvement, include an assessment of the resident's strengths and needs, and incorporate the resident's personal and cultural preferences in developing the goals of care. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are the endpoint of an interdisciplinary process. 2. Review of the medical record revealed Resident #68 was admitted on [DATE] with diagnoses that included encephalopathy, disseminated mycobacterium avium-intracellulare complex, human immunodeficiency viruses, severe protein-calorie malnutrition, dysphagia, congenital cytomegalovirus, pressure ulcer of sacral region, dementia, and sensorineural hearing loss. The admission/readmit form dated 03/12/25 revealed Resident #68 had impaired vision and wore (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 15 of 47 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 07/02/2025 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 glasses. Level of Harm - Minimal harm or potential for actual harm The admission Minimum Data Set (MDS) date 03/15/25 revealed Resident #68 had cognitive impairment, impaired vision, and did not wear glasses. The quarterly MDS dated [DATE] revealed Resident #68 had impaired vision, and did not wear glasses. Residents Affected - Few An observation on 06/23/25 at 1:15 P.M. revealed Resident #68 had glasses with one lens on the right and tape on the right side of the glasses and the nose area. An interview on 06/24/25 at 9:07 A.M. with Resident #68's family member revealed Resident #68 was deaf and read lips or read what was written on paper to communicate. An interview on 06/25/25 at 8:51 A.M. Licensed Practical Nurse (LPN) #353 verified Resident #68 was deaf and read lips or used a communication board. An interview on 06/26/25 at 8:10 A.M. Regional Nurse #601 verified Resident #68 was admitted to the facility with broken glasses. An additional interview on 06/26/25 at 9:35 A.M. Regional Nurse #601 verified there was not a care plan for Resident #68's impaired vision. Review of Care Plans, Comprehensive Person-Centered policy (no date) revealed care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The resident will be informed of his or her right to participate in his or her treatment. The care planning process will facilitate resident and/or representative involvement, include an assessment of the resident's strengths and needs, and incorporate the resident's personal and cultural preferences in developing the goals of care. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are the endpoint of an interdisciplinary process. 3. Review of medical record for Resident #72 revealed an initial admission date of 06/01/25 and readmitted on [DATE] with diagnosis including periprosthetic fracture around internal prosthetic right hip joint, other mechanical complication of other internal joint prosthesis, fibromyalgia, protein-calorie malnutrition, repeated falls, major depressive disorder, chronic pain and opioid use. Review of activities care plan created 03/18/25 revised on 06/01/25 revealed interventions to provide the resident with materials for individual activities as desired. The resident likes the following independent activities: writing paper/pens. The resident's preferred activities was writing books. Observations on 06/23/25, 06/24/25, and 06/25/25 revealed Resident #72 did not attend activities outside of her room and had no writing paper/pens. Interview on 06/25/25 at 3:19 P.M. with Activity Director #216 revealed the resident cannot tell her what she likes to do. The AD stated the resident is scared and did not want to come out of her room to attend activities but the AD offers her crayons to color and the resident will accept coffee. Interview on 06/26/25 2:18 P.M. with Activity Director #216 verified the resident's care plan was not revised to reflect refusals to attend activities and activity preferences. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 16 of 47 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 07/02/2025 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Review of Care Plans, Comprehensive Person-Centered policy (no date) revealed care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The resident will be informed of his or her right to participate in his or her treatment. The care planning process will facilitate resident and/or representative involvement, include an assessment of the resident's strengths and needs, and incorporate the resident's personal and cultural preferences in developing the goals of care. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident are the endpoint of an interdisciplinary process. Event ID: Facility ID: 366207 If continuation sheet Page 17 of 47 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 07/02/2025 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 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 Based on observation, record review, policy and interview, the facility failed to ensure nail care was provided to dependent residents. This affected two (Resident #61 and #78) of four residents reviewed for activities of daily living. The census was 90. Residents Affected - Few Findings include: 1. Review of Resident #78 revealed a 05/01/25 admission with diagnoses including fracture of T11-T12 vertebra, protein calorie malnutrition, fracture of first lumbar vertebra, valve endocarditis, lumbosacral radiculopathy, lumbar spondylosis, muscle wasting and atrophy, difficulty walking, cognitive communication deficit, low back pain, and mood disorder Review of the 05/06/25 admission Minimum Data Set (MDS) Assessment revealed the resident was independent for daily decision. The resident had no functional impairment and was in need of partial/moderate assistance with personal hygiene. Interview and observation on 06/24/25 at 12:20 P.M. with Resident #78 revealed he asked staff for fingernail clippers and did not get them. He said he had ripped off his fingernails and they were jagged. He showed that his thumb nails were long because they were too thick to tear off. Further observation of the resident's fingernails revealed the nails were jagged with sharp edges and dark debris under the nails. The resident also had long toenails. Interview 06/24/25 at 4:43 P.M. with Certified Nurse Aide #244 revealed she provided the resident a bed bath. She verified she has never cut or cleaned his nails. Observation of Resident #78 06/24/25 at 4:48 P.M. with Licensed Practical Nurse (LPN) #353 verified Resident #78's thumb nails and toe nails were long. He showed her where he has ripped them off and they were jagged and had debris under the nails. The resident said no one had cleaned his nails or cut them since he arrived. LPN #353 stated activities will do nails in the activity room but they do not go to individual rooms unless the residents are on the locked unit. Interview 06/24/25 at 4:55 P.M. with the Director of Nursing verified the facility has shower aides who are to do nail care with showers. Review of the facilities Care of Fingernails/Toenails policy revised October 2010 included the purpose of this procedure are to clean the nail bed to keep nails trimmed and to prevent infections. Nail care includes daily cleaning and regular trimming. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Notify the supervisor if the resident refuses the care. The following information should be recorded on the residents medical record. The date and time the nail care was given, the name and title of the individual who administered the nail care. The condition of the resident nails and nailbeds including redness or irritation of the skin of hands and feet, breaks or cracks in skin especially between toes, pale bluish or gray discoloration of feet, bluish or dark colored nail beds, corns or calluses, ingrown nails, bleeding and/or pain or any difficulties in cutting the residents' nails. If the resident refused the treatment the reason why should be documented an the intervention taken along with the signature and title of the person recording the data. Notify the supervisor if the resident refuses the care. 2. Review of Resident #61 revealed a 02/09/23 admission with diagnoses including dementia, alcohol (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 18 of 47 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 07/02/2025 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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Review of the 02/10/23 Activity of Daily Living (ADL) plan of care included the resident had an ADL self-care performance deficit. Interventions included a 05/16/24 intervention with bathing and showering to check nail length and trim and clean on bath day and as necessary. Review of the 06/01/25 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making with no behaviors. She sometimes felt socially isolated. She has minimal difficulty hearing with no hearing aide. Has the ability to understand. Clear speech, and is understood. She had adequate vision without corrective lenses. She had trouble concentrating and falling asleep, feeling down, depressed or hopeless, with little pleasure in doing things. She had no functional impairment. The resident was supervision/ touch assistance for personal hygiene. Medications included antipsychotic, antidepressant, anticonvulsant. Receives antipsychotic on routine basis and no gradual dose reduction (GDR) had been attempted. The physician indicated a GDR was clinically contraindicated. Observation 06/24/25 at 10:35 A.M. revealed the resident had very long toe nails on her great toes bilaterally. Interview 06/24/25 at 10:35 A.M. with the resident revealed she had not been seen by a podiatrist to have her toenails cut since she was admitted . Review of the 04/23/25 podiatry list revealed the resident was not on the list to be seen. Interview 06/26/25 at 9:27 A.M. with Guardian #700 revealed Resident #61 is eligible for Veteran's benefits. She included she had asked in the past for the resident to take advantage of the veteran benefits for ancillary services. Interview 06/26/25 at 9:49 A.M. with the Director of Nursing verified the resident had not had ancillary services since admission. This deficiency represents non-compliance investigated under Complaint Number OH00166595 and OH00165933. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 19 of 47 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 07/02/2025 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, policy and interview, the facility also failed to remove a resident's surgical staples and administer antibiotics to meet professional standards. This affected two residents (#134 and #234) out of 29 residents reviewed for appropriate care and services. Facility census was 90. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #234 was admitted on [DATE] with diagnoses that included staphylococcal arthritis right hip, osteomyelitis of vertebra, type 2 diabetes, protein-calorie malnutrition, asthma, hypertension, major depressive disorder, and anxiety disorder. The quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #234 was cognitively intact. Review of the after visit summary (AVS) from the hospital dated 06/16/25 revealed Resident #234's surgical staples would be removed at the skilled nursing facility two weeks post operative on 06/20/25. An interview on 06/23/25 at 11:58 A.M. Resident #234 stated he recently had surgery and needed staples removed. Resident #234 was unsure when the appointment for the staple removal was. An interview on 06/25/25 at 3:50 P.M. the director of nursing (DON) stated Resident #234 probably would not allow the skilled nursing facility staff to remove the staples. The DON was not aware the AVS revealed Resident #234's staples were to be removed by the facility staff on 06/20/25. An additional interview on 06/26/25 at 2:38 P.M. the DON verified there was an order on the AVS for the skilled nursing facility to remove Resident #234's staples. The DON stated Resident #234 permitted staff to remove the staples on 06/25/25. 2. A review of the medical record for Resident #134 revealed an admission date 05/21/25 with diagnoses including osteomyelitis of right foot, congestive heart failure (CHF), and type two diabetes. Resident #134 was discharged from the facility on 05/25/25. A review of Resident #134's physician orders revealed an order dated 05/21/25 for antibiotic Daptomycin Intravenous Solution Reconstituted use 14.5 milliliter (ml) per hour (hr) intravenously at bedtime for wound until 06/22/25, order was discontinued on 05/23/25. An order dated 05/23/25 for antibiotic Daptomycin Intravenous Solution Reconstituted use 700 milligram (mg) intravenously at bedtime for staph infection of right foot until 06/22/25, order was discontinued on 05/25/25, and an order dated 05/25/25 for antibiotic Daptomycin Intravenous Solution Reconstituted use 700 milligram (mg) intravenously at bedtime for staph infection of right foot until 06/25/25, order was discontinued on 05/27/25. A review of Resident #134's Medication Administration Record (MAR) dated 05/21/25 to 05/25/25 revealed the order for antibiotic Daptomycin Intravenous Solution Reconstituted use 14.5 milliliter (ml) per hour (hr) intravenously at bedtime for wound until 06/22/25 was marked on 05/21/25 as not administered with no reason documented and marked on 05/22/25 as not administered due to being in the care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 20 of 47 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 07/02/2025 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 of the pharmacy. Further review revealed the order for antibiotic Daptomycin Intravenous Solution Reconstituted use 700 milligram (mg) intravenously at bedtime for staph infection of right foot until 06/22/25 was marked as being administered on 05/23/25 and 05/24/25. On 05/25/25 and 05/26/25 the order for Daptomycin Intravenous Solution Reconstituted use 700 milligram (mg) intravenously at bedtime for staph infection of right foot until 06/22/25 was marked as being not administered due to Resident #134 not being at the facility. A review of Resident #134's progress notes dated 05/21/25 to 05/25/25 revealed no notifications to the physician concerning the required clarification of the order dated 05/21/25 for antibiotic Daptomycin Intravenous Solution Reconstituted use 14.5 milliliter (ml) per hour (hr) intravenously at bedtime for wound until 06/22/25, and there were no entries in the progress notes to reflect the physician was notified of the two dose of antibiotic not being administered to Resident #134. An interview on 06/30/25 at 1:43 P.M. with the Director of Nursing (DON) confirmed Resident #134 was not administered the antibiotic Daptomycin on 05/21/25 and 05/22/25, and there were no notifications to the physician reflecting the need for the order clarification or the missed doses of the antibiotic. A review of the facility's policy titled Change in a Resident's Condition or Status dated 05/17 revealed the nurse will notify the resident's Attending Physician or Physician on call when there is a need to alter the resident's medical treatment. This deficiency represents non-compliance investigated under Complaint Number OH00166200. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 21 of 47 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 07/02/2025 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #61 revealed a 02/09/23 admission with diagnoses including dementia, alcohol induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Residents Affected - Few Review of the 06/01/25 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making with no behaviors. She has minimal difficulty hearing with no hearing aide, had the ability to understand. Clear speech, and is understood. She had adequate vision without corrective lenses. Interview 06/24/25 at 10:34 A.M. with Resident #61 revealed she wore glasses for distance vision but had not seen an eye doctor since she was admitted to the facility. The resident indicated she wore glasses while driving and for distance vision before admission. The resident was unable to find her glasses in her room. Review of the record revealed no evidence of the resident having an optometry consult while a resident in the facility. Interview 06/26/25 at 9:27 A.M. with Guardian #700 revealed Resident #61 was eligible for Veteran's benefits. She included she had asked staff, in the past, for the resident to take advantage of the veteran benefits for ancillary services. Interview 06/26/25 at 9:49 A.M. with the Director of Nursing verified the resident had not had ancillary services including optometry care since admission. This deficiency represents non-compliance investigated under Complaint Number OH00166595 and OH00165933. Based on observation, record review, and interview, the facility failed to provide Resident #61 and #68 with adequate and timely vision care. This affected two (Resident #61 and #68) of three residents reviewed for vision care. Facility census was 90. Findings include: 1. Review of the medical record revealed Resident #68 was admitted on [DATE] with diagnoses that included encephalopathy, disseminated mycobacterium avium-intracellulare complex, human immunodeficiency viruses, severe protein-calorie malnutrition, dysphagia, congenital cytomegalovirus, pressure ulcer of sacral region, dementia, and sensorineural hearing loss. The admission/readmit form dated 03/12/25 revealed Resident #68 had impaired vision, wore glasses, and was deaf. The admission Minimum Data Set (MDS) date 03/15/25 revealed Resident #68 had cognitive impairment, had highly impaired hearing, impaired vision, and did not wear glasses. The quarterly MDS dated [DATE] revealed Resident #68 had impaired vision, and did not wear glasses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 22 of 47 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 07/02/2025 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 0685 Level of Harm - Minimal harm or potential for actual harm A list of residents with vision appointments at the facility on 06/04/25 revealed Resident #68 was not on the list of residents seen. An observation on 06/23/25 at 1:15 P.M. revealed Resident #68 had glasses with one lens on the right side, no lens on the left side and tape on the right side of the glasses and the nose area. Residents Affected - Few An interview on 06/24/25 at 9:07 A.M. with Resident #68's family member revealed Resident #68 was deaf and read lips or read what was written on paper to communicate. An interview on 06/25/25 at 8:51 A.M. Licensed Practical Nurse (LPN) #353 verified Resident #68 was deaf and read lips or used a communication board. An interview on 06/26/25 at 8:10 A.M. Regional Nurse #601 verified Resident #68 was admitted to the facility with broken glasses. A follow-up interview on 06/26/25 at 9:35 A.M. with Regional Nurse #601 verified Resident #68 had not seen the eye doctor and was unaware Resident #68 had glasses that only had one lens and the frame and lens were taped together. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 23 of 47 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 07/02/2025 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to provide a comprehensive, resident centered treatment plan for the prevention and/or management of pressure ulcers. This affected one (Resident #68) out of two residents reviewed for pressure ulcer care. Residents Affected - Few Findings include: Review of the medical record revealed Resident #68 was admitted on [DATE] with diagnoses that included encephalopathy, disseminated mycobacterium avium-intracellulare complex, human immunodeficiency viruses, severe protein-calorie malnutrition, dysphagia, congenital cytomegalovirus, a stage III (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed) pressure ulcer of sacral region, dementia, and sensorineural hearing loss. The nursing admit/readmit care plan dated 03/12/25 revealed Resident #68 had a pressure ulcer to the right buttock and sacrum. There was no documentation of the size or any description of the wounds. The comments revealed Resident #68 needed to be seen by the wound nurse. A plan of care dated 03/12/25 revealed Resident #68 was at risk for skin breakdown related to decreased mobility and pressure ulcers. Interventions included an air mattress to the bed, encourage to turn and reposition every two hours and as needed, weekly treatment documentation to include measurement of each area of skin breakdown with width, length, depth, type of tissue, exudate, and any other notable changes or observations. Review of admission orders revealed no treatment orders for the wounds to Resident #68's right buttock or sacrum. A wound care note by the wound doctor dated 03/18/25 revealed the initial evaluation was completed and Resident #68 had a stage III pressure ulcer that was present upon admission. There was a large area to the sacral region that measured 8.4 centimeters (cm) long, 4.1 cm wide, and 0.2 cm deep with 100 percent granulation and a moderate amount of serosanguinous (exudate that appears as a light pink, thin, and watery fluid) and bloody exudate. The area was discovered upon admission to the facility. Review of the treatment administration record (TAR) revealed a treatment to cleanse Resident #68's sacrum with normal saline, pat dry, apply collagen (biological dressings derived from natural collagen sources that promotes wound healing by stimulating new tissue growth), and covered with a dressing every Tuesday, Thursday, and Saturday was not documented until 03/20/25. Documentation of weights on 05/13/25 and 05/27/25 revealed Resident #68's highest weight of 160 pounds. A plan of care dated 06/17/25 revealed Resident #68 had a pressure ulcer to the sacrum. Interventions included to administer treatments as ordered and air mattress to bed. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #68 was cognitively impaired and admitted with a stage III pressure ulcer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 24 of 47 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 07/02/2025 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 - Minimal harm or potential for actual harm The current physician orders on 06/23/25 included a low air loss mattress to be checked for placement and function every shift and the sacrum to be cleansed with normal saline, patted dry, silver alginate (a specialized wound care product that combines the absorbent properties of alginate with the antimicrobial effects of silver, making it effective for managing various types of wounds, especially those with moderate to heavy exudate) applied and covered with a dressing. Residents Affected - Few On 06/24/25 Resident #68 weighed 158 pounds. An observation on 06/25/25 at 8:51 A.M. revealed Resident #68's air mattress was set to 180 pounds. On 06/25/25 at 9:02 A.M. Licensed Practical Nurse (LPN) #353 verified Resident #68's air mattress was set at 180 pounds. On 06/26/25 at 8:17 A.M. the Director of Nursing (DON) verified Resident #68's air mattress was set at 180 pounds and Resident #68's most recent weight was 158 pounds. On 06/26/25 at 2:36 P.M. interview with the DON verified an order for a treatment to Resident #68's right buttock and/or sacrum was not put in place upon admission. The DON verified there were no treatments documented on the TAR until 03/20/25. The DON also verified there was no description of the wounds until an outside wound doctor saw Resident #68 on 03/18/25. The DON verified there was not documentation of the pressure ulcer to the right buttock. The only pressure ulcer identified by the wound doctor was to Resident #68's sacrum. Review of the wound and skin care policy (no date) revealed if a pressure area/ulcer was present, the resident will be placed on a wound program and the area will be measured/tracked weekly and as needed until resolved. A treatment will be initiated as ordered by the physician. Documentation of pressure areas/ulcers include measurement of the width, length, depth, wound margins, undermining, clock hands for tunneling, drainage, amount of drainage including the type, color, and odor. The site of the pressure ulcer will be described. This deficiency identifies non-compliance under Complaint Number OH00166200. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 25 of 47 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 07/02/2025 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 - Few 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 record review, interview, observation and policy review the facility failed to provide a comprehensive, resident centered fall prevention plan and failed to adequately assess residents after a fall. This affected two (Resident #5 and #135) of three residents reviewed for appropriate care and services. Facility census was 90. Findings include: 1. Review of the medical record revealed Resident #5 was admitted on [DATE] and readmitted on [DATE] with diagnosis that included generalized idiopathic epilepsy and epileptic syndromes, schizophrenia, hypertension, anxiety disorder, disruptive mood dysregulation disorder, repeated falls, restlessness and agitation, senile degeneration of the brain and glaucoma. Review of the physicians orders dated 05/21/25 revealed a low bed with mat beside the bed was ordered. The plan of care dated 06/17/22 revealed Resident #5 was at risk for falls with an added intervention dated 05/08/25 for a low bed with a mat beside the bed (on the floor). Observations on 06/24/25 at 1:07 P.M., 06/25/25 at 9:26 A.M. and 11:51 A.M. revealed a mattress was on the floor, beside the bed. Interview on 06/30/25 at 3:04 P.M. with the Director of Nursing verified there was a mattress on the floor beside the resident's bed, but the order in the electronic medical record (EMR) reflected a mat to the floor. 2. Review of the medical record revealed Resident #135 was admitted on [DATE] and discharged to the hospital on [DATE] with diagnoses that included fracture of pubis, diabetes mellitus, chronic kidney disease stage 3, seizures, bipolar, and major depressive disorder. The Morse Fall scale dated 05/15/25 revealed Resident #135 was at high risk for falls. The plan of care dated 05/16/25 and created on 05/20/25 revealed Resident #135 was at high risk for falls. Interventions initiated on 05/16/25 but created on 05/20/25 included to change Resident #135's bed to low bed with a mat beside the bed and grab bars to allow the resident to change positions in bed, encourage to wear nonskid footwear, keep bed in the lowest position, and keep call light within reach. A Fall and Neuro form authored by Licensed Practical Nurse (LPN) #220 that was not part of the medical record revealed on 05/16/25 at 1:00 P.M. Resident #135 was observed on the floor and had rolled out of bed while sleeping. Resident #135 had a hematoma above the left eye. Under the section for injuries, LPN #220 documented there were no injuries. LPN #220 documented Resident #135's call light was within reach. There were no statements documented. A description of the size and color of the hematoma was not documented. A general progress note dated 05/16/25 at 1:00 P.M. entered on 05/20/25 at 11:24 A.M. and authored (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 26 of 47 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 07/02/2025 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 - Few by the Director of Nursing (DON) revealed the nurse observed Resident #135 lying on the floor next to the bed. Resident #135 had a hematoma above the left eye. Resident #135 was assisted back into bed. Neurological checks were started and Resident #135 was provided an ice pack for face. A new intervention for grab bars was put in place. Resident #135's family, the DON, and physician were notified of the fall. An interdisciplinary note dated 05/16/25 at 5:43 P.M. entered on 05/20/25 at 11:44 A.M. and authored by DON revealed Resident #135 had a fall on 05/16/25 at 1:00 P.M. Resident #135 was observed lying on the floor next to the bed. Resident #135 had a hematoma above the left eye. Interventions included to change bed to low bed with a mat beside the bed, and grab bars to allow Resident #135 to change positions in bed. Resident #135 was at high risk for falls. A general progress note (struck out by LPN #220) dated 05/16/25 at 6:09 P.M. revealed Resident #135's daughter stated staff had been told upon admission that Resident #135 was a fall risk. Resident #135's daughter asked why Resident #135 did not have bed rails on the bed. The daughter stated she was not leaving until bed rails were put on Resident #135's bed. A bed with side rails was provided for Resident #135. The discharge/return anticipated Minimum Data Set (MDS) dated [DATE] revealed Resident #135 was independent with cognitive skills, required substantial/maximal assistance with rolling and sitting to lying, lying to sitting, and was dependent from sitting to standing, toileting, and showering. An interview on 06/26/25 at 4:49 P.M. DON stated when Resident #135 fell, the nurse working did the initial report and documented under risk assessments which was not part of the medical record. DON stated only the nurse that documented the note on 05/16/25 at 6:09 P.M. could strike out the note. DON could not say why the note was struck out but possibly due to the note said bed rails instead of grab bars. A general progress note entered on 06/28/25 but dated 05/16/25 at 1:00 P.M. authored by LPN #220 revealed Resident #135 was observed lying on the floor next to the bed. Resident #135 that a hematoma above the left eye that was approximately 1.6 centimeters (cm) in size. An intervention for grab bars was put in place. A general progress note entered on 06/28/25 but dated 05/16/25 at 6:09 P.M. authored by LPN #220 revealed Resident #135 had a hematoma that measured 1.6 cm long and 1.6 cm wide. Resident #135's daughter stated she had told staff on admission at Resident #135 was a fall risk and would not leave until Resident #135 had a bed with rails or grab bars An interview on 06/30/25 at 9:12 A.M. Resident #135's daughter stated she was present when Resident #135 was admitted . The daughter lowered Resident #135's bed and told the staff Resident #135 had fallen out of bed in the past and needed side rails to the bed. The staff stated a physician order would be needed to use side rails or put a mat on the floor next to the bed. Resident #135's daughter stated Resident #135 had a large hematoma and a black eye after fall from bed. When Resident #135 was transferred to the hospital on [DATE], the emergency medical technicians asked Resident #135 if anyone had assessed Resident #135 due to the facial injuries received from the fall. An interview on 06/30/25 at 11:58 A.M. DON stated fall interventions upon admission included Resident #135's bed to be in the low position and nonskid socks were to be worn when out of bed. DON verified the documentation did not reveal if Resident #135's bed was in a low position or if nonskid (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 27 of 47 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 07/02/2025 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 socks were in place. DON also verified LPN #220 entered documentation for 05/16/25 on 06/28/25 to include the size of the hematoma. DON verified there was no other documentation of the size or characterizes of the hematoma in the progress notes, fall investigation, or skin assessment documentation from 05/16/25 to 05/18/25. DON verified fall interventions of grab bars, low bed, and a mat to the floor were not put in place until after Resident #135 had a fall from bed. Residents Affected - Few Review of the fall policy (no date) revealed staff, with physician's guidance will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. This deficiency represents non-compliance investigated under Complaint Number OH00166595 and OH00165933. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 28 of 47 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 07/02/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, and staff interview the facility failed to store respiratory equipment in a safe and sanitary manner. This affected one resident (Resident #80) of two residents reviewed for respiratory care. The facility census was 90. Residents Affected - Few Findings Include: A review of Resident #80's medical record reviewed admission date 05/30/25 with the following diagnoses including chronic obstructive pulmonary disease (COPD), respiratory failure, anxiety, high blood pressure, and type two diabetes. Resident #80 had intact cognition and required limited assistance from staff to complete activities of daily living (ADL) tasks. A review of Resident #80's physician orders revealed an order dated 05/31/25 for the use of a Bilevel Positive Airway Pressure (BIPAP- a type of non-invasive ventilation that helps people with breathing difficulties) with settings at 12/6 (the amount of inspiratory and expiratory support provided to assist with easier breathing) at bedtime as needed (PRN) and an order date 05/31/25 to Clean BIPAP mask, after use daily and PRN, with soap and water, then allow to dry. Keep mask stored properly in allocated bag every night shift for respiratory care/device care/infection prevention. A review of Resident #80's Medication Administration Record dated 06/01/25 to 06/30/25 revealed the order for BIPAP with settings at 12/6 at bedtime as needed (PRN) was not marked as being used by Resident #80. An observation on 06/23/25 at 3:19 P.M. revealed Resident #80's BIPAP machine was lying on the floor in front of the air conditioning unit. There was no barrier under the BIPAP machine and the face mask was lying on top of the BIPAP machine without a barrier or secured in a plastic bag. An interview on 06/23/25 at 3:30 P.M. with Licensed Practical Nurse (LPN) #309 confirmed Resident #80's BIPAP machine was lying on the floor without a barrier beneath and the BIPAP face mask was lying on top of the BIPAP machine without a barrier or secured in a plastic bag. LPN #309 stated the BIPAP machine should not be stored on the floor and the face mask and tubing should be stored in a plastic bag. LPN #309 moved the BIPAP machine from the floor to the desk in the room and removed the face mask and tubing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 29 of 47 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 07/02/2025 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 Based on medical record review and interview, the facility failed to ensure a resident was provided with identified pain was provided with adequate pain control. This affected one resident (#78) of 29 residents reviewed for care and treatment. The facility census was 90. Residents Affected - Few Findings include: Review of Resident #78's medical record revealed a 05/01/25 admission with diagnoses including fracture of T11-T12 vertebra, protein calorie malnutrition, fracture of first lumbar vertebra, valve endocarditis, lumbosacral radiculopathy, lumbar spondylosis, muscle wasting and atrophy, difficulty walking, cognitive communication deficit, idiopathic peripheral neuropathy, low back pain, mood disorder, fatty liver, intervertebral disc degeneration lumbosacral, hypertension, and irritable bowel. Review of the 05/06/25 admission Minimum Data Set (MDS) Assessment revealed the resident was independent for daily decision making with no signs or symptoms of delirium and was often socially isolated. The resident had no functional impairment. He used a walker. The resident was in need of partial/moderate assistance with personal hygiene. The resident received as needed pain medication with occasional pain. Interview on 06/23/25 at 1:54 P.M. with Resident #78 revealed the facility ran out of his pain medicine this past weekend. The resident stated he went from 5:00 A.M. till 11:00 P.M. without pain medication when he can have it every six hours. Review of physician orders included an order dated 06/04/25 for oxycodone (narcotic pain medication) 5 milligrams (mg) give one tablet by mouth every six hours as needed for pain. Review of the medication administration record (MAR) revealed on 06/21/25 the resident was administered oxycodone at 6:49 A.M. and 8:54 P.M. Interview on 06/24/25 at 4:32 P.M. with Licensed Practical Nurse (LPN) #230 revealed the facility did run out of the resident's pain medication the morning of 06/21/25. She indicated Registered Nurse (RN) #228 called the pharmacy and they said they needed a new prescription. She revealed they were unable to get ahold of MED1 (the physician service used by the facility). If they could have reached them they could have pulled the pain medication from the emergency drug kit (EDKIT). Staff could not get ahold of the physician group so there was a delay in the resident receiving pain medication. LPN #230 indicated the resident did ask for the pain medication and she told the resident they were out of his medication. Resident #78 said he was in pain. The pain was usually in his back. LPN #230 verified she was unable to administer Resident #78 pain medication during her 12 hour shift. Review of the MAR revealed Resident #78 was administered oxycodone 5 mg at 8:54 P.M. and routine ibuprofen at 9:00 P.M. for a pain level of eight. Interview on 06/25/25 at 10:36 A.M. with the Director of Nursing (DON) verified the facility did not have a policy to check all the medications on Friday to make sure there were enough for the weekend. The DON stated the pharmacy knows when a prescription is expiring and emails her. The DON said this resident's (#78) prescription came from the Orthopedic physician and not their physician group for the facility. Thus, she did not receive an email of the prescription expiring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 30 of 47 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 07/02/2025 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 Interview on 06/30/25 at 2:55 P.M. with Resident # 78 revealed he had pain in his back and right shoulder of an eight (1-10 pain scale) the day he did not have pain medication available. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 31 of 47 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 07/02/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on medical record review, observation, interview and review of facility policy the facility failed to ensure medications were stored securely and failed to remove expired medications from the third-floor medication storage room. This affected one resident (Resident #80) of six residents reviewed for medication administration and the potential to affect 46 residents residing on the third floor. The facility census was 90. Findings Include: 1. A review of Resident #80's medical record reviewed admission date 05/30/25 with the following diagnoses including chronic obstructive pulmonary disease (COPD), respiratory failure, anxiety, high blood pressure, and type two diabetes. Resident #80 had intact cognition and required limited assistance from staff to complete activities of daily living (ADL) tasks. A review of Resident #80's physician orders revealed an order dated 05/31/25 for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed (PRN) for wheezing and an order dated 05/31/25 for Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three (3) milliliters (ml) administer 3 ml via nebulizer four times a day for shortness of breath. A review of Resident #80's Medication Administration Record (MAR) dated 06/01/25 to 06/24/25 revealed Resident #80's order for aerosol medication Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three (3) milliliters (ml) administer 3 ml via nebulizer four times a day for shortness of breath was marked as administered every four hours. Further review revealed Resident #80's order for aerosol medication Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 4 hours as needed (PRN) for wheezing was not marked as being administered. A review of Resident #80's COPD care plan dated 06/09/25 revealed approaches including give aerosol medications as ordered and monitor for effectiveness. There were no approaches for having aerosol medications at bedside. A review of Resident #80's assessments revealed no assessments completed for self-administration of aerosol medications or for aerosol medications to be kept at bedside. An observation on 06/23/25 at 3:19 P.M. revealed on Resident #80's bedside table an unlabeled aerosol inhaler and two opened packets of Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three (3) milliliters (ml) individual vials. There was a nebulizer machine sitting at the foot of Resident #80's bed with tubing and face mask hanging over the footboard. An interview on 06/23/25 at 3:30 P.M. with Licensed Practical Nurse (LPN) #309 confirmed the unlabeled aerosol inhaler and two opened packets of Ipratropium-Albuterol Solution 0.5-2.5 (3) milligram (mg) per three (3) milliliters (ml) individual vials lying on Resident #80's bedside table. LPN #309 stated rescue aerosol inhalers are allowed to be kept at bedside only when there is an order and the resident has been assessed for knowledge and ability to administer the medications appropriately. LPN #309 also confirmed Resident #80 did not have an order or an assessment completed to have the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 32 of 47 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 07/02/2025 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 0761 aerosol medications at bedside. Level of Harm - Minimal harm or potential for actual harm 2. An observation on 06/25/25 at 7:30 A.M. revealed in the third-floor medication storage room an unopened bottle of over the counter (OTC) supplement Vitamin B6 with a best by used date of 04/22 and an unopened box of OTC Nicotine Patches 7 mg with a best used by date 04/25. Residents Affected - Few An interview on 06/25/25 at 7:45 A.M. with LPN #353 confirmed the unopened bottle of over the counter (OTC) supplement Vitamin B6 with a best by used date 04/22 and an unopened box of OTC Nicotine Patches 7 mg with a best used by date 04/25. LPN #353 stated central supply restocks the medication rooms and will verify the expiration dates of the OTC supplements and medications. LPN #353 removed the expired supplement and medication from the third-floor medication storage room. A review of the facility's policy Administering Medications dated 2012 revealed the expiration/beyond use date on the medications label must be checked prior to administering. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 33 of 47 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 07/02/2025 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview, the facility failed to provide routine dental care. This affected one (Resident #61) of three residents reviewed for dental care. Residents Affected - Few Findings include: Review of Resident #61 revealed a 02/09/23 admission with diagnoses including dementia, alcohol induced amnesic disorder, hypertension, type 2 diabetes, conversion disorder with seizures or convulsions, psychosis not due to a substance or known physiological condition, restlessness and agitation, anxiety disorder, post traumatic stress disorder and major depressive disorder. Review of the 01/15/25 Annual Minimum Data Set Assessment (MDS) revealed no dental issues. Review of the 06/01/25 Quarterly Minimum Data Set Assessment (MDS) revealed the resident was moderately impaired for daily decision making with no behaviors. She sometimes felt socially isolated. She has minimal difficulty hearing with no hearing aide. Has the ability to understand. Clear speech, and is understood. She had adequate vision without corrective lenses. She had trouble concentrating and falling asleep, feeling down, depressed or hopeless, with little pleasure in doing things. She had no functional impairment. The resident was supervision/ touch assistance for personal hygiene. Medications included antipsychotic, antidepressant, anticonvulsant. Receives antipsychotic on routine basis and no gradual dose reduction (GDR) had been attempted. The physician indicated a GDR was clinically contraindicated. Interview 06/24/25 at 10:33 A.M. with Resident #61 revealed she had not seen a dentist since she arrived. She affirmed she had not had her teeth cleaned by a dental hygienist since admission. Review of the last visit to the facility by the dentist on 02/17/25 revealed Resident #61 was not on the list to be seen. The record contained no evidence of the resident being see by a dentist since her 02/09/23 admission. There was no evidence of an oral examination in 2024 or 2025. Interview 06/26/25 at 9:27 A.M. with Guardian #700 revealed Resident #61 is eligible for Veteran's benefits. She included she had asked in the past for the facility to make arrangements with the VA for Resident #61 to take advantage of the veteran benefits for ancillary services. Interview 06/26/25 at 9:49 A.M. with the Director of Nursing verified the resident had not had ancillary services including dental care since admission. On 06/26/25 at 11:02 A.M. Resident #61 was walking in hall on the behavior unit where she reside. She said her gum hurts. The resident pulled up her upper lip and exposed a white ulcer on the upper right gum. She included her gum had been bothering her about a week and a half. Licensed Practical Nurse #232 stated she would call the nurse practitioner when shown the ulcer. Interview 07/01/25 at 11:24 A.M. with Regional Nurse #601 included the company does not do oral assessments. The company who owned the facility prior to the current company did oral assessments. She included the assessments in the computer from 2023 were done by the prior owners of the facility. This deficiency represents non-compliance investigated under Complaint Number OH00166595 and OH00165933. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 34 of 47 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 07/02/2025 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, sanitizing instructions, and policy review, the facility failed to ensure the staff were properly trained on how to check the sanitization level in the dishwasher. This had the potential to affect all 90 residents. Facility census was 90. Findings include: Review of the dishwasher chemical log from 06/01/25 through 06/22/25 revealed the chemical reading was 200 parts per million (ppm) three times a day every day. Observation on 06/23/25 at 8:20 A.M. revealed Dietary Supervisor #296 used a test strip to check the chemical reading in the dishwasher. Dietary Supervisor #296 stated the dishwasher was a low temperature and used chemicals to sanitize the dishes. Dietary Supervisor #296 was unsure if the chemical level had been checked on 06/23/25. Dietary Supervisor #296 stated the bleach container was low and needed replaced. Dietary Supervisor #296 instructed the staff to rewash the dishes that had been done that morning. The bleach container was replaced and Dietary Supervisor #296 ran the dishwasher five times and dipped a test strip each time and the test strip did not turn a color (purple) that could be compared to the color chart provided. An observation at this time also revealed Dietary Aide #264 was scraping plates and putting the dishes on the racks to go through the dishwasher. An interview with Dietary Aide #264 revealed she was hired in May and was not trained on how to check the chemicals in the dishwasher. An interview on 06/23/25 at 9:54 A.M. Regional Director of Operations #602 stated the dishwasher was working correctly but Dietary Supervisor #296 was nervous and was dipping the test strips at the wrong time. An interview on 06/25/25 at 11:57 A.M. Dietary Supervisor #296 verified he was dipping the chemical strip on the rinse cycle instead of the sanitizing cycle. Review of the instructions to test chlorine levels in a dishwasher using test strips revealed a test load of dishes should be ran and then a sample collected of the final rinse water. The test strip should be dipped into the water and for a few seconds and then the color of the strip should be compared to the color chart provided with the test kit. The color on the strip indicated the chlorine concentration in ppm. The target concentration was typically 50 to 100 ppm for chlorine-based sanitizers. A more detailed breakdown included to run a test load to ensure the sanitizer concentration being tested was the same in a typical load. After the cycle was complete, a sample of the final rinse water should be collected. A good place to collect from was a cup or other item that had been in the final rinse cycle. Generally, the test strip was dipped into the water for a few seconds, ensuring the strip was fully submerged. The test strip should be immediately compared to the color chart provided with the test kit. The closest matching color indicated the chlorine concentration in ppm. If the concentration was within the recommended range (usually 50-100 ppm for chlorine) you could be confident the dishwasher was sanitizing properly. If the concentration was too low, you may need to adjust the sanitizer dispenser or add more sanitizer. If it was too high, you may need to dilute the solution. Sanitizer solutions can lose effectiveness over time, so it is important to retest the solution regularly, especially if using chlorine-based sanitizers. Retesting every two hours is a good practice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 35 of 47 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 07/02/2025 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Review of the Dishwashing Machine Use policy (no date) revealed food service staff required to operate the dishwashing machine will be trained in all steps of dishwasher machine use by the supervisor or designee proficient in all aspects of proper use and sanitation. Dishwashing machine chemical sanitizer concentration and contact times for chlorine was 50-100 ppm for 10 seconds. A supervisor will check the dishwashing machine for proper concentration of sanitizer solution after filling the dishwashing machine and once a week thereafter. Concentration will be recorded in a facility approved log. Event ID: Facility ID: 366207 If continuation sheet Page 36 of 47 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 07/02/2025 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 0825 Provide or get specialized rehabilitative services as required for a resident. 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 interviews and facility policy review, the facility failed to initiate therapy services for skilled residents. This affected two residents (#5, #285) out of two residents reviewed for rehab and restorative services. The facility's census was 90. Residents Affected - Few Findings Include: 1. A review of the medical record for Resident #285 revealed admission date 06/18/25 with the following diagnoses including but not limited to aftercare following joint replacement of left hip, high blood pressure, and depression. Resident #285 had intact cognition and required limited assistance from staff to complete activities of daily living (ADL) tasks. A review of Resident #285's physician orders revealed an order dated 06/19/25 to be admitted to skilled level of care. A review of Resident #285's hospital discharge paperwork dated 06/18/25 revealed physical therapy and occupational therapy orders were recommended for Resident #285 related to left hip joint replacement. A review of Resident #285's physical therapy (PT) and occupational therapy (OT) evaluations and service notes dated 06/23/25 revealed PT and OT services were initiated on 06/23/25, five days after Resident #285 was admitted to the facility for skilled level of care. An interview on 06/25/25 at 1:04 P.M. with Director of Rehab (DOR) #505 confirmed Resident #285 was not evaluated for therapy services until day five of admission to the facility. DOR #505 stated the usual time frame for therapy evaluation after admission is 48 hours. Therapy evaluations are scheduled when either an occupational therapist or a physical therapist is available to complete the evaluation either in person or by Telehealth. DOR #505 stated Resident #285 was able to move around the room using a walker and was independent with ADL tasks including bed mobility and transfers, therefore DOR #505 scheduled the therapy evaluations on 06/23/25 when a physical therapist would be at the facility, since the occupational therapist was not available. 2. Review of the medical record revealed Resident #5 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included generalized idiopathic epilepsy and epileptic syndromes, schizophrenia, hypertension, anxiety disorder, disruptive mood dysregulation disorder, repeated falls, restlessness and agitation, senile degeneration of brain and glaucoma. Review of the medical record revealed Resident #5 had a fall on 03/11/25 and documentation revealed an intervention for a STAT (immediate) EKG (electrocardiogram) and resident to be evaluated for walker usage with therapy. Subsequent review of the medical record revealed Resident #5 had two additional falls on 03/21/25 and 03/26/25. Review of Resident #5's physician's orders revealed order for PT to eval and treat. PT clarification order. PT to eval and treat 6x for 2 weeks per POC including gait training. There ex, there act, group, manual, and neuro [NAME] dated 04/04/25. Review of physical therapy evaluation and plan of treatment revealed Resident #5 was not evaluated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 37 of 47 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 07/02/2025 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few until 03/29/25. Physical therapy Discharge summary dated [DATE] revealed recommendations of 24-hour care and home exercise program. Interview on 06/30/25 at 3:04 P.M. with the Director of Nursing #226 verified no evaluation for walker by therapy completed after immediate fall intervention on 03/11/25 until 03/29/25. No orders, staff education or care plan for home exercise program recommended by therapy on 05/04/25. Review of facility policy titled Scheduling Therapy Services Revised July 2013 states Therapy is scheduled in coordination with Nursing Service and is documented in the resident's medical records FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 38 of 47 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 07/02/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility documentation review, and staff interview the facility failed to ensure resident activity documentation was accurate. This affected one resident (#72) of one resident reviewed for activities. Facility census was 90. Findings include: Review of the medical record for Resident #72 revealed an initial admission date of 06/01/25 and readmitted on [DATE] with diagnoses including periprosthetic fracture around internal prosthetic right hip joint, other mechanical complication of other internal joint prosthesis, fibromyalgia, protein-calorie malnutrition, repeated falls, major depressive disorder, chronic pain and opioid use. Review of the facility staff daily activity documentation for June 2025 revealed Resident #72 attended and was provided activities. Resident #71 was not in the facility from 06/15/25 to 06/19/25 due to hospitalization. Interview on 06/26/25 at 2:18 P.M. with Activity Director #216 verified the staff documentation was inaccurate and Resident #72 was out of the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 39 of 47 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 07/02/2025 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm 2. Review of Resident #10's medical record revealed a 05/21/24 admission with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, asthma, epileptic seizures, mood disorder, dysthymic disorder, post-traumatic stress disorder, macular degeneration, major depressive disorder, neuropathy, arthritis, malignant neoplasm of lung and bronchus, chronic obstructive pulmonary disease, hyperlipidemia, history of malignant neoplasm of pancreas, insomnia, gastroesophageal reflux disease, and nicotine dependence. Residents Affected - Few On 02/15/25 at 5:01 P.M. the emergency squad arrived at the facility stating they received a 911 call from the resident due to nausea, vomiting and diarrhea. The resident's temperature was normal 98.6 degrees Fahrenheit on discharge. The resident was admitted with a diagnosis of diarrhea. The resident was readmitted to the facility 02/19/25 at 8:00 P.M. with an order for Sulfamethoxazole-Trimethoprim Oral Tablet 800-160 milligrams (mg) (Bactrim) (antibiotic medication) by mouth two times a day for bacterial infection. There was no stop date. On 02/21/25 the order was changed to one tablet twice a day for sepsis/cellulitis for three days. The resident per nurses note did not exhibit any signs or symptoms of pain or discomfort upon readmission. Review of the 02/19/25 hospital discharge summary included primary diagnoses of sepsis, cellulitis and nausea, vomiting and diarrhea. The report indicated the resident was hospitalized for nausea, vomiting, diarrhea and suspected sepsis. The resident was administered Vancomycin and Cefepime (both antibiotic medications) at the hospital due to a CT scan showing cellulitis. Cefepime was discontinued as all cultures were negative. The resident had leukocytosis >20,000, tachycardia and hypotension which was responsive to fluid resuscitation, secondary to acute diarrhea illness/cdiff versus virus versus other. A CT scan did not show acute intra-abdominal pathology but did show abdominal wall edema that could be consistent with left sided cellulitis. Tender but otherwise no evidence of erythema. Vancomycin was continued for possible cellulitis. The resident was discharged with Bactrim to complete treatment. The Respiratory Viral Panel was negative. The cdiff was canceled as no more diarrhea. The urinalysis was clean. The blood culture showed no growth of organism. The resident was asplenic. The resident had a history of pancreatic cancer. The CT scan did not show pancreatitis but showed possible cellulitis although there was no visible erythema on exam. The resident had normal white blood cell count on discharge. Review of the McGeer criteria dated 02/19/25 indicated the resident was evaluated for a skin and soft tissue infection. The criteria checked as positive was heat (warmth) at affected area, redness (erythema) at affected site, swelling at affected site, tenderness or pain at affected site. The resident was marked for fever, leukocytosis and acute functional decline. The criteria indicated four areas needed to be positive on the top section of the criteria and on from the bottom section of criteria to meet criteria for antibiotic use. It was indicated the resident met criteria. Review of the facility discharge to hospital, hospital discharge paperwork and readmission assessment revealed no evidence of heat (warmth) at affected area, or redness (erythema) at affected site. The discharge included no erythema. There was no evidence of any erythema. The resident was marked for fever when there was no evidence of the resident ever having a fever or acute functional decline. The resident met two criteria (tenderness and swelling) at affected site not four criteria as needed to meet McGeer criteria. Review of Resident #10's Medication Administration Record revealed the resident had a total of nine (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 40 of 47 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 07/02/2025 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 0881 doses, four and a half days of Bactrim. Level of Harm - Minimal harm or potential for actual harm Interview 07/02/25 at 2:17 P.M. with the Director of Nursing verified Resident #10 did not meet four criteria as needed to meet McGeer criteria for the use of an antibiotic. The resident did not have warmth at the site, or erythema and they were both marked as present. The readmission antibiotic order did not have a stop date or indication for use. Residents Affected - Few Review of the facility's Antibiotic Stewardship policy (revised December 2016) included when a resident is admitted from the emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders. Discharge or transfer medical records must include all of the drug and dosing elements including a stop date and indication for use. Based on medical record review, facility antibiotic stewardship program review, staff interview and facility policy review the facility failed to assess for appropriate use and monitor the use of antibiotic medications. This affected two residents (Residents #10 and #134) out of three residents reviewed for antibiotic use. The facility's census was 90. Findings Include: A review of the medical record for Resident #134 revealed an admission date 05/21/25 with diagnoses including osteomyelitis of right foot, congestive heart failure (CHF), and type two diabetes. Resident #134 discharged from the facility on 05/25/25. A review of Resident #134's physician orders revealed an order dated 05/21/25 antibiotic Daptomycin Intravenous Solution Reconstituted use 14.5 milliliter (ml) per hour (hr) intravenously at bedtime for wound until 06/22/25, order was discontinued on 05/23/25. An order dated 05/23/25 for antibiotic Daptomycin Intravenous Solution Reconstituted use 700 milligram (mg) intravenously at bedtime for staph infection of right foot until 06/22/25, order was discontinued on 05/25/25, and an order dated 05/25/25 for antibiotic Daptomycin Intravenous Solution Reconstituted use 700 milligram (mg) intravenously at bedtime for staph infection of right foot until 06/25/25, order was discontinued on 05/27/25. A review of the facility's antibiotic stewardship tracking logs dated 05/01/25 to 05/31/25 revealed there were no entries documented for Resident #134's use of antibiotic medication Daptomycin upon admission to the facility. There was no monitoring form (McGeers) completed to reflect the appropriateness of the use of the antibiotic medication Daptomycin for Resident #134. An interview on 07/01/25 at 3:00 P.M. with the Director of Nursing (DON) confirmed there was no antibiotic tracking or monitoring form completed for the Resident #134 upon admission to the facility and the ongoing use of the antibiotic medication Daptomycin for a wound infection. Review of the facility's policy titled Antibiotic Stewardship (dated 12/16) revealed the purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents. When a resident is admitted from the emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 41 of 47 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 07/02/2025 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Based on review of the facility's antibiotic stewardship program and staff interviews the facility failed to ensure the facility's antibiotic stewardship program was completed by a certified infection control preventionist (ICP). This had the potential to affect all residents residing in the facility. The facility's census was 90. Findings Include: A review of the facility's antibiotic stewardship program dated 05/01/25 to 06/30/25 revealed the monthly tracking logs, trending maps, and the antibiotic criteria forms (McGeers) being completed by the facility's Director of Nursing (DON). There was no signatures on the monthly tracking logs to reflect an ICP was monitoring the program. A review of the facility's infection control program revealed the facility's ICP is the Regional Director of Clinical Services (RDCS) #601. RDCS #601's ICP certification was received in 12/21/19. There was no ICP certification on file for the DON. An interview on 07/01/25 at 2:53 P.M. with the DON revealed the antibiotic stewardship program required monthly tracking, trending, and completion of the antibiotic criteria forms were being completed by the DON. The DON does not have an ICP certification. RDCS #601 monitors the facility's antibiotic stewardship program with the DON actually completing the required documentation. An interview on 07/01/25 at 3:03 P.M. with RDCS #601 confirmed the facility's DON was completing the monthly documentation including the trending, tracking and completion of the antibiotic criteria forms for the facility's antibiotic stewardship program, even though the DON does not have an ICP certification. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 42 of 47 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 07/02/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, work orders, policy and interview, the facility failed to ensure cool air temperatures, functional sinks, functional shower rooms, maintenance of ceilings, walls, floors, window seals and vanities, furniture, mattress, toilet paper holders, and functional hand sanitizer dispensers. This affected 24 (Resident's #24, #26, #27, #28, #32, #37, #38. #39, #40, #49, #52, #53, #56, #57, #58, #59, #60, #68, #73, #75, #76, #78, #185, and #285) of 90 residents in the facility. Findings include: 1. Review of quote dated 04/22/25 from heating, ventilation, and air conditioning (HVAC) company revealed cooling tower repairs due to coil froze and burst due to being shut off over the winter. The coil would need replaced for a total of $79,990. A quote dated 04/24/25 was received from the same HVAC company for temporary cooling tower, temporary pump, piping, electric, and breakers as needed for a total of $48,659.00. The work was completed and paid for sometime in May. Review of temperature logs from 04/28/25 to 06/12/25 revealed temperatures from 74 degrees to 82 degrees. The temperatures for resident rooms at 80 degrees or above had notation of air conditioner unit being off and/or windows open. A work order dated 06/06/25 revealed the air unit on the second floor (Blue) was not working. On 06/11/25 a work order was placed for a problem with air conditioning in Resident #57's room. On 06/13/25 a work order was placed for air conditioning not working for Resident #60. A timeline of events revealed on 06/22/25 maintenance reported to the facility to assist with elevated temperatures. HVAC company was contacted when complaints were received on increased temperatures. Residents were offered extra fans and portable air conditioning units. On 06/23/25 the facility implemented the Extreme Heat Policy. All residents were monitored for signs and symptoms of heat exhaustion every shift. Residents were offered to transfer to another facility, residents were offered an extra fan and/or portable air conditioner to use, and were educated on hydration, wearing light clothing, and turning off lights in their room. The facility attempted to obtain commercial portable air conditioner units but was unsuccessful due to multiple company's being out of stock. A email dated 06/23/25 at 3:46 P.M. from the HVAC company to [NAME] President of Plant Operations #600 revealed on 06/22/25 a technician arrived on site. An air bleeder on the building loop at the cooling tower was spraying out water. The bleeder was valved off and water was added. The power to the heat pumps on the second and third floor were cycled. A new air bleeder will need to be installed. Observations and interviews on 06/23/25 from 10:25 A.M. to 1:22 P.M. Residents #26, #28, #38, #60, #73, and #75 stated it was hot in the facility. Resident rooms and common areas were warm and multiple fans and portable air conditioners were noted. An observation on 06/23/25 at 1:11 P.M. of the thermostat at the nurses station on the third floor near the elevator showed 84 degrees. An observation on 06/23/25 at 1:12 P.M. of the nurses station on the back unit on the third floor had an electronic thermometer that showed 85 degrees. On 06/23/25 at 1:47 P.M. weather.com revealed the temperature in Columbus, Ohio, was 94 degrees. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 43 of 47 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 07/02/2025 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 0921 On 06/23/25 room temperatures were conducted with [NAME] President of Plant Operations #600 revealed the following temperatures: Level of Harm - Minimal harm or potential for actual harm At 1:50 P.M. Resident #78's room was 81.8 degrees Residents Affected - Many At 1:51 P.M. Resident #76's room was 82.9 degrees At 1:52 P.M. Resident #59's room was 82.2 degrees At 1:52 P.M. Resident #40's room was 82 degrees At 1:56 P.M. Resident #52's room was 81.1 degrees At 1:57 P.M. the common area on the locked unit was 81.8 degrees At 2:14 P.M. Resident #68's room was 83.3 degrees At 2:15 P.M. Resident #75's room was 84.2 degrees At 2:16 P.M. Resident #38's room was 84 degrees At 2:17 P.M. Resident #73's room was 81.1 degrees At 2:23 P.M. the nurses station on the third floor near the elevators was 85 degrees At 2:24 P.M. Resident #57's room was 85 degrees At 2:31 P.M. the therapy room was 84 degrees An interview on 06/23/25 at 3:50 P.M. [NAME] President of Plant Operations #600 revealed the cooling tower fan was running backwards and caused breakers to trip which resulted in the air conditioning not working properly. An interview on 06/24/24 at 10:19 A.M. Occupational Therapist #501 verified therapy was being completed in resident rooms because the therapy room was hot. An interview on 06/24/24 at 10:22 A.M. Therapy Director #505 verified therapy was only done in the therapy room if residents wanted therapy done there because the therapy room was hot. Therapy Director #505 stated a portable air conditioner and two fan were placed in the therapy room to help with the heat. An additional interview on 06/30/25 at 8:47 A.M. [NAME] President of Plant Operations #600 verified in April a temporary chiller was used until a part could be made. The end of May the part was available and the cooling tower was fixed. On 06/22/25 there were complaints of the air conditioning not working properly. The HVAC company was called and it was discovered the high voltage was wired wrong and caused the units to trip and an air bleeder was found. Excessive heat policy dated 11/30/14 revealed air conditioning will be utilized. If air conditioning was not appropriate or feasible, fans would be utilized to provide air circulation. Fluid hydration would be encouraged and cool fluids would be passed to residents on a regular basis. Window treatments would be closed to block out the sun where appropriate, residents would be encouraged to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 44 of 47 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 07/02/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm relocate and spend time in the cooler sections of the building, residents would be monitored closely for signs of dehydration, respiratory difficulties, and transferred to appropriate facilities if indicated. The facility must maintain temperature range of 71 to 81 degrees. 2. Observations 06/23/25 between 10:33 A.M. and 2:13 P.M. revealed the following: Residents Affected - Many Resident's #53 and #58's bathroom did not have a roller to hold their toilet paper. Resident's Resident #37 and #49's bathroom did not have a roller to hold their toilet paper. One third of the vanity surrounding Resident #49's sink was missing. Resident #39's recliner was heavily worn with the fabric off on the headrest, arms and seat. Resident #24's sink had a note on it that it was out of order. The resident's had [NAME] and [NAME] bathrooms and a sink in their room. There was no evidence of hand sanitizer in the room in lieu of the sink being out of order. Three of four wall mounted hand sanitizers in the Behavior Unit did not dispense sanitizer when activated. Resident's #32 and #56's bathroom floor had 14 damaged, discolored floor tiles. Resident #27's overbed table and sink vanity were delaminating. The air conditioner was not working. Resident #52's sink and window seal were delaminating and chipped. The air conditioner was frozen and not cooling the room. The hall window outside room [ROOM NUMBER] had approximately two feet of the window seal missing. The Behavior Unit's shower room was patched and not painted near the corner of the sink over an approximately three feet in length and one foot in width area. Resident #185's overbed table was delaminating. Resident #78's room sink had laminate broken off leaving jagged edges. There were holes in the linoleum of the bathroom floor. The bedroom and bathroom doors were heavily scraped and damaged. The paint was scraped off the thresholds of the bedroom and bathroom doors. The air conditioner was not working. The knobs were off the air conditioner controls. The bedroom ceiling had an approximate four foot by two foot area damaged yellowish in color. The sink bowl was rusty colored. The temperature in the second floor lounge was 85 degrees at 11:40 A.M. The paint of the front of the second floor nurse station was scraped and dirty. There was a yellow stain in the ceiling tile of the between the elevator and second floor nurse station. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 45 of 47 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 07/02/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm The activity room had flooring missing in an approximate one and one half foot by one foot area and an approximate two inch by three inch corner. The activity room bathroom toilet had a black mold looking color around the water line. The floor was visibly dark, dirty. The walls were patched and not painted and the molding was off the wall. Residents Affected - Many The bottom half of the elevator under the handrail was heavily scraped with the paint off. The back wall of the elevator above the handrail had large areas of plaster missing and was not painted. The hall wall from the dining room to the lobby below the handrails was heavily marred with dark scraped areas and damaged drywall. On 06/25/25 at 9:55 A.M. the Regional Director of Operations #602 and [NAME] President of Plant Operations #600 toured the above areas and verified the described areas had not been maintained. Observation 06/30/25 at 02:55 P.M. revealed there was a hole in the ceiling of Resident #78's room approximately eight inches by three inches. The ceiling had a liquid dripping into a fracture pan below. Interview 06/30/25 at 02:55 P.M. with Resident #78 revealed his ceiling started to leak on Saturday 06/28/25. He revealed there was also a leak in the middle of the room over the weekend. He put a Styrofoam cup on a table to catch the drips however, it was next to his bed which made it difficult to get out of bed. Interview 06/30/25 at 02:59 P.M. with Regional Director of Maintenance #702 verified the leak, He came in the room and started to pull the wet loose ceiling down. He opened an approximate one foot by one foot in the ceiling and stated the resident would need to be moved to another room. Interview 06/30/25 at 03:10 P.M. with Certified Nurse Assistant #244 revealed Resident #24 who's sink was out of order goes to the bathroom himself. She included he needs help wiping. She verified the resident did not have hand sanitizer or wipes in his room and verified his sink was not working. She did not know how he was washing his hands. 3) An observation on 06/25/25 at 4:30 P.M. of the large shower room located on the unit 3-Out revealed the toilet and sink were covered with plastic sheeting to prevent use. There was a hole in the tile surrounding the shower handle approximately three inches long by two inches wide to the left of the handle with wall material exposed. There was a dark substance noted to the bottom of the walls in the front corners of the shower and along the top part of the rubber kick plate behind the sink and the toilet. An interview on 06/26/25 at 2:05 P.M. with the [NAME] President of Maintenance (VPM) #600 revealed the facility had notified him on 06/16/25 concerning the large shower room on 3-Out was out of order related to ruptured water pipe. VPM #600 was unsure of how long the shower had been out of order before the facility had notified him. An interview on 06/26/25 at 4:25 P.M. with LPN #240 confirmed the plastic sheeting on the toilet and sink, the hole in the tile by the shower handle and the dark substance in the corners of the shower and behind the sink and toilet. LPN #240 stated this shower room had been out of use for several months due to a water pipe that had leaked and ruptured. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 46 of 47 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 07/02/2025 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 4) A review of Resident #285's medical record revealed admission date 06/18/25 with the following diagnoses including but not limited to aftercare following joint replacement of left hip, high blood pressure, and depression. Resident #285 was cognitively intact and required standby assist by staff to complete activities of daily living (ADL) tasks including transfers and bed mobility. An observation on 06/23/25 12:49 P.M. of Resident #285's bed revealed the bed frame was too long for the mattress. The mattress was touching the footboard which allowed for an approximately two-foot-wide gap between the headboard and the top of the mattress. Further observations on 06/24/25 at 10:00 A.M., 06/25/25 at 1:10 P.M., 06/26/25 at 9:15 A.M. and on 06/30/25 at 3:25 P.M revealed Resident #285's mattress continued to be too short for the bed frame. An interview on 07/01/25 at 8:15 A.M. with LPN #240 confirmed Resident #285's mattress was too short for the bedframe which resulted in a large gap between the headboard and the top of the mattress. LPN #240 stated either the housekeeping staff, or the clinical staff will notify central supply concerning mattresses that need replaced. These deficiencies represents non-compliance investigated under Master Complaint Number OH00166595, OH00166200, OH00165971, and OH00165933. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366207 If continuation sheet Page 47 of 47