Bella Terrace Rehabilitation And Nursing Center

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

Interview with Resident #74 on 01/07/26 at 11:45 A.M. revealed resident heard the firearm go off but she said she didn't know what the sound was, and stated she found out the next day it was a gun. She said she didn't know anyone who saw it happen.

Interview with CNA #381 on 01/07/26 at 1:02 P.M. revealed he didn't see the firearm but heard the sound when it discharged , but did not know what the sound was from at the time. He said he saw RN #505 running up the stairs afterwards and RN #505 had asked him if he had heard the sound. He said there was dust everywhere. He said he did not know of anyone other than RN #505 who was present at the time the firearm discharged .

Interview with CNA #323 on 01/22/26 at 5:50 P.M. revealed she was on break when the firearm went off and she heard a loud bang but did not see what happened. She said she saw the hole in the floor and she found bullet casings on the floor.

Interview with Licensed Practical Nurse (LPN) #365 on 01/22/26 at 4:55 P.M. revealed she was working that evening in another area of the facility. She did not hear the firearm go off but heard about the incident that evening and saw the damage to the floor.

Interview with LPN #805 on 01/26/26 at 10:37 A.M. revealed he heard the sound of the firearm when it discharged but did not see the firearm.

Review of personnel file for RN #505 revealed his last day of employment was 12/01/25.

Interview on 01/07/26 with Human Resources Manager #313 confirmed RN #505 was terminated on 12/01/25.

Review of facility policy titled, Firearms and Other Weapons, revised April 2007 revealed the facility prohibited employees, residents, visitors, vendors or others from possessing firearms or other weapons while in/on facility premises.

This deficiency represents non-compliance investigated under Complaint Numbers OH001295678 and OH001295679.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

8/13/25 revealed no orders for the medication Melatonin. Interview on 01/08/26 at 12:20 P.M. with DON confirmed Resident # 94 was sent to the hospital after nurse administered approximately seven, melatonin three mg. Stated resident was at the hospital for a few hours for observation and was sent back to the facility with no new orders. Review of policy titled Administering Medications dated December 2012 revealed medications must be administered in accordance with the orders, including any required time frame, the individual administering the medication must initial the resident's MAR on the appropriate line

after giving each medication and before administering the next ones and the individual administering the medication must check the label three times to verify the right resident, right medication, right dose, right time and right route of administration before giving the medication.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

revealed there was an approximately two foot by 5 inch area on the wall with white paint in the corner of a tan wall and an overhead fan covered in dust. Certified Nursing Assistant #337 verified both. She said she didn't know who was responsible for cleaning the fan dust.Observation and interview on 01/13/26 at 9:40 A.M. in shower room on the third floor revealed there were five wet towels piled on the floor in the shower area. Certified Nursing Assistant (CNA) #248 confirmed the towels were there. She said a resident must have taken a shower overnight. She said the staff normally would remove them if they were told about them.Observation and interview on 01/22/26 at 1:05 P.M. in the shower room on the third floor there was a pile of wet towels in the room. Certified Nursing Assistant (CNA) #248 confirmed the towels were there. She said she didn't know who was covering the area.These deficiencies represent non-compliance investigated under Master Complaint Number 2699666, 2591930, 1295681, and 1295679.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

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 0925

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

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 review of work orders, the facility failed to maintain an environment free from a pest's infestation. This had potential to affect all 82 residents.Findings include:Observation on 12/30/25 at 12:26 P.M. in the first-floor dining room of multiple dead insects (a variety of insects including insects that resembled spiders and cockroaches (roaches)) along the walls near the windows.Interview on 12/31/25 at 8:59 A.M. with Resident #88 who said the roaches aren't living with us, we are living with them. She said

they put roach traps around and are trying to [eradicate the cockroaches]. She said the roaches come out when the housekeeper mops. She said she sees the roaches climbing up the walls and she has fears they will fall down on her.Interview on 12/31/25 at 9:34 A.M. with Maintenance Director #258 revealed they had

an issue with cockroaches, but he felt it was getting better. He said they switched [pest] companies three months ago and now he no longer had cockroaches running across his desk.Observation on 12/31/25 at 9:35 A.M. of the second-floor common area revealed multiple dead insects (a variety of insects including insects that resembled spiders and cockroaches (roaches)) on the windowsill by the entrance to memory care. Interview on 01/05/26 at 9:27 A.M. with Resident #87 revealed she saw the cockroaches in her room and in the hallways and she saw them come out of the kitchen. She said she was killing half a dozen a day.

She said it had slowed down some, but she wished they would have fumigated the whole place.Interview

on 01/05/26 at 7:22 A.M. with Resident #56 revealed he would have one or two cockroaches in his room but mostly he saw them in the hallways.Interview on 01/05/26 at 2:48 P.M. with Resident #90 revealed she felt

the insect issues were bad, but they had gotten better.Interview on 01/05/26 at 4:10 P.M. with Regional Maintenance Director #605 revealed the resident in room [ROOM NUMBER] was a hoarder. He said when

the resident was away from his room, they went in to get rid of the trash including empty shampoo bottles and empty grocery bags and he said they found a cockroach infestation in there and brought the exterminators in on this day for that room. He said they were German cockroaches.Observation and

interview on 01/06/26 at 10:36 A.M. revealed a cockroach crawling up the wall in the third-floor shower room. Regional Maintenance Director #605 was present and confirmed that it was a German cockroach.Interview on 01/07/26 at 11:45 A.M. with Resident #74 revealed she didn't have too many bug issues where she was on the third floor. She said on the first and second floors they [cockroaches] were everywhere.Observation and interview on 01/08/25 at 8:29 A.M. revealed two cockroach traps in the kitchen by the door. Dietary Supervisor #238 said they had issues with cockroaches, but he felt it had gotten better.Interview on 01/12/26 at 10:36 A.M. with Resident #50 revealed she didn't want housekeeping to come in her room because she believed they brought the insects in with their mops.Interview on 01/12/26 at 2:39 P.M. with Resident #27 revealed the place was roached out. He elaborated and stated they were everywhere and they came out at night. He noted he saw one two days ago. Interview on 01/12/26 at 3:04 P.M. with Resident #268 revealed she saw roaches come out from under her bed.Interview on 01/12/26 at 3:25 P.M. with Resident #35 revealed his biggest complaint was the cockroaches because they were repulsive.Observation on 01/13/26 at 11:07 A.M. revealed the exterminator approaching maintenance managers and asking them where he should focus.Review of pest control work orders dated 09/09/25, 09/29/25, 10/06/25, 10/17/25, 10/22/25, 10/29/25, 12/08/25, 12/16/25 and 01/05/26 revealed they were treating both individual rooms and common areas and the primary issue and focus on the visits were the eradication of cockroaches. This deficiency represents non-compliance investigated under Master Complaint Number 2699666, 2593662, 2591930, 1295681, and 1295679.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet