Inspection·February 2, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on medical record review, staff interview, and review of facility policy, the facility failed to provide timely physician and resident representative notification of changes in condition. This affected one (#31) of two residents reviewed for notification of change. The facility census was 53. Findings include: 1. Review of Resident #31's medical record revealed an admission date of 03/09/22. Diagnoses included type II diabetes, dementia, hypertensive chronic kidney disease, atrial fibrillation, other symptoms and signs concerning food and fluid intake, weakness and metabolic encephalopathy. Review of the annual Minimum Data Set (MDS) assessment, dated 01/12/23, revealed Resident #31 was moderately cognitively impaired, required limited assistance with activities of daily living (ADLs), supervision for eating and experienced a significant weight loss and was not on physician prescribed weight loss program. Review of a plan of care focus area, initiated 01/13/23, revealed Resident #31 experienced a significant weight loss. Interventions included provide diet, supplements, medications, adaptive equipment and snacks as ordered, offer encouragement and assistance with eating as needed and weigh as ordered. Review of current physician orders revealed Resident #31 was ordered a regular, mechanical soft, ground meat diet. In addition, Resident #31 was ordered Ensure pudding one time daily, Glucerna supplement two times daily and three snacks daily. Review of Resident #31's weights revealed on 07/01/2022, the resident weighed 106.6 pounds (lbs.). Resident #31's weights revealed on 12/03/2022, the resident weighed 97.4 lbs. On 01/09/2023, the resident weighed 92.4 pounds, indicating a 5.13% significant weight loss in one month and a significant weight loss of 13.32% in six months. Review of progress notes from 01/09/23 through 01/30/23 revealed no evidence Resident #31's physician or representative were notified of the resident's significant weight loss. Interview on 02/02/23 at 7:33 A.M. with the Director of Nursing (DON) revealed the typical process for weight loss was to document all residents with weight loss on a log which the physician reviewed each Tuesday when he visited the facility. The DON stated a facility event document, which was part of the facility's risk management program, was sometimes created for significant weight loss and notifications were documented on the event document. The DON confirmed an event document was not created following Resident #31's significant weight loss on 01/09/23. The DON verified there was no evidence Resident #31's physician was notified of the resident's significant weight loss until 01/31/23 and there was no evidence the resident's representative was notified of the weight loss. Review of facility policy titled Guidelines for Weight Tracking, reviewed 03/16/22, revealed residents who had a weight that seemed out of normal range would be re-weighed to determine accuracy of the original weight. In addition, the physician, resident representative and dietitian shall be notified of a weight variance of 5% in 30 days, 7.5% in 90 days and 10% in 180 days days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366365 If continuation sheet Page 2 of 12 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 366365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows at Bellevue 101 Auxiliary Drive Bellevue, OH 44811 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, medical record review, family interview and staff interview, the facility failed to ensure dependent residents were provided assistance with shaving. This affected one (#16) of four residents reviewed for activities of daily living (ADLs). The facility census was 53. Residents Affected - Few Findings include: Review of Resident #16's medical record revealed an admission date of 03/27/19. Diagnoses included vascular dementia, type II diabetes, chronic kidney disease, macular degeneration, hypertension, depressive disorder and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/01/23, revealed Resident #16 was severely cognitively impaired and required limited one person assistance with personal hygiene. Review of a plan of care focus area, reviewed 01/05/23, revealed Resident #16 required staff assistance to complete activities of daily living (ADLs) completely and safely related to cerebrovascular disease, dementia, vision, medications and weakness and Resident #16 would have ADLs met safely by staff assistance. Observation on 01/30/23 at 11:28 A.M. revealed Resident #16 was assisted back to the 100 Hall, after having her hair done. Resident #16 was noted to have significant hair on her chin. Interview on 01/30/23 at 1:35 P.M. with Resident #16's family member revealed family visited over the weekend and noticed the resident had hair on her chin. The family member stated he believed staff assisted Resident #16 with shaving on the days she had her hair done. Observation on 01/31/23 at 11:25 A.M. revealed Resident #16 sitting in the common area of the 100 Hall unit. Resident #16 was observed to have multiple hairs on her chin. Observation on 02/01/23 at 7:50 A.M. revealed Resident #16 was eating breakfast in the dining room. Resident #16 was observed to still have significant hair on her chin. Interview on 02/01/23 at 8:44 A.M. with State Tested Nurse Aide (STNA) #313 revealed Resident #16 required extensive assistance with ADLs, including grooming and hygiene. STNA #313 stated the resident typically had her hair done weekly by the beautician and did not refuse care. While assistance with shaving could be done anytime it was needed, STNA #313 confirmed Resident #16's shower days were Tuesdays and Thursdays and assistance with shaving should have been completed on those days. STNA #313 stated she would take care of it today. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366365 If continuation sheet Page 3 of 12 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 366365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows at Bellevue 101 Auxiliary Drive Bellevue, OH 44811 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 observations, medical record review, staff interview, and review of facility policy, the facility failed to implement fall interventions as care planned and per physician orders. This affected one (Resident #9) of two residents reviewed for falls. The facility census was 53. Findings include: Review of the medical record revealed Resident #9 admitted to the facility on [DATE]. Diagnoses included memory deficit following cerebral infarct, vascular dementia, psychotic disturbance, mood disturbance, anxiety disorder, disorientation, weakness, altered mental status, cognitive communication deficit, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. Review of Minimum Data Set assessment (MDS) dated [DATE] revealed Resident #9 could not complete the assessment of cognitive functioning. Resident #9 was dependent on staff for bed mobility, toileting, activities of daily living, bathing, locomotion, and dressing. Resident #9 required extensive assistance for transferring. Review of the care plan dated 01/10/23 revealed Resident #9 was at risk for falls due to decreased strength, mobility, high risk medications, and cognition. Interventions included the use of a fall mat next to the bed while the resident was laying down. Review of the fall risk assessment dated [DATE] revealed Resident #9 was at moderate risk for falls. Review of the current physician orders revealed orders for a fall mat next to the bed while the resident was laying in bed. Observations on 01/30/23 at 2:34 P.M. revealed Resident #9 was laying in bed without a fall mat in place to the floor. Observations on 01/31/23 at 7:52 A.M., 11:35 A.M., 2:36 P.M., and 2:44 P.M. revealed Resident #9 was laying in bed without a fall mat in place to the floor. Interview with Licensed Practical Nurse (LPN) #316 on 01/31/23 at 03:48 P.M. verified a fall mat was not in place while Resident #9 was in bed. Review of facility policy titled Fall Management Program Guidelines, dated 03/22, revealed to carry out any orders prescribed by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366365 If continuation sheet Page 4 of 12 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 366365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows at Bellevue 101 Auxiliary Drive Bellevue, OH 44811 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, resident and staff interview, and review of facility policy, the facility failed to ensure the physician followed up timely on dietitian recommendations for a resident with a significant weight loss. This affected one (#31) of one residents reviewed for nutrition. The facility census was 53. Residents Affected - Few Findings include: Review of Resident #31's medical record revealed an admission date of 03/09/22. Diagnoses included type II diabetes, dementia, hypertensive chronic kidney disease, atrial fibrillation, other symptoms and signs concerning food and fluid intake, weakness and metabolic encephalopathy. Review of the annual Minimum Data Set (MDS) assessment, dated 01/12/23, revealed Resident #31 was moderately cognitively impaired, required supervision for eating, experienced a significant weight loss, and was not on physician prescribed weight loss program. Review of a plan of care focus area, initiated 01/13/23, revealed Resident #31 experienced a significant weight loss. Interventions included provide diet, supplements, medications, adaptive equipment and snacks as ordered, offer encouragement and assistance with eating as needed and weigh as ordered. Review of current physician orders revealed Resident #31 was ordered a regular, mechanical soft, ground meat diet. In addition, Resident #31 was ordered Ensure pudding one time daily, Glucerna supplement two times daily and three snacks daily. Review of Resident #31's weights revealed on 07/01/2022, the resident weighed 106.6 pounds (lbs.). Resident #31's weights revealed on 12/03/2022, the resident weighed 97.4 lbs. On 01/09/2023, the resident weighed 92.4 pounds, indicating a 5.13% significant weight loss in one month and a significant weight loss of 13.32% in six months. Review of the Nutritional Quarterly/re-admission Observation, dated 01/13/23, revealed Resident #31 screened for malnutrition with advanced age, multiple medications, low body mass index (BMI), dementia and dysphagia. Resident #31's intakes were documented as good at 75% or more for 90% of meals, was on three supplements and three snacks daily and noted to accept those well also. It was recommended for Resident #31's diabetes medications to be evaluated to potentially reduce effects of weight loss. Review of a nursing progress note dated 01/16/23 revealed dietitian recommendations were printed and sent to the physician. Further review of progress notes from 01/16/23 through 01/30/23 revealed no evidence Resident #31's physician evaluated the resident's diabetes medications as recommended by the dietitian. Interview on 02/01/23 at 8:56 A.M. of the Director of Nursing (DON) revealed she discussed the dietitian's recommendations, made on 01/13/23, with Resident #31's physician on 01/31/23. The DON stated the physician was hesitant to make any changes to Resident #31's diabetes medications due to unstable blood sugar levels. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366365 If continuation sheet Page 5 of 12 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 366365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows at Bellevue 101 Auxiliary Drive Bellevue, OH 44811 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 02/02/23 at 10:28 A.M. of Medical Director (MD) #415 confirmed he did not address the dietitian recommendation to review Resident #31's diabetes medications until 01/31/23. MD #415 stated the problem was the recommendation was made but the facility did not send a list of Resident #31's medications for him to review. MD#415 stated he did not have access to or know how to access the resident's medications via the electronic medical record (EMR) and stated he had weekly meetings with the Administrator and would be discussing with her how to ensure he received needed information to follow up on recommendations timely. MD #415 stated he typically followed the dietitian recommendations and, while he was uncertain it would have an impact on the resident's weight, he was looking at making changes to one of Resident #31's diabetes medications. Interview on 02/02/23 at 11:38 A.M. of Resident #31 confirmed she was aware she had lost weight. Resident #31 stated she was provided enough to eat, consumed two nutritional supplements daily, had an ensure pudding each day and was provided multiple snacks daily, including peanut butter and jelly sandwiches, fruit, peanut butter crackers. Resident #31 attributed her weight loss to being retired and not being as active as she once was. Review of facility policy titled Nutritional Recommendation Guideline, reviewed 12/01/21, revealed the suggested discipline follows up on recommendation(s) in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366365 If continuation sheet Page 6 of 12 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 366365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows at Bellevue 101 Auxiliary Drive Bellevue, OH 44811 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and review of facility policy, the facility failed to properly store oxygen tubing and follow their policy to date oxygen tubing when put into use. This affected one (#13) of one resident reviewed for oxygen administration. The facility identified 10 residents who had orders for oxygen. The facility census was 53. Residents Affected - Few Findings include: Review of the medical record revealed Resident #13 admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia and unspecified asthma. Review of the Minimum Data Set (MDS) assessment, dated 01/02/23, revealed Resident #13 had severe cognitive impairment. Review of current physician's orders revealed orders for oxygen as needed for shortness of breath every four hours, change oxygen tubing monthly, and assess respiratory status twice daily. Observations on 01/30/23 at 12:19 P.M. revealed Resident #13's oxygen tubing was not dated and oxygen tubing draped across bed. Observations on 01/31/23 at 7:49 A.M. and 11:33 A.M. Resident #13 oxygen tubing noted to be undated and laying on the floor. Observations on 01/31/23 at 11:33 A.M. Resident #13 oxygen tubing noted to be undated and laying on Resident # 13's bed. Review of the facility policy titled Administration of Oxygen, dated 12/22, revealed oxygen tubing was to be changed monthly and dated. Interview with Licensed Practical Nurse (LPN) # 411 verified Resident #13 oxygen tubing was undated and not stored appropriately. LPN #411 verified the facility policy was to date tubing and and stored in a plastic bag attached to the oxygen concentrator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366365 If continuation sheet Page 7 of 12 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 366365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows at Bellevue 101 Auxiliary Drive Bellevue, OH 44811 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 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review, review of pharmacy delivery slips, and review of a facility policy, the facility failed to ensure the pharmacy sent resident medications to the facility as ordered. This affected one (#7) of five residents reviewed for unnecessary medications. The census was 53. Findings include: Review of Resident #7's medical record revealed an admission date of 04/10/22. Diagnoses included diabetes mellitus type II, anemia, hypokalemia, peripheral vascular disease, altered mental status, acute pulmonary edema, and COVID-19. Review of the most recently completed Minimum Data Set (MDS) assessment, dated 01/12/23, revealed Resident #7 was assessed with moderately impaired cognition. Review of a nursing progress note dated 12/31/22 revealed Resident #7 tested positive for COVID-19 with no abnormal lung sounds or shortness of breath exhibited. Review of a subsequent nursing progress note dated 12/31/22 revealed a new order was given for Resident #7 to receive the medication to treat COVID-19, Paxlovid. Review of a physician order dated 12/31/22 revealed Resident #7 was ordered Paxlovid 300 milligrams (mg)-100 mg three tablets twice daily. Review of the December 2022 medication administration record (MAR) revealed Resident #7 did not receive the ordered Paxlovid on 12/31/22 with a note documented on 12/31/22 at 8:48 P.M. stating the medication was not available. Review of the January 2023 MAR revealed Resident #7 did not receive Paxlovid as ordered on 01/02/23, on 01/03/23 in evening, or on 01/04/23 in the morning. Nurses documented in the comments on 01/02/23 at 9:03 A.M. and at 8:56 P.M., on 01/03/23 at 10:16 A.M., and on 01/04/23 at 8:39 A.M. that the medication was not available. Review of pharmacy delivery sheets dated 12/31/22 and 01/03/23 revealed no evidence of Resident #7's Paxlovid being sent to the facility. Review of nursing progress notes between 12/31/22 and 01/04/23 revealed Resident #7 remained asymptomatic of COVID-19 symptoms. Review of a nursing progress note dated 01/04/23 at 5:33 P.M. revealed Resident #7's Paxlovid was discontinued due to the medication not received from the pharmacy and Resident #7 was five days out from her positive COVID-19 test. Interview on 01/31/23 at 2:48 P.M. with Resident #7 stated when she had COVID-19 in the beginning of January 2023 she did not have any symptoms other than an occasional cough. Resident #7 stated she did not feel tired or experience any changes in her respiratory status. Resident #7 stated she felt she recovered from her COVID-19 infection and had no lasting effects from it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366365 If continuation sheet Page 8 of 12 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 366365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows at Bellevue 101 Auxiliary Drive Bellevue, OH 44811 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 Interview on 02/03/23 at 12:22 P.M. with Regional Clinical Support (RCS) #416 stated the pharmacy indicated Resident #7's Paxlovid was sent to the facility sometime between 12/31/22 and 01/04/23 but they did not have any delivery slips confirming that. RCS #416 stated the pharmacy received the order for Paxlovid on 12/31/22 and it should have been received in the facility the following day. RCS #416 stated the facility had pharmacy delivery slips from 12/31/22 and 01/03/22 and Resident #7's Paxlovid was not delivered on either of those days. Interview on 02/03/23 at 1:20 P.M. with Director of Nursing (DON) #332 stated the pharmacy told her Resident #7's Paxlovid was delivered to the facility on [DATE], but the facility did not have any record of it. DON #332 stated she reviewed the 12/31/22 pharmacy delivery slip and verified Resident #7's Paxlovid was not on the list. DON #332 confirmed the facility did not have any other pharmacy delivery slips between 12/31/22 and 01/04/23 other than what was provided. Review of a facility policy titled, Medication Ordering and Receiving from Pharmacy, revised November 2018, revealed medication orders are written on a medication order form provided by the pharmacy, written in the chart by the physician, electronic order, or written on a transfer order form and transmitted to the pharmacy. A licensed nurse or certified technician as permitted receives the medications delivered to the facility and documents that the delivery was received and verifies medications received with the medication order form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366365 If continuation sheet Page 9 of 12 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 366365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows at Bellevue 101 Auxiliary Drive Bellevue, OH 44811 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm Based on observation, staff interview, and medical record review, the facility failed to ensure residents were provided adaptive equipment during meals. This affected one (#34) of five residents observed eating meals in their room on the 100 Hall. The facility identified six residents in the facility with orders for adaptive eating equipment. The census was 53. Residents Affected - Few Findings include: Review of Resident #34's medical record revealed an admission date of 07/24/21. Diagnoses including anemia in chronic kidney disease, unspecified protein-calorie malnutrition, unspecified dementia, chronic kidney disease, facial weakness following cerebral infarction, and hemiplagia and hemiparesis. Review of the Minimum Data Set (MDS) assessment completed on 11/21/22 revealed Resident #34 was assessed with severely impaired cognitive skills for daily decision making and required limited assistance with eating. Review of a care plan dated 07/26/21 revealed a nutritional risk care plan with an intervention to provide diet, supplements, medications, and adaptive equipment as ordered. Review of a physician order dated 11/16/22 revealed Resident #34 was to have a plate guard for all meals on the right side of the plate for increased self feeding and decreased spillage. Observation on 01/31/22 at 12:25 P.M. revealed Resident #34 in her bed on the 100 Hall sitting up and awaiting lunch. Further observation revealed Resident #34 received her lunch tray from staff and was assisted with tray set up. Resident #34's plate contained beef brisket and french fries and no plate guard in place on Resident #34's plate. Observation on 01/31/22 at 12:32 P.M. revealed Resident #34 fed herself and ate her lunch with no plate guard in place. Interview on 01/31/22 at 12:40 P.M. with Stated Tested Nurse Aide (STNA) #313 stated she never saw Resident #34 with a plate guard to her meal plate and was not aware one was needed. Observation on 01/31/22 at 12:40 P.M. of Resident #34 eating in her room with STNA #313 verified Resident #34 did not have a plate guard in place and she was eating lunch in her room. Interview on 01/31/22 at 12:42 P.M. with Licensed Practical Nurse (LPN) #315 verified Resident #34 had a physician order for a plate guard for all meals, but stated she did not consistently work on Resident #34's hall so she was not aware how often, if ever, Resident #34 was given a plate guard. Observation on 01/31/22 at 12:45 P.M. with LPN #315 confirmed Resident #34 was eating in her room with no plate guard in place. Interview on 01/31/22 at 1:10 P.M. with [NAME] #341 stated the kitchen staff are made aware of all residents with order for adaptive eating equipment and keep a paper in the kitchen with what each resident required with meals. [NAME] #341 stated she knew Resident #34 was to have a plate guard in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366365 If continuation sheet Page 10 of 12 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 366365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows at Bellevue 101 Auxiliary Drive Bellevue, OH 44811 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 0810 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete place for all meals. [NAME] #341 stated the plate guard for Resident #34's plate was not put in place in the kitchen because Resident #34 ate in her room and the plate cover used for the hall trays would not fit over the plate if a plate guard was applied. [NAME] #341 stated Resident #34's plate guard should be applied after she was served her meal tray in her room. Review of a facility policy titled Meal Service, revised January 2023, revealed adaptive equipment is provided as ordered to aid an individual in feeding self when necessary. Items are included in the tray set up or during dining room service. Nursing will make final arrangement of the devices as part of the presentation. Dining service staff will deliver tray carts to each nurse's station and nursing staff will deliver and collect trays from individuals. Event ID: Facility ID: 366365 If continuation sheet Page 11 of 12 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 366365 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willows at Bellevue 101 Auxiliary Drive Bellevue, OH 44811 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 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observations and staff interviews, the facility failed to ensure furniture in living quarters was maintained in good condition. This affected one (#9) of one resident reviewed. The facility census was 53. Residents Affected - Few Findings include: Observations on 01/30/23 at 09:29 A.M. of Resident #9's room revealed the left door of the wardrobe had the wood grain laminate peeling off the door down the entire left side and hanging loosely from the door Interview with State Tested Nursing Assistant (STNA) #386 on 02/01/23 at 04:17 P.M. verified the wardrobe for Resident #9 had the laminate peeling off the door. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366365 If continuation sheet Page 12 of 12