Health inspection·April 10, 2025

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 medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure call lights were within reach. This affected two (#11 and #33) of two residents reviewed for call lights. The facility census was 57. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #11 revealed diagnoses including encephalopathy, myocardial infarction, stage four chronic kidney disease, venous insufficiency, anxiety, bipolar disorder, depression, schizoaffective disorder, left knee effusion, history of falling, chronic pain, weakness, lymphedema, cardiac pacemaker, atrial fibrillation, communication deficit, and mild cognitive impairment. Review of the quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] for Resident #11 revealed she was a fall risk, had mild cognitive impairment, used a wheelchair, required supervision with transfers, and required assistance with toileting. Observation on 04/07/25 at 9:46 A.M. of Resident #11's room revealed she was unable to see or reach her call light. Resident #11 was sitting in her recliner next to her bed and the call light was tangled around the back of the bed handle. Subsequent interview with Graduate Resident Care Associate (GRCA) #406 confirmed Resident #11 could not see or reach her call light. 2. Review of the medical record for Resident #33 revealed diagnoses including congestive heart failure, heart disease, hypertension, disorientation, fall on the same level, and unsteady gait. Review of the quarterly MDS assessment dated [DATE] revealed Resident #33 was cognitively intact, used a manual wheelchair and required moderate assistance with transfers, bathing, and toileting. Observation on 04/07/25 at 9:42 A.M. of Resident #33's room revealed Resident #33 was sitting in her wheelchair in the center of her room. The bed was against the wall and the call light was tied to the bed handle on the wall side of the bed, out of her reach of the resident. Subsequent interview with Floor Technician #405 confirmed Resident #33 was not able to reach her call light. Observation on 04/09/25 at 10:07 A.M. of Resident #33's room revealed Resident #33 was sitting in her wheelchair at the side of her bed. The bed was against the wall and the call light was tied to the bed handle on the wall side of the bed, opposite the resident and out of the resident's reach. Subsequent interview with GRCA #409 confirmed Resident #33 was not able to reach her call light. Page 1 of 4 366365 366365 04/10/2025 Willows at Bellevue 101 Auxiliary Drive Bellevue, OH 44811

F 0558 Review of facility policy titled Guidelines for Answering Call Lights dated 12/17/24 indicated call lights would be placed within reach of residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 366365 Page 2 of 4 366365 04/10/2025 Willows at Bellevue 101 Auxiliary Drive Bellevue, OH 44811

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 medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure Resident #205 received oxygen at the correct rate as prescribed by the physician. This affected one (Resident #205) of one resident reviewed for respiratory care. The facility census was 57. Residents Affected - Few Findings include: Review of the medical record revealed Resident #205 was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure with hypoxia, acute kidney failure, heart failure, chronic kidney disease, chronic venous insufficiency (peripheral), type II diabetes mellitus, obstructive sleep apnea, dyspnea, hypoxemia, and weakness. Review of the admission Minimum Data Set assessment dated [DATE] identified Resident #205 was cognitively intact. The resident required some level of staff assistance for all activities of daily living and also received oxygen therapy. Review of the active physician orders for April 2025 identified an order dated 03/27/25 for continuous oxygen at two liters per nasal cannula. Review of the plan of care dated 03/27/25 revealed Resident #205 had the potential for complications, functional and cognitive status decline. Interventions included administering oxygen per orders. Review of the vital sign record for 03/27/25 through 04/06/25 revealed Resident #205 was receiving oxygen at three liters on 03/29/25 at 4:00 A.M., 04/01/25 at 4:03 A.M., 04/01/25 at 4:17 P.M., 04/02/25 at 7:38 A.M., 04/02/25 at 1:33 P.M., 04/02/25 at 3:43 P.M., 04/03/25 at 7:57 A.M., 04/03/25 at 7:59 A.M., 04/04/25 at 11:37 P.M., 04/06/25 at 6:31 A.M., 04/06/25 at 6:32 A.M., 04/06/25 at 9:13 A.M., and 04/06/25 at 10:53 A.M. During an observation on 04/07/25 at 10:40 A.M., Resident #205's oxygen concentrator was running at three liters per minute while Resident #205 was receiving the oxygen via nasal cannula. During an interview at the time of observation, Resident #205 reported they were supposed to receive two liters of oxygen per minute. During a follow-up observation on 04/07/25 at 11:28 A.M., Resident #205's oxygen concentrator was running at three liters per minute while Resident #205 was receiving the oxygen via nasal cannula. An interview on 04/10/25 at 8:23 A.M. with the Director of Nursing confirmed Resident #205 had a physician order for two liters of oxygen and did not have an order for three liters of oxygen. The Director of Nursing verified the oxygen for Resident #205 was being administered at three liters per minute via nasal cannula. Review of the facility policy titled Administration of Oxygen, dated May 2018, revealed physician orders would be verified when oxygen was administered. 366365 Page 3 of 4 366365 04/10/2025 Willows at Bellevue 101 Auxiliary Drive Bellevue, OH 44811

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of the facility policies, the facility failed to ensure food items stored in unit refrigerators were labeled and dated and further failed to ensure unit refrigerators did not contain expired food items. This had the potential to affect all 57 residents who received food from the kitchen. The facility census was 57. Findings include: Observation beginning on 04/07/25 at approximately 5:38 P.M. of the unit refrigerator located centrally between all resident units hallways with Registered Nurse (RN) #396 revealed the following concerns: In the refrigerator, there was one plastic container containing prunes which was dated 03/29/25, one plastic container containing potato soup which was dated 03/30/25, one plastic container containing grapefruit which was labeled 03/30/25, one container of prunes which was dated 03/31/25, one undated disposable container from a restaurant which contained fried chicken, two containers of pudding which expired in August 2024, and one unlabeled and undated container of cottage cheese which had been opened. Interview at the time of observation, with RN #396, confirmed the areas of concern. Additional observation and interview on 04/10/25 at 5:52 P.M. with Dietary Manager #344 further verified the areas of concern. Dietary Manager #344 verified prepared items should be disposed of within three days of being placed in the refrigerator. Review of the facility policy titled Food Brought Into Facility, dated 11/22/17, revealed the purpose of the policy was storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. The policy stated food brought in by family members, friends or gusts must be inspected by a staff member, properly labeled and dated, and stored and discarded in conjunction with the facility's Date [NAME] and Labeling policy and procedure. Review of the facility policy titled Food Safety and Handling, not dated, revealed prepared leftover food items must be discarded within three days and ready-to-eat potentially hazardous foods must be marked with the date of preparation and consumed or discarded within seven days (including he day of preparation). 366365 Page 4 of 4