Health inspection·April 24, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/23/24 at 1:28 P.M. with Regional Director of Clinical Services #613 verified staff were not to be on their personal phones and standing up while feeding residents. Review of the facility policy labeled, Telephones, Employee Use Of, dated July 2010, revealed cellular phones may be used for personal calls and text messaging only when the employee was on an authorized meal and/ or break. The employee cell phone would remain off and/ or silent during all other work hours. Review of the facility policy labeled, Assistance with Meals, dated July 2017, revealed residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents who cannot feed themselves would be fed with the attention to safety, comfort, and dignity including to not stand over residents while assisting them with meals and keeping interactions with other staff to a minimum. This deficiency represents non-compliance investigated under Master Complaint Number OH00152695 and Complaint Number OH00152624. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365708 If continuation sheet Page 2 of 7 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 365708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Woods Rehabilitation and Nursing 9625 Market Street North Lima, OH 44452 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility did not ensure a homelike environment was maintained on the Buckeye unit including ensuring the unit did not have a pervasive offensive odor. This had the potential to affect all 31 residents (#1, #6, #7, #9, #10, #11, #13, #15, #25, #26, #28, #33, #34, #39, #44, #47, #51, #52, #54, #55, #56, #57, #59, #60, #63, #66, #67, #68, #73, #76, and #77) residing on the Buckeye unit. Findings included: 1. Review of the medical record for Resident #68 revealed an admission date of 09/22/16 with diagnoses including schizoaffective disorder, chronic obstructive pulmonary disease, and diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 had intact cognition as his Brief Interview for Mental Status (BIMS) score was a 15 of 15. He required only set-up and/or clean-up assist with eating. Interview on 04/23/24 at 3:35 P.M. with Resident #68 revealed he ate his lunch in the dining room, and the smell that comes from the kitchen was sometimes really bad. He stated, it smells like vomit. 2. Review of the medical record for Resident #52 revealed an admission date of 07/06/21 with diagnoses including Tourette's disorder, schizoaffective disorder, diabetes, and dysphagia. Review of the quarterly MDS assessment dated [DATE] revealed Resident #52 had intact cognition as his BIMS score was 13 of 15. He required only set-up and/or clean-up assist with eating. Interview on 04/23/24 at 3:38 P.M. with Resident #52 revealed he ate in the Buckeye dining room, and there was a bad smell coming from the kitchen all the time. He stated, a bad, bad smell as he wrinkled up his nose. 3. Observation on 04/23/24 from 8:15 A.M. to 8:33 A.M. revealed an unpleasant smell on the Buckeye unit, including in the dining room. The smell appeared to be coming from the kitchen as it was located right next to the dining room. Observation on 04/23/24 from 8:33 A.M. to 8:46 A.M. of the kitchen revealed a strong offensive odor throughout the kitchen that resembled the smell of fecal matter/sour milk. The dishwasher was not running but there was a small sump pump (pump used to remove water) under the dishwasher that covered a circular drain. Observation revealed surrounding the circular drain was light greenish liquid material coming up from the drain approximately three feet in diameter. At 8:37 A.M. a large amount of greenish brown liquid material was pouring out of the drain by the dishwasher without the dishwasher running. The material covered the floor surrounding the dishwasher and was heading towards the tray line that was approximately 10 feet in diameter. Staff were observed walking through the material attempting to complete tray line. The material smelled like fecal matter. Interview on 04/23/24 at 8:29 A.M. with Dietary Aide #601 revealed they had an issue with the drain flooding for over a month. She stated the smell was worse than cow manure, and she was often sick (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365708 If continuation sheet Page 3 of 7 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 365708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Woods Rehabilitation and Nursing 9625 Market Street North Lima, OH 44452 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 with a headache and stomachache as she felt it was from the smell of the material coming out of the drain. Level of Harm - Minimal harm or potential for actual harm Interview on 04/23/24 at 8:33 A.M. with [NAME] #602 revealed the drain had been an issue for over a month and did not feel the facility was doing anything about it to correct the issue. She stated the drain poured all kinds of colors and nasty stuff. She verified there was a strong odor and stated, smells honestly like poop. Residents Affected - Some Interview on 04/23/24 at 8:36 A.M. with Cook/Dietary Aide #603 verified there was a strong odor in the kitchen and stated it smelled like, poop, vomit, and pee all mixed together as that was how bad it was. Interview on 04/23/24 at 9:35 A.M. with the Administrator revealed they had a plumbing contractor out, and they were going to start work on the issue on 05/02/24 or 05/03/24, but she had not seen the actual issue of the drain herself. She revealed she thought the kitchen was not utilizing the dishwasher and only using disposable dishes until they had the issue fixed. Observation of the kitchen and interview on 04/23/24 at 9:41 A.M. with the Administrator and Maintenance Director #605 revealed Cook/Dietary Aide #603 was standing in front of the dishwasher in greenish/brown material that continued to pour out from the drain under the dishwasher. The Administrator verified the smell was foul and strong as she described it as old food. The Maintenance Director #605 revealed he thought the drain was a main drain and that possibly the showers did drain into the kitchen drain. Interview on 04/23/24 at 10:22 A.M. with Activities/State Tested Nursing Assistant (STNA) #606 revealed the hall on the Buckeye unit, behind the kitchen where residents reside, had an offensive odor for about a month. Interview and observation on 04/23/24 at 11:17 A.M. with Maintenance Director #605 verified according to the blueprints, the drain under the dishwasher was a sewer sanitation pipe. Interview on 04/23/24 at 11:09 A.M. with STNA #608 revealed the kitchen was always flooding, and the Buckeye unit had a bad smell throughout the unit. Interview on 04/23/24 at 1:44 P.M. with Dietary Manager #614 revealed the kitchen flooded multiple times a day and verified the smell was awful as she described it like sewer throughout the kitchen and out of the kitchen onto the Buckeye unit. Interview on 04/24/24 11:38 A.M. Regional Director of Clinical Services #613 revealed the facility did not have a policy regarding homelike environment including prevention of pervasive offensive odors. This deficiency represents non-compliance investigated under Complaint Number OH00152636. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365708 If continuation sheet Page 4 of 7 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 365708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Woods Rehabilitation and Nursing 9625 Market Street North Lima, OH 44452 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 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 interview, observation, and review of facility policy the facility did not ensure the kitchen was maintained in a sanitary manner. This had the potential to affect all residents that resided at the facility except two residents (#53 and #72) identified by the facility as receiving no food from the kitchen. The facility census was 76. Findings include: Observation on 04/23/24 from 8:15 A.M. to 8:33 A.M. revealed an unpleasant smell on the Buckeye unit, including the dining room. The smell appeared to be coming from the kitchen. Observation on 04/23/24 from 8:33 A.M. to 8:46 A.M. of the kitchen revealed a strong offensive odor throughout the kitchen that resembled the smell of fecal matter/sour milk. The dishwasher was not running but there was a small sump pump (pump used to remove water) under the dishwasher that covered a circular drain. Observation revealed surrounding the circular drain was light greenish liquid material coming up from the drain approximately three feet in diameter. At 8:37 A.M. a large amount of greenish brown liquid material was pouring out of the drain by the dishwasher without the dishwasher running. The material covered the floor surrounding the dishwasher and was heading towards the tray line that was approximately 10 feet in diameter. Staff were observed walking through the material attempting to complete tray line. The material smelled like fecal matter. Interview on 04/23/24 at 8:29 A.M. with Dietary Aide #601 revealed they had an issue with the drain flooding for over a month. Most of the time they were not running any water in the kitchen, including the dishwasher and three compartment sink, but she felt when the unit was providing showers the water backed up into the kitchen. She verified the kitchen floor flooded daily including by the tray line and that they often had to walk/stand in it to complete the tray line. She stated the smell was worse than cow manure, and she was often sick with a headache and stomachache as she felt it was from the smell of the material coming out of the drain. Interview on 04/23/24 at 8:33 A.M. with [NAME] #602 revealed the drain had been an issue for over a month and did not feel the facility was doing anything about it to correct the issue. She stated the drain poured all kinds of colors and nasty stuff. She verified there was a strong odor and stated, smells honestly like poop. She cooked and served food while standing in the material as almost every day the kitchen flooded as material would just pour out of the drain. Interview on 04/23/24 at 8:36 A.M. with Cook/Dietary Aide #603 verified there was a strong odor in the kitchen and stated it smelled like, poop, vomit, and pee all mixed together as that was how bad it was. She stated it appeared when staff were providing showers on the unit, the drain would flood the kitchen, and it had been an issue for over a month. The material got all over the kitchen including where they prepared and served food as the sump pump was unable to keep up with the amount of dirty water coming from the drain. She revealed she had to stand in the material while she prepared and served the food and as she washed the dishes. Interview on 04/23/24 at 9:35 A.M. with the Administrator revealed they had a plumbing contractor out, and they were going to start work on the issue on 05/02/24 or 05/03/24, but she had not seen the actual issue of the drain herself. She revealed she thought the kitchen was not utilizing the dishwasher and only using disposable dishes until they had the issue fixed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365708 If continuation sheet Page 5 of 7 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 365708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Woods Rehabilitation and Nursing 9625 Market Street North Lima, OH 44452 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 0812 Level of Harm - Minimal harm or potential for actual harm Observation of the kitchen and interview on 04/23/24 at 9:41 A.M. with the Administrator and Maintenance Director #605 revealed Cook/Dietary Aide #603 was standing in front of the dishwasher in greenish/brown material that continued to pour out from the drain under the dishwasher. The Administrator verified the smell was foul and strong as she described it as old food. The Maintenance Director #605 revealed he thought the drain was a main drain and that possibly the showers did drain into the kitchen drain. Residents Affected - Many Interview on 04/23/24 at 10:22 A.M. with Activities/State Tested Nursing Assistant (STNA) #606 revealed the hall on the Buckeye unit, behind the kitchen where residents reside, had an offensive odor for about a month. Interview on 04/23/24 at 10:32 A.M. with the Administrator revealed she had spoken to the Regional Dietary Manager #619, and he had given Dietary Manager #614 the directive to only use Styrofoam and not use the dishwasher only the three compartments sink due to the drain overflowing, but that the dietary staff had not followed the directive. Interview and observation on 04/23/24 at 11:17 A.M. with the Maintenance Director #605 verified according to the blueprints, the drain under the dishwasher was a sewer sanitation pipe. Interview on 04/23/24 at 11:09 A.M. with STNA #608 revealed the kitchen was always flooding, and the Buckeye unit had a bad smell throughout the unit. Interview on 04/23/24 at 12:51 P.M. with Excavating Manager of Plumbing Company #611 revealed the drain did hook to a sewer line, but there was a P-trap (a trap consisting of a U-bend with the upper part of its outlet bent horizontally) to prevent the sewer gases from coming up. He verified using the dishwasher was causing the back up of water as the pipe needed replaced. He was unable to explain why the drain was pouring out material when no water was being used in the kitchen, including the dishwasher until they started digging up the floor. He revealed they were scheduled to start fixing the issue on 05/02/24 or 05/03/24. Interview on 04/23/24 at 1:44 P.M. with Dietary Manager #614 revealed the kitchen flooded multiple times a day, and she sent pictures to corporate of how bad the situation was. She revealed she worked in the kitchen and had to stand in a large amount of dirty water/waste material while she was preparing and serving food. She felt this was unsanitary but that it seemed like a waiting game as she did not feel Maintenance Director #605 was trying to properly fix the situation to serve food in a sanitary manner. She revealed she was concerned as they had items plugged in electrically, and standing in large amounts of water was a safety concern. She discussed her concern with Regional Dietary Manager #619 who gave her the directive to stop using the dishwasher and only use disposable utensils and dishware. She revealed at first, she did, but the issue continued without getting fixed and residents complained of cold food since they were being served on Styrofoam. She stopped using the Styrofoam and went back to utilizing the dishwasher. She did not feel it made a difference if she used the dishwasher or not as water poured out of the drain no matter if they did or did not. She verified that the smell was awful and described it like sewer throughout the kitchen and onto the Buckeye unit. She had dietary staff leaving sick because of the smell. Interview on 04/24/24 at 9:11 A.M. with Regional Dietary Manager #619 revealed he was notified approximately two and a half weeks ago of the drain overflowing and had given the directive to use disposable utensils/dishware and to stop utilizing the dishwasher. He had instructed them to use the three compartments sink as he felt the sump pump would be able to keep up if not utilizing a large (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365708 If continuation sheet Page 6 of 7 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 365708 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willow Woods Rehabilitation and Nursing 9625 Market Street North Lima, OH 44452 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many volume of water. He never had communicated with Dietary Manager #614 to stop utilizing the disposable dishware and had not realized they had stopped following his directive. He verified he had given the directive to shut down the kitchen and cater for all food when he was informed of the observation that had taken place on 04/23/24. The kitchen would remain closed, and they had a mobile kitchen on its way until the drain/pipe was fixed. He stated it was a sanitary concern especially since the drain was connected to a sewer pipe. Review of the facility policy labeled, Preventing Foodborne Illness- Food Handling, dated July 2014, revealed food would be served, prepared, handled, and serviced so that risk of foodborne illness was minimized. This deficiency represents non-compliance investigated under Complaint Number OH00152636. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365708 If continuation sheet Page 7 of 7