Inspection·October 7, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a physician order start date of 09/27/25 revealed Resident #49 may go out on a leave of absence with supervision. Review of an Elopement Review dated 09/27/25 revealed Resident #49 was high risk for elopement with an elopement score of 10. Review of an Elopement Review assessment dated [DATE] revealed Resident #49 was ambulatory and had predisposing diagnosis of paranoid schizophrenia and bipolar disorder. Mental status was cognitively intact, and Resident #49 was responsive to redirection and cues. Resident #49 had an elopement episode in the past three months on 09/27/25. There was no medical cause increasing confusion, there was no psychological cause. Resident #49 was moved to secure unit. Review of a Medical Visit assessment , dated 10/01/25 , written by Physician Assistant (PA) #371, revealed Resident #49 had a recent elopement. Resident #49 was seen on 10/01/25 after she had eloped over the weekend. PA #371 assessed Resident #49 as alert , and in no distress. Resident #49 stated to PA #371 she left to inquire about moving to another facility next door. Resident #49 denied current desire to leave the facility. Review of plan of care, revision date 09/27/25, revealed Resident #49 was at risk for elopement due to impaired cognition and competence. Intervention included reside on a secured unit. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or a book. Identify pattern of wandering, divert as needed and intervene as appropriate. Leave of absence with supervision was updated. Review of the facility document titled Witness Statement Form, dated 09/27/25, written by certified nurse assistant (CNA) #373 revealed she came out of room one on the Buckeye unit and heard the back door alarm go off. CNA #373 walked down the hall to check the door, and did not see anyone outside, therefore CNA #373 turned off the alarm. CNA #373 thought the wind set the alarm off. The last time CNA #373 saw Resident #49 was 4:50 A.M. Review of the facility document titled Witness Statement Form, dated 09/27/25 at 5:30 A.M., written by CNA #311 revealed they did not witness the incident but assisted with the return of Resident #49 to the facility. Review of the facility document titled Witness Statement Form, dated 09/27/25 at 5:30 A.M., written by Licensed Practical Nurse (LPN) #322 revealed the last time Resident #49 was seen was 5:00 A.M. exiting her room and standing in the hallway near the vending machine on the Buckeye Unit. Review of facility document titled , Resident Leave of Absence Log, on 09/27/25, revealed Resident #49 did not sign out at 5:00 A.M. to leave the facility . Resident #49 ' s sister signed Resident out on 09/27/25 at 10:24 A.M. and Resident #49 returned to the facility on [DATE] at 3:22 P.M. An interview on 10/06/25 at 9:55 A.M. with Housekeeper #339 revealed Resident #49 got out of the facility and was gone for 20 minutes without staff realizing Resident #49 was gone. A staff member silenced the alarm and did not report the door alarm went off. An interview on 10/06/25 at 10:00 A.M. with CNA # 359 revealed Resident #49 left the facility early one morning. Resident #49 was known to wander. An interview on 10/06/25 at 10:15 A.M. with Central Supply #362 revealed Resident #49 got out of a locked door at the end of the Buckeye unit. The alarm sounded but the aid did not notify the nurse and a head count was not done. Resident #49 walked to another facility when Resident #49 was found. An interview on 10/06/25 at 10:25 A.M. with Resident #26 revealed Resident #49 got out of the building and ended up at another facility. An interview on 10/06/25 at 10:30 A.M. with Licensed Practical Nurse (LPN) #306 revealed Resident #49 got out of the building through a fire door. An interview on 10/06/25 at 10:45 A.M. with Resident #49 verified she went out the door at the end of the Buckeye unit after she pushed the door open. Resident #49 stated she heard the alarm go off, and no staff were around her when she left the facility out the door while the alarm was sounding. Resident #49 stated they did not like me on the road without a vehicle. An observation on 10/06/25 at 10:50 A.M. of the Buckeye Unit revealed it was a locked unit which required pass code for any staff member or resident to leave or enter the unit from other areas of the facility. At (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365708 If continuation sheet Page 2 of 4 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 10/07/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the end of the long hall there was an exit door that led outside to the side of the building. The door was not in view of the nurse station or the dining room on the Buckeye unit. This door which Resident #49 exited out of to the outside of the facility could be opened after pressing on the door for 15 seconds, as it was a fire door exit. The door would emit a loud alarm to alert staff and the alarm would need to be shut off by staff to stop the alarm sound. An interview on 10/06/25 at 12:03 P.M. with Physician Assistant #371 revealed Resident #49 was not safe to be outside the facility unsupervised. An interview on 10/06/25 with Resident #49 ' s Guardian #372 revealed Resident #49 was smart enough to hold the door handle for 15 seconds to exit the facility. Guardian #372 stated she was notified Resident #49 got out of the facility, a staff member heard an alarm but did not see anybody outside so they turned off the alarm. Guardian #372 stated they were told that Resident #49 was last seen on 09/27/25 at 5:00 A.M. and was found at the other facility at 5:20 A.M. An observation on 10/06/25 at 12:15 P.M. with Maintenance Director (MD) #333 revealed the Buckeye Unit long hall exit door alarm sounded when pushed on the handle for 15 seconds and opened to the outside. Once outside there was a crossroad leading to another nursing facility on the property. MD #333 stated Resident #49 walked approximately 75 feet to the other facility traveling up a slight hill that graded upward. There was car traffic observed driving down the street to reach the facility. An interview on 10/06/25 at 12:50 P.M. with the Administrator revealed Resident #49 went from this facility to another facility without staff knowledge until the other facility called to see if the facility was missing a resident. CNA #373 was fired because they did not follow protocol and did not respond properly when the door alarm sounded. The Administrator stated corrective action had been put into place to ensure there would be no further incidents. Review of the facility policy titled Elopements, revised December 2007, revealed staff shall investigate and report all cases of missing residents. Staff shall promptly report any resident who tried to leave the premises to the charge nurse or the director of nursing. When the departing resident returns to the facility the DON would examine for injuries, notify the attending physician, notify legal guardian, complete and file incident report and document the event in the medical record. Review of the facility policy titled Signing Residents Out, dated August 2006, revealed all residents leaving the facility must be signed out. Staff observing a resident leaving the premises and having doubts about the resident being properly signed out, should notify their supervisor at once. Restrictions noted on the residents chart concerning who may not sign the resident out must be honored. As a result of the incident, the facility took the following corrective actions starting 09/27/25: On 09/27/25 the Administrator directed LPN #322 to move resident #49 to fully secured unit, after notifying the physician and responsible party. On 09/27/25 a root cause analysis was conducted by the Administrator, [NAME] President of Operations (VPO) #378, the DON , and Regional Director of Clinical Services (RDCS) #379. VPO #378 educated the Administrator and the DON on elopement and wandering resident policy and best practice, leave of absence policy, abuse policy, supervision of residents policy, and change in condition policy.On 09/27/25, Ad-hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator , the DON, Medical Director #374, Activities Director #356, Transportation Director #370, Dietary Manager #327, Staffing Coordinator #362, and Business Office Manager #301. Reviewed root cause analysis and corrective action. The Administrator educated those in attendance on elopement and wandering resident policy and best practice, leave of absence policy, abuse policy, supervision of residents policy, and change in condition policy.On 09/27/25, the DON and Assistant Director of Nursing (ADON) #314 reviewed and updated elopement assessments for all residents (71 of 71 residents).On 09/27/25 the Activities Director #356 and Business Office Manager #301 updated BIMS assessments for 71 of 71 residents. On 09/27/25, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365708 If continuation sheet Page 3 of 4 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 10/07/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete the DON and ADON #314 reviewed and updated, if needed, elopement care plans for 71 of 71 residents. On 09/27/25 the staffing coordinator #362 completed door checks of all facility exit doors.On 09/27/25 the DON reviewed and updated elopement binders. Resident #1, #2, #5, #13, #17, #20, #22, #27, #28, #38, #72, #43, #49, #58, #62, #70 were identified as elopement risk and verified information was in the Elopement binder. On 09/27/25 the Administrator updated door codes on all facility exit doors.On 09/27/25 the Staffing Coordinator #362, Dietary Manager #327, Transportation Director #370, and the Administrator initiated staff education on elopement and wandering resident policy and best practice, leave of absence policy, abuse policy, supervision of residents policy, and change in condition policy. 71/71 staff educated. The Agency Nurse Company was provided with an education on elopement and leave of absence policy and procedure and a quiz for all incoming agency aids to the facility.On 09/27/2 the Administrator conducted elopement drills on afternoon shift and day shift. ADON #314 completed/will complete one elopement drill on each shift weekly for four weeks then one elopement drill on rotating shifts monthly for three months and randomly thereafter beginning 09/27/25 and ending 02/27/26. The DON would complete audits of documentation for change in condition five times a week and randomly thereafter beginning 09/29/25 and ending 10/24/25. The Administrator completed/will complete audits of bed boards for change in leave of absence five times a week for four weeks and randomly thereafter beginning 09/29/25 and ending 10/24/25.At the time of the survey completed on 10/07/25, there were no further incidents of non-compliance identified related to hazards/accident risk. This deficiency represents non-compliance investigated under Complaint Number 2633309. Event ID: Facility ID: 365708 If continuation sheet Page 4 of 4