Health inspection·November 25, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Nursing (DON). The root cause was determined to be the staff member not following protocol for the resident lift and lack of supervision. VP of Operations #575 and VP of Clinical Services #576 provided education to the Administrator and DON on the following topics: transfer assistance, supervision of residents, call light availability, mechanical lift usage, change in condition, dignity, and facility abuse and neglect policy.Review of the witness statement dated [DATE] authored by Registered Nurses (RNs) #537 and #539 and CNAs #507, #512, #521, #523, #524, and #566 revealed CNA #567 placed Resident # 62 in a Sara Steady lift and left the resident standing there alone while she went to find help. CNA #567 was gone approximately four to five minutes according to witness statements. Resident #62 was found slumped over the Sara Steady bar, absent of vital signs, with bloody bowel movement noted. Resident #62 was placed in bed, and CPR was initiated. The resident was then transferred to the hospital. CNA #567 was immediately removed from her duties.Review of the hospital paperwork dated [DATE] revealed Resident #62 was transferred to the hospital by the local fire department. Personnel arrived at the facility at 6:38 P.M. and assisted nurses with ongoing CPR. The ambulance arrived at the facility at 6:42 P.M. and initiated compressions with the use of the LUCAS machine. Ambulance crew administered epinephrine and intubated the resident. A pulse was detected, and the resident was transferred to the local hospital by ambulance at 7:07 PM. with diagnoses including cardiac arrest. On [DATE], the resident expired after family withdrew care. Time of death was 10:06 P.M. The cause of death of was bilateral pneumonia versus massive aspiration or combination of these possibilities. Interview with RN #539 on [DATE] at 11:44 A.M. revealed at approximately, 6:15 P.M. on [DATE] report was given between RNs for shift change. They heard someone yelling for help. RNs #539 and #537 grabbed the crash cart and responded to Resident #62's room. Upon entering the room, Resident #62 was in the Sara Steady lift. CNAs were present in the room upon their arrival. Resident #62 was unresponsive, absent of vital signs. Resident #62's code status was checked and verified to be Full Code. Staff placed the resident in bed, called Code Blue, started CPR, called 911. The local fire department assumed CPR upon arrival. The resident regained a pulse and was transported to the local hospital. CNA #567 was immediately suspended and not left unattended; RN # 539 sat with her while she wrote a witness statement, and she was sent home directly after.Interview with CNA #512 [DATE] at 2:49 P.M. CNA # 567 called my phone for help with Resident #62 in the Sara Steady because she wouldn't stand. I told CNA #567 I would be down to help. I walked down to the other hallway and I called CNA 567 three times, and I couldn't find her. I walked into Resident #62's room and found her slumped over the Sara Steady bar with a bloody bowel movement and immediately called for help from the other staff. Resident #62 was moved to the bed, CPR was started.Review of the manufacture's guidelines for the Sara Steady Lift explicitly state that a resident must never be left unattended in the Sara Steady lift. The device is an aid for transfers and supported standing, not a seating device for long periods. A trained caregiver must always be present and maintain control of the device during the entire transfer process and any period the resident is in the Sara Steady. The Sara Steady is designed for safe and active sit-to-stand transfers (e.g., to/from a chair, bed, or toilet) and as a supportive aid for tasks like changing incontinence pads, not for unassisted seating or transportation for long distances/periods. The warning labels on the equipment specifically state: To prevent falls, never leave the patient unattended in the Sara Steady.Review of the undated manufacturer's guidelines revealed constant supervision by a trained caregiver must always be present and maintain control of the device during the entire transfer process and any period the resident is in the Sara Steady.- Intended Use: The Sara Steady is designed for safe and active sit-to-stand transfers (e.g., to/from a chair, bed, or toilet) and as a supportive aid for tasks like changing incontinence pads, not for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365708 If continuation sheet Page 2 of 3 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 11/25/2025 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete unassisted seating or transportation for long distances/periods.- Fall Prevention: The warning labels on the equipment specifically state: To prevent falls, never leave the patient unattended in the Sara Steady.Patient Participation: The device is intended for use by residents who can bear some weight on at least one leg, have some upper body strength, and can actively participate in the standing process by pulling themselves up with the support of the handlebars.- Caregiver Training: Use of the equipment requires a caregiver trained in following the instructions for use and in assessing the resident's condition and capabilities before each use.- Failing to follow these guidelines could result in serious injury or falls for the resident. The deficient practice was corrected on [DATE] when the facility implemented the following corrective actions: - On [DATE] at 7:20 P.M. LPN #524 notified Resident #62's son of the transport to the hospital. He reported that he had just spoken to the hospital.- On [DATE] at 7:30 P.M. LPN #524 notified Medical Director #578 of Resident #62's transfer to the hospital.- On [DATE] at 8:19 P.M. CNA #567 was suspended pending investigation.- On [DATE], all staff were immediately educated by the DON on transfer assistance, supervision of residents. Call light availability, mechanical lift usage, change in condition, dignity, and facility abuse and neglect policy.- On [DATE] at 9:00 am-9:30 A.M. the DON reviewed the clinical documentation for the past 72 hours to ensure all changes in condition were addressed.- On [DATE] from 10:30 A.M. to 10:55 A.M. an Ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, DON, Assistant Director of Nursing (ADON) #576, Medical Director #578, Activities Director #557, Staffing Coordinator #561, Business Office Manager #503, Human Resources (HR) Director #545, Wound RN #528, Social Services Director (SSD) #514. The root cause analysis was reviewed and corrective action taken. The Administrator educated those in attendance on transfer assistance, supervision of residents, call light availability, mechanical lift usage, change in condition, dignity and facility abuse and neglect policy.- On [DATE], Activity Director #557 and Wound RN #528 completed interviews of all residents with a BIMS greater than 12 and assessments of all residents with a BIMS score of 12 or lower to ensure freedom of abuse, neglect, and misappropriation. - On [DATE], the DON and ADON #576 reviewed and updated transfer status orders for all residents, reviewed and updated care plans as necessary for transfer status for all residents, and reviewed and updated Kardex and Point of Care tasks as necessary for transfer status for all residents.- On [DATE] from 10:56 A.M. to 11:45 A.M. SSD #514 completed an observational audit to ensure all residents' call lights were within reach in room and residents were treated with dignity and respect.- On [DATE], the DON completed an audit to ensure all nurses had valid CPR training. - On [DATE], competencies were initiated by Regional Director of Clinical [NAME] #577 and CNA Supervisor #561to ensure all nursing staff is competent utilizing lifts. Competencies will be completed prior to the next scheduled shift. - Beginning [DATE] the Administrator/designee will complete observational audits and interviews with five residents a week for four weeks and randomly thereafter to ensure no abuse/neglect allegations and that call lights are within reach through [DATE].- Beginning [DATE], the DON/designee will complete an audit of documentation for change in condition an new admissions to ensure appropriate care planning, orders, assessments and interventions for resident transfer status five times a week for four weeks and randomly thereafter though [DATE].- Beginning on [DATE], the Administrator/designee will complete observational audits and interviews with five residents a week for four weeks and randomly thereafter to ensure residents are being transferred appropriately through [DATE]. This deficiency represents noncompliance investigated under Master Complaint Number 2667747 and Complaint Number 2667167. Event ID: Facility ID: 365708 If continuation sheet Page 3 of 3