Health inspection·June 13, 2019

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record reviews and staff interviews, the facility failed to ensure a physician was notified when a residents pressure ulcer increased in size. This affected one one (#43) out of five residents reviewed for pressure ulcers. The facility identified a total of five residents with pressure ulcers. Facility census was 66. Findings include: Review of Resident #43's medical record identified admission to the facility occurred on 04/30/13 with medical diagnosis including paraplegia (since 1970's) related to a motorcycle accident, panic with agoraphobia, neurogenic bladder with catheter, diabetes, high blood pressure and history of pressure ulcers with osteomyelitis. The quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #43 is alert, oriented and cognitively intact and high risk for pressure ulcer development. The record included a written plan of care, dated 05/21/19, for pressure ulcer interventions. The plan including the development of a pressure ulcer to the right hip and to notify the physician if treatments were not effective. Observation of Resident #43's right hip pressure ulcer was completed on 06/12/19 at 10:45 A.M. with Registered Nurse (RN) #103. The wound is observed as a stage II pressure ulcer and was measured by the wound nurse 1.8 centimeters (cm) by 1.8 cm by 0.1 cm. RN #103 confirmed she did notify the physician today and the treatment was changed. Review of Resident #43's progress notes dated 05/20/19 at 11:04 A.M. identified a pressure ulcer to the right hip was noted. The wound was measured to be a Stage II Pressure Ulcer: Partial-thickness skin loss with exposed dermis presenting as a shallow open ulcer. The measurements on 05/20/19 identified 0.3 cm by 0.5 cm by 0.1 cm at that time, with a new order for cleaning with house wound cleanser and apply house wound gel every other day. Review of the treatment administration record (TAR) confirmed the wound was treated as ordered. Wound notes dated 05/22/19, identified the right hip wound measured 1.0 cm by 0.8 cm by 0.1 cm and continued to be a stage II. The TAR confirmed no changes in treatments were completed. Wounds notes dated 05/29/19 identified the right hip measured 1.2 cm by 1.0 cm 0.1 cm and continued to be a stage II. The records identified no notification to the physician and or change in the treatment of the wound. Page 1 of 6 365769 365769 06/13/2019 Willows at Willard The 1050 Neal Zick Road Willard, OH 44890

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Wound notes dated 06/05/19 identified the right hip wound measured 1.3 cm by 1.2 cm 0.1 cm and continued to be a stage II. The notes identified no notification to the physician and change in the treatment of the wound. Review of the TAR from 05/20/19 through 06/07/19 identified the facility was uses dermal cleanser and Gel solosite (house supplies) every other day during this time; however, there was no evidence of physician notification of decline in wound measurements and or changes made to the wound treatments. Interview with RN #103 on 06/11/19 at 1:21 P.M. The interview confirmed there was not evidence of physician notification and/or change in treatments to Resident #43' right hip from 05/20/19 through 06/08/19 even though the wound was deteriorating/increasing in size during that time. 365769 Page 2 of 6 365769 06/13/2019 Willows at Willard The 1050 Neal Zick Road Willard, OH 44890

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and staff interviews, the facility failed to ensure the ombudsman was notified when residents were discharged to the hospital. This affected three (#43, #46 and #68) out of three residents reviewed for hospitalization. Facility census was 66. Findings include: 1. Review of Resident #43's medical record revealed the resident was admitted to the facility on [DATE]. Diagnosis include paraplegia. The record identified Resident #43 required hospitalizations on 02/17/19 through 02/22/19; 02/27/19 through 03/03/19; 04/02/19 through 04/07/19. The record identified evidence the resident was provided with written evidence of notification of the reason for each of the transfers; however, there was no evidence of notification to the ombudsman. 2. Review of Resident #46's medical record revealed the resident was admitted to the facility on [DATE]. Diagnosis include dementia. The record identified Resident #46 went to the hospital on [DATE] through 03/25/19. The Discharge summary dated [DATE] confirmed the family was notified; however, no information was provided to the ombudsman. 3. Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE]. Diagnosis include end stage renal disease. The record identified Resident #68 was transferred to the hospital on [DATE] and remained in the hospital until 03/24/19 when the resident passed away. The record review revealed the family received notification of the hospital; however, there was no notification to the ombudsman completed. Interview with the Director of Nursing (DON) occurred on 06/11/19 09:21 A.M. The interview confirmed the ombudsman notification was not completed for Resident #43, Resident #46 and Resident #68 all of whom went to the hospital. 365769 Page 3 of 6 365769 06/13/2019 Willows at Willard The 1050 Neal Zick Road Willard, OH 44890

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record reviews and staff interviews, the facility failed to ensure a resident received a change in treatment and/or the physician was notified when a residents pressure ulcer increased in size. This affected one one (#43) out of five residents reviewed for pressure ulcers. The facility identified a total of five residents with pressure ulcers. Facility census was 66. Residents Affected - Few Findings include: Review of Resident #43's medical record identified admission to the facility occurred on 04/30/13 with medical diagnosis including paraplegia (since 1970's) related to a motorcycle accident, panic with agoraphobia, neurogenic bladder with catheter, diabetes, high blood pressure and history of pressure ulcers with osteomyelitis. The quarterly minimum data set (MDS) assessment dated [DATE] identified Resident #43 is alert, oriented and cognitively intact and high risk for pressure ulcer development. The record included a written plan of care, dated 05/21/19, for pressure ulcer interventions. The plan including the development of a pressure ulcer to the right hip and to notify the physician if treatments were not effective. Observation of Resident #43's right hip pressure ulcer was completed on 06/12/19 at 10:45 A.M. with Registered Nurse (RN) #103. The wound is observed as a stage II pressure ulcer and was measured by the wound nurse 1.8 centimeters (cm) by 1.8 cm by 0.1 cm. RN #103 confirmed she did notify the physician today and the treatment was changed. Further review of Resident #43's progress notes dated 05/20/19 at 11:04 A.M. identified a pressure ulcer to the right hip was noted. The wound was measured to be a Stage II Pressure Ulcer: Partial-thickness skin loss with exposed dermis presenting as a shallow open ulcer. The measurements on 05/20/19 identified 0.3 cm by 0.5 cm by 0.1 cm at that time, with a new order for cleaning with house wound cleanser and apply house wound gel every other day. Review of the treatment administration record (TAR) confirmed the wound was treated as ordered. Wound notes dated 05/22/19, identified the right hip wound measured 1.0 cm by 0.8 cm by 0.1 cm and continued to be a stage II. The TAR confirmed no changes in treatments were completed. Wounds notes dated 05/29/19 identified the right hip measured 1.2 cm by 1.0 cm 0.1 cm and continued to be a stage II. The records identified no notification to the physician and or change in the treatment of the wound. Wound notes dated 06/05/19 identified the right hip wound measured 1.3 cm by 1.2 cm 0.1 cm and continued to be a stage II. The notes identified no notification to the physician and change in the treatment of the wound. Review of the TAR from 05/20/19 through 06/07/19 identified the facility was uses dermal cleanser and Gel solosite (house supplies) every other day during this time; however, there was no evidence of physician notification of decline in wound measurements and or changes made to the wound treatments. 365769 Page 4 of 6 365769 06/13/2019 Willows at Willard The 1050 Neal Zick Road Willard, OH 44890

F 0686 Level of Harm - Minimal harm or potential for actual harm Interview with RN #103 on 06/11/19 at 1:21 P.M. The interview confirmed there was not evidence of physician notification and/or change in treatments to Resident #43' right hip from 05/20/19 through 06/08/19 even though the wound was deteriorating/increasing in size during that time. Residents Affected - Few 365769 Page 5 of 6 365769 06/13/2019 Willows at Willard The 1050 Neal Zick Road Willard, OH 44890

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure staff completed daily range of motion (ROM) exercises as directed by therapy. This affected one (#48) of one resident reviewed for range of motion services. The facility census was 66. Findings Include: Review of Resident #48's medical record review revealed an admission date of 6/13/13. Diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, and flaccid hemiplegia affecting left non-dominant side. Review of Resident #48's Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment and upper extremity impairment on one side. Review of Resident #48's care plan dated 05/15/19 revealed the resident required a resting soft hand splint. The nurse to apply and provide ROM before and after. Review of Resident #48's physician order dated 12/28/16 revealed an order for a resting soft hand splint to left hand on in the evening and off in the morning. Review of Resident #48's Treatment Administration Record (TAR) dated June 2019 revealed an order for resting soft hand splint to left hand on every evening and off in the morning. Review of Resident #48's restorative care program recommendation completed by Occupational Therapy dated 01/05/17 revealed a recommendation for bilateral upper extremities active ROM in all planes times 15 repetitions two to three times per week. Wear the resting hand splint through the night. Monitor skin on left upper extremity in splint area. The record review revealed the restorative care program had not been implemented and there was no documentation regarding providing Resident #48 with ROM services. Interview on 06/11/19 at 2:58 P.M. with Registered Nurse (RN) #34 verified there is no documentation of the staff completing ROM for Resident #34's left hand as directed per therapy. RN #34 also verified the facility did not have a written program for the staff to be directed. Interview on 06/11/19 3:15 P.M. with State Tested Nursing Assistant (STNA) #5 verified she does not complete upper extremity ROM exercises for Resident #48. STNA #5 verified there was no ROM task in the electronic care tracker to direct the staff to complete ROM exercises. Interview on 06/11/19 at 3:36 P.M. with Certified Occupational Therapy Assistant (COTA) #109 stated Resident #48 stated a restorative program was written for the resident upon discharge from therapy services. Review of facility policy titled Restorative Mobility Program dated 05/15/16 revealed the facility should determine resident specific needs to enhance mobility by analyzing the assessments and communication with direct caregivers. 365769 Page 6 of 6