Health inspection·August 9, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of a policy, the facility failed to ensure fall interventions were in place as ordered and care planned. This affected one (#21) of three residents reviewed for falls. The facility census was 68. Findings include: Review of Resident #21's medical record revealed admission to the facility occurred on 12/24/18. Resident #21 had medical diagnoses including Alzheimer's disease, high blood pressure, and repeated falls. Review of Resident #21's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had severe impaired cognition, was independent with mobility in a wheelchair, and was a high risk for falling with recent falls identified. Review of Resident #21's medical record revealed a fall risk plan of care dated 01/04/19 with interventions including a sign on the bedside stand to remind to use the call light to get up, place a Dycem (non-slip pad) to the wheelchair and recliner, and a non-skid mat in front of the recliner. Review of Resident #21's physician orders also included the fall interventions that were listed in the plan of care. Observation of Resident #21's room on 08/09/23 at 9:48 A.M. with Registered Nurse (RN) #23 confirmed there was no Dycem in Resident #21's wheelchair or recliner, no non-skid mat in front of the recliner, and no sign posted on the bedside table. RN #23 confirmed Resident #21's physician orders and plan of care included the fall interventions that were not in place at the time of the observation. Observation of Resident #21's room with the Director of Nursing and RN #23 on 08/09/23 at 10:33 A.M. revealed RN #23 located the Dycem at the nursing station and placed it in Resident #21's wheelchair and recliner. The facility attempted to locate the non-skid mat that should be in front of Resident #21's recliner, and Resident #21 did not have any signs posted on the bedside stand. Review of the facility fall policy and procedure, dated 03/16/22, revealed care plan intervention should be implemented that address the resident risk factors. This deficiency represents non-compliance investigated under Complaint Number OH00144930. Page 1 of 2 365769 365769 08/09/2023 Willows at Willard The 1050 Neal Zick Road Willard, OH 44890

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of a facility policy, the facility failed to ensure medications were stored in a safe and secure manner. This affected two (100 and 300) of three hallway medication carts observed. This had the potential to affect 48 (#1, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #29, #30, #31, #32, #37, #39, #40, #41, #42, #43, #44, #45, #47, #48, #49, #51, #52, #53, #54, #55, #56, #57, #61, #62, and #63) residents who resided on the 100 and 300 hallways. The facility census was 63. Findings include: 1. Observation on 08/09/23 at 8:03 A.M. revealed a medication cart on the 300 hallway was sitting in the hallway with a cup of liquid medication on top of the cart. The cart and medication were unattended by any staff members. The medication cart was observed to have Licensed Practical Nurse (LPN) #22's name badge sitting next to the cup of liquid medication on top of it. On 08/09/23 at 8:05 A.M., Registered Nurse (RN) #23 approached the medication cart and confirmed the presence of the full cup of liquid medication sitting on the medication cart. RN #23 confirmed staff should not leave any medications unattended, and removed the medication to dispose of it. 2. Observation on 08/09/23 at 8:37 A.M. revealed a medication cart on the 100 hallway sitting just outside room [ROOM NUMBER]. The medication cart was unlocked with no staff in the area. Observation on 08/09/23 at 8:45 A.M. revealed RN #21 was located on the unit. Interview with RN #21 at that time confirmed she left the medication cart unlocked and unsecured on the 100 hallway. RN #21 confirmed the medication cart should be locked at all times when not attended as to prevent unauthorized access. Review of the facility medication storage policy dated November 2018 revealed the medication supply is accessible only to licensed facility personnel and those lawfully authorized to administer medications, and medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. This deficiency represents non-compliance investigated under Complaint Number OH00144930. 365769 Page 2 of 2