Inspection visit
Inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 6
Event ID:
365769
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
365769
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willows at Willard The
1050 Neal Zick Road
Willard, OH 44890
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365769
If continuation sheet
Page 2 of 6
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
365769
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willows at Willard The
1050 Neal Zick Road
Willard, OH 44890
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365769
If continuation sheet
Page 3 of 6
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
365769
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willows at Willard The
1050 Neal Zick Road
Willard, OH 44890
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 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.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365769
If continuation sheet
Page 4 of 6
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
365769
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willows at Willard The
1050 Neal Zick Road
Willard, OH 44890
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 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
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365769
If continuation sheet
Page 5 of 6
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
365769
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/13/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willows at Willard The
1050 Neal Zick Road
Willard, OH 44890
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 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.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365769
If continuation sheet
Page 6 of 6
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F688 - Mobility
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.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the June 13, 2019 survey of WILLOWS AT WILLARD THE?
This was a inspection survey of WILLOWS AT WILLARD THE on June 13, 2019. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WILLOWS AT WILLARD THE on June 13, 2019?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.