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. 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 2 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 08/09/2023 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)