F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to ensure Resident #67's central line intravenous
catheter dressing was changed per the physician order. This affected one (Resident #67) of one resident
reviewed for intravenous access.
Residents Affected - Few
Findings include:
Review of Resident #67's medical record revealed she was readmitted to the facility on [DATE] with
diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease and
essential hypertension. Review of Resident #67's Minimum Data Set (MDS) 3.0 assessment dated [DATE]
revealed Resident #67 exhibited intact cognition.
Review of Resident #67's physician orders revealed an order dated 12/05/22 to change the central line
catheter dressing weekly and as needed.
Review of Resident #67's medication administration records (MARS) from 01/01/23 to 01/10/23 revealed
Licensed Practical Nurse (LPN) 975 documented she completed the central line catheter dressing on
01/06/23.
Observation on 01/09/23 at 9:13 A.M. with Registered Nurse (RN) #814 of Resident #67's central line
catheter dressing located in her right chest wall revealed the dressing was dated 12/31/22.
Interview on 01/09/23 at 9:15 A.M. with RN #814 confirmed the dressing was dated 12/31/22 and was not
changed per the physician orders.
Interview on 01/11/23 at 12:49 P.M. with the Director of Nursing (DON) confirmed Licensed Practical Nurse
(LPN) #975 documented she changed Resident #67's central line catheter dressing on 01/06/22
inaccurately.
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 3
Event ID:
365785
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
365785
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willowood Care Center of Brunswick
1186 Hadcock Rd
Brunswick, OH 44212
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation and interview the facility failed to serve meals at a palatable temperature. This had
the potential to affect 89 of 90 residents who ate meals served from the kitchen. Resident #64 received
nothing by mouth.
Residents Affected - Many
Findings include:
Interview on 01/09/23 at 9:26 A.M. with Resident #57 revealed the food was not hot and you don't get a hot
meal on weekends.
Interview on 01/09/23 at 9:49 A.M. with Resident #63 revealed the food was cold.
Interview on 01/09/23 at 10:10 A.M. with Resident #27 revealed food was terrible and cold.
Interview on 01/09/23 at 10:16 A.M. with Resident #86 revealed the food was sometimes good and
sometimes bad.
Interview on 01/09/23 at 10:38 A.M. with Resident #82 revealed breakfast was always late and cold.
Observation on 01/10/23 at 11:48 A.M. revealed the meal tray line started. A test tray was conducted on
01/10/23 at 12:37 P.M. with Registered Dietitian (RD) #917. The meal tray consisted of a pork chop,
stuffing, sliced zucchini, roll and a carton of milk. The food temperatures were obtained using a digital
thermometer which revealed the pork chop was 118 degrees Fahrenheit (F), the stuffing was 138 degrees
F, sliced zucchini was 122 degrees F, and the carton of milk was 46.7 degrees F. The zucchini and stuffing
tasted warm and the pork chop was lukewarm.
Interview on 01/10/23 at 12:42 P.M. with the RD #917 confirmed the pork chop was lukewarm and the
carton of milk should have been maintained at 41 degrees F or below when served. RD #917 stated the
facility purchased a plate warmer but it was not large enough to hold all the plates needed for resident
meals and this could have caused some of the food temperature loss.
Interview on 01/10/23 at 2:06 P.M. with Dietary Manager #874 revealed he was aware of resident concerns
related to cold food and had spoken with the facility about obtaining more covered food delivery carts.
.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365785
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
365785
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Willowood Care Center of Brunswick
1186 Hadcock Rd
Brunswick, OH 44212
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation and interview the facility failed to maintain the dish machine in working order. This
affected all residents who received meals from the facility. The facility identified one resident (Resident #64)
who did not receive meals from the kitchen. The facility census was 90.
Findings include:
Observation on 01/09/23 at 8:42 A.M. with Registered Dietitian (RD) #917 revealed the facility's low
temperature dish machine did not meet the proper sanitation level. The two five-gallon drums of sanitizing
chemicals with tubing leading to the dish machine were empty.
Review of the January 2023 dish machine temperature and sanitation log located near the dish machine
revealed it was not consistently being completed.
Interview on 01/09/23 at 8:44 A.M. with RD #917 confirmed the low temperature dish machine did not meet
the proper sanitation level. RD #917 stated she was unsure how long the dish machine sanitation drums
had been empty. RD #917 was unable to locate additional sanitizing chemicals to replace the empty
five-gallon drums.
Interview on 01/10/23 at 8:58 A.M. with Dietary Manager #874 revealed he was unsure how long the dish
machine sanitizing chemicals had been out.
Interview on 01/10/23 at 2:06 P.M. with Dietary Manager #874 revealed he was unaware the dish machine
temperatures were not being recorded consistently.
Review of the facility infection control logs revealed no concerns related to gastro-intestinal illness.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365785
If continuation sheet
Page 3 of 3
