Inspection·November 22, 2023

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, resident interviews, and staff interviews the facility failed to maintain a clean, safe, sanitary and well-maintained environment. This had the potential to affect all residents. The facility census was 83. Findings Include: Interview on 11/19/23 at 8:05 A.M. with Housekeeper (HKPR) #744 revealed the facility was cleaned daily but she was the only housekeeper working and the housekeeping department was extremely short staffed. HKPR #744 revealed she tried to get to as many rooms as she could during her shift. An environmental tour was conducted on 11/19/23 between 8:25 A.M. and 8:40 A.M. with Nursing Supervisor (NS) #839. The following was observed and verified at the time of discovery: • Carpeted areas throughout the entire facility (hallways and common areas) including unit Zone #1, #3, #5, #6, #7, and #9 were noted with noticeable instances of stains, debris, and other unknown substances. • The room occupied by Resident #22 and #58 was noted to have food crumbs, dirt, debris, and various stains. • The room occupied by Resident #71 was noted to have food crumbs, used napkins, dirt, debris, and various stains. • The room occupied by Resident #17 and #45 was noted to have food crumbs throughout the room. • The room occupied by Resident #67 and #81 was noted to have various stains on the floor. (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 2 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 11/22/2023 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)