Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willoughby Post Acute during CMS and state inspections, most recent first.
A resident with major depressive disorder, anxiety, and multiple psychotropic medications had documented moderately severe depression on PHQ-9 and MDS assessments, along with care plans that listed psychiatrist consults and social services visits only "as indicated." Although the resident had signed consent for psychological services and family sent a text to the social worker reporting that the resident was very depressed, talking about making very bad decisions, and requesting therapy, no referral was made and there is no evidence the resident was ever seen by behavioral health providers. In the weeks before the event, the resident reported increased anxiety and received PRN Hydroxyzine on multiple days without clear documentation of the indication, and no behaviors were charted. The situation culminated when the resident ingested antifreeze in an apparent suicide attempt, telling staff he did not want to be alive anymore, demonstrating the facility’s failure to provide necessary behavioral health care and services.
A resident admitted for respite care with hospice services suffered a fall resulting in leg fractures, but did not receive timely pain assessment or intervention. Despite exhibiting severe pain behaviors throughout the night, staff failed to document pain assessments, offer or administer pain medication, or notify hospice until the following day. The resident's injuries were only identified after a hospice nurse intervened and ordered an x-ray, leading to hospital transfer.
Surveyors found that carpeting throughout the facility's hallways was heavily stained and discolored, with multiple large black and brown stains observed in various locations. Despite routine cleaning, the Environmental Service Manager and Administrator confirmed the stains persisted due to the age of the carpeting, and no active plans or quotes for replacement were in place. This failure did not meet the facility's policy for providing a clean and comfortable environment.
The facility did not keep an area free from accident hazards and failed to provide adequate supervision, resulting in an increased risk of accidents for residents.
A resident was not protected from a significant medication error due to a failure in the medication administration process.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility was found to have insufficient staffing levels, with a one-star staffing rating and low weekend staffing. Interviews with CNAs and residents revealed that due to staff call-offs, residents were not checked and changed every two hours, and some did not receive scheduled showers. Residents reported delays in staff responding to call lights and inconsistent bathing, especially on weekends.
The facility failed to properly clean and sanitize rooms before admitting new residents, as observed in a room claimed to be deep cleaned but found with personal items and dirt. The Housekeeping Supervisor acknowledged past concerns and temporary solutions, while a resident's daughter reported a dirty room upon admission. The facility's cleaning policy was not followed, leading to this deficiency.
A facility failed to collect a urinalysis for a resident as ordered by a physician. The resident, who had type two diabetes and other conditions, was noted to have worsening confusion and anxiety, prompting a stat urinalysis order. The urinalysis was delayed, and subsequent orders for a straight catheterization were not documented as completed. The DON confirmed the failure to collect the urinalysis and the lack of documentation explaining the omission.
A resident received incorrect medication due to a failure in following the facility's medication administration policy. The resident, who was cognitively intact and had a history of heart-related conditions, was mistakenly given another resident's medication, including a blood pressure pill and a multivitamin. The error was not documented, and the nurse involved initially denied the mistake. The facility's policy on the Five Rights of medication administration was not followed, leading to this deficiency.
A medication error occurred when a nurse administered a blood pressure pill and a multivitamin intended for another resident to a cognitively intact resident with multiple health conditions. The error was not documented in the resident's medical record, and there was no physician notification or new orders recorded. The resident's daughter witnessed the error, and the facility's policy on medication administration was not followed.
A resident with secondary parkinsonism did not receive their antiparkinsonian medication, Rytary, as prescribed, leading to significant medication errors. The medication was often administered late, and on one occasion, two doses were given together. The DON confirmed the issue, noting that nurses might not have been recording administration times accurately, which violated the facility's policy.
The facility failed to maintain a clean and homelike environment for two residents, as evidenced by spider webs and a black substance under the sink in a resident's room. Despite a grievance from a resident's family and photo evidence, the issues remained unaddressed, as confirmed by a survey and the Maintenance Director. This deficiency was investigated under a specific complaint number.
Failure to Provide Behavioral Health Services for Depressed Resident Leading to Suicide Attempt
Penalty
Summary
The deficiency involves the facility’s failure to ensure that necessary behavioral health services were provided to a resident with significant mental health diagnoses and documented depressive symptoms. The resident was admitted with multiple medical and psychiatric diagnoses, including major depressive disorder, generalized anxiety disorder, and alcohol abuse, and had signed a supplemental admission agreement granting permission to receive psychological services. Physician orders included multiple psychotropic medications for depression, anxiety, and agitation, as well as an order for staff to record behavior monitoring each shift using a defined numerical behavior scale. A PHQ-9 assessment in early January showed a score of 15, indicating moderately severe depression with recommended treatment actions including pharmacotherapy with psychotherapy, and the quarterly MDS documented a total mood severity score of 15 with little interest in activities and poor appetite over most of the lookback period. Despite these findings and the resident’s psychiatric diagnoses, the care plan only listed psychiatrist consults and social services visits as "as indicated" and there is no evidence in the record that psychological or psychiatric services were actually provided during the resident’s stay. The DON confirmed that the resident had signed permission to receive psychological services and that the resident did not receive such services while in the facility. The social worker acknowledged receiving a text message from the resident’s son reporting increased depression and requesting some kind of therapy, stating the resident was very depressed and talking about making very bad decisions, and asking if someone could talk him through continuing therapy. The social worker did not make a referral for psychological services and could not provide evidence that the resident was ever seen or evaluated by behavioral health providers. In the weeks preceding the incident, the resident reported increased anxiety related to financial worries, leading to a 14-day PRN order for Hydroxyzine, which was administered on eight days during that period. Nursing documentation did not specify whether the Hydroxyzine was given for anxiety or itching, and no behaviors were documented on the MAR or in corresponding progress notes. On the day of the incident, the resident’s son called the facility after receiving a goodbye call from the resident. Staff found the resident alert with a bright yellow substance on his gown and bedding, an open bottle of antifreeze on the bedside table in an open Amazon box, and the resident admitted to putting antifreeze in a coffee cup and drinking it, stating he could not get a gun and that he did not want to be alive anymore. The resident and his son both reported prior expressions of wanting to harm himself and worsening depression in the weeks leading up to the suicide attempt. The facility’s own behavioral health services policy stated that residents exhibiting signs of emotional or psychosocial distress would receive services and support to address their needs, but the resident did not receive behavioral health services despite documented depression, anxiety, and family-reported concerns.
Failure to Provide Timely Pain Assessment and Intervention After Fall
Penalty
Summary
A deficiency occurred when a resident admitted for respite care with hospice services experienced a fall resulting in displaced fractures of the left tibia and fibula. Despite the fall, there was no evidence of a pain assessment at admission or after the incident. The resident was found on the floor by an LPN, who documented no apparent injuries and did not complete a pain assessment or notify hospice of the fall. Throughout the night following the fall, the resident exhibited significant distress, including screaming, crying, and aggression, yet there was no documentation of pain assessments, offers or refusals of pain medication, or notification to hospice regarding the resident's deteriorating condition. The resident's pain escalated, and it was not until a hospice visit the following day that swelling, bruising, and inability to bear weight on the left knee were observed. The hospice nurse notified the facility, and an x-ray was ordered, which later confirmed the fractures. The medication administration record showed no pain medication was offered, refused, or administered until nearly 24 hours after the fall, despite the resident's ongoing and escalating pain. Interviews with staff confirmed a lack of pain assessment, inadequate documentation, and failure to notify hospice in a timely manner. Facility policy required pain assessment at admission and during changes in condition, but this was not followed. The resident was eventually transferred to the hospital after the fractures were identified, but there was no documentation of the transfer, pain assessment at discharge, or communication of x-ray results to hospice. The failure to provide timely and adequate pain assessment and intervention following the fall resulted in actual harm to the resident.
Failure to Maintain Clean and Sanitary Carpeting in Facility Hallways
Penalty
Summary
The facility failed to maintain the carpeting in the hallways of all units in a clean and sanitary condition, as observed during multiple walkthroughs. Surveyors noted that the carpeting throughout the facility was discolored and contained numerous black and brown stains of varying sizes in multiple locations, including near double doors, entrances to resident rooms, lounge areas, elevator lobbies, and outside utility rooms. These findings were confirmed during an environmental tour with the Environmental Service Manager and the Administrator, who both acknowledged the presence of extensive staining and discoloration. Interviews with the Environmental Service Manager revealed that while routine cleaning was performed by a floor technician, the age and condition of the carpeting prevented effective removal of the stains. The Environmental Service Manager was aware of the issue but was unsure if any steps had been taken to obtain quotes or initiate the process for carpet replacement. The Administrator also confirmed that no quotes had been obtained and no active plans were in place to replace the carpeting. Review of the facility's policy indicated that residents were to be provided with a safe, clean, comfortable, and homelike environment, which was not met in this instance.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Insufficient Staffing Levels
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by a review of the Payroll-Based Journal (PBJ) Staffing Data Report and interviews with residents and staff. The facility, with a census of 132 residents, was found to have a one-star staffing rating and excessively low weekend staffing for the fiscal year quarter 3 of 2024. The facility's assessment indicated a certified bed capacity of 157, with an average daily census of 19.4 for short stays and 105.4 for long stays. Despite this, the staffing levels on specific dates were below the required levels, with licensed nurses at 1.05 and nurse aides at 1.4 on one day, and licensed nurses at 1.05 and nurse aides at 1.29 on another day. Interviews with Certified Nursing Assistants (CNAs) and residents revealed that due to staff call-offs, residents were not being checked and changed every two hours, and some did not receive their scheduled showers. Residents reported that it could take up to an hour for staff to respond to call lights, and showers and bathing were not consistently provided, particularly on weekends. The facility's administrator confirmed that corporate staff reviewed the actual staff punches used to submit the PBJ. This deficiency was investigated under Complaint Number OH00158759.
Failure to Properly Clean and Sanitize Rooms Before New Admissions
Penalty
Summary
The facility failed to ensure that rooms were appropriately cleaned and sanitized before admitting new residents, which had the potential to affect all new admissions. During an interview, the Housekeeping Supervisor stated that rooms are supposed to be deep cleaned within 24 hours of a resident's discharge. This deep cleaning process includes removing all trash, packing the former resident's belongings, emptying and cleaning drawers and closets, and cleaning all surfaces. However, observations revealed that a room, which was claimed to be deep cleaned and ready for a new admission, contained a white brief, oxygen tubing, a used urinal with dried urine, and a collection canister with dried urine in the nightstand. Additionally, another observation of the same room showed potato chips and crumbs in the nightstand drawer, large dust piles behind the stand, and dry drips of fluid on the stand, indicating that the cleaning process was not thoroughly completed. The Housekeeping Supervisor acknowledged that there had been previous concerns about rooms not being deep cleaned before new admissions, and attempts to rotate housekeepers to address the issue were only temporarily effective. An interview with a resident's daughter revealed that upon admission, the room appeared dirty, with unclean floors and personal items from another resident still present in the drawers and closet. The facility's policy on routine cleaning, which aligns with CDC recommendations and OSHA standards, was not adhered to, leading to this deficiency. The report indicates that this issue was investigated under a specific complaint number.
Failure to Collect Urinalysis as Ordered
Penalty
Summary
The facility failed to collect a urinalysis for a resident as per the physician's orders. The resident, who was cognitively intact, had a diagnosis of type two diabetes mellitus, hydronephrosis, weakness, and retention of urine. The resident was dependent on toileting and frequently incontinent of urine. A Certified Nurse Practitioner noted worsening confusion and anxiety in the resident and ordered a urinalysis to be sent stat. However, the urinalysis was not collected until three days later, and the results showed mixed flora, preventing a sensitivity test. Subsequently, a new physician order was issued to perform a straight catheterization for a urinalysis with culture and sensitivity, but there was no documentation that this was completed. The Director of Nursing confirmed that the urinalysis was not collected as ordered and that there was no documentation explaining why it was not done. This deficiency was identified during an investigation under a specific complaint number.
Medication Error Due to Incorrect Administration
Penalty
Summary
The facility failed to administer the correct medication to a resident, resulting in a medication error. The incident involved a resident who was cognitively intact and had a medical history including endocarditis, heart failure, hypertension, vascular dementia, and weakness. On the day of the error, the resident was mistakenly given another resident's medication, which included a blood pressure pill and a multivitamin. The error was not documented in the resident's medical record, and there was no record of physician notification or any new orders regarding the error. The Director of Nursing (DON) confirmed the lack of documentation and acknowledged that the Registered Nurse (RN) involved did not record the names of the medications administered in error. The resident's daughter witnessed the error and reported that the nurse initially denied the mistake but later admitted it after reviewing the records. The daughter noted that the incorrect medications given included sodium bicarbonate, colace, norvasc, and simethicone. The facility's policy on medication administration emphasizes the importance of the Five Rights, including the right resident and right drug, which were not adhered to in this case. The deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's medication administration policy.
Failure to Document Medication Error and Notify Physician
Penalty
Summary
The facility failed to document a medication error involving a resident who was cognitively intact and had diagnoses including endocarditis, heart failure, hypertension, vascular dementia, and weakness. The error occurred when a registered nurse administered a blood pressure pill and a multivitamin intended for another resident to this resident. The incident was not documented in the resident's medical record, and there was no record of physician notification or any new orders following the error. The Director of Nursing confirmed the lack of documentation and acknowledged that the nurse involved did not record the names of the medications administered in error. The resident's daughter witnessed the error and reported that the nurse initially denied the mistake but later admitted it after reviewing the records. The daughter noted the medications given in error were sodium bicarbonate, colace, norvasc, and simethicone. Despite the error, the resident's blood pressure was monitored, and no abnormal readings were observed. The facility's policy on medication administration emphasizes the importance of the Five Rights, including verifying the right resident and medication, which was not adhered to in this case.
Failure to Administer Antiparkinsonian Medication Timely
Penalty
Summary
The facility failed to administer an antiparkinsonian medication, Rytary, as ordered by the prescriber, resulting in a significant medication error for Resident #118. The resident, who was admitted with diagnoses including hereditary spastic paraplegia and secondary parkinsonism, was prescribed Rytary to be taken four times daily. However, a review of the medication administration record from August to September 2024 revealed multiple instances where the medication was administered late. Specific instances included doses being given several hours after the scheduled time, and on one occasion, two doses were administered together instead of separately. Interviews conducted with Resident #118 and the Director of Nursing (DON) confirmed the medication administration issues. The resident expressed concerns about the late administration of his medication, which was supposed to be given four times a day. The DON acknowledged the findings and suggested that nurses might not have been signing off on medication administration at the actual time it was given, contrary to the facility's policy. The facility's policy required medications to be administered within 60 minutes of the scheduled time and recorded immediately after administration. This deficiency was investigated under Complaint Number OH00157103.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for two residents, as observed during a survey. Resident #134, who had diagnoses including congestive heart failure, anemia, hypertension, hyperlipidemia, and glaucoma, was noted to have intact cognition according to a Minimum Data Set 3.0 assessment. A grievance was logged by the family of Resident #134, expressing concerns about the cleanliness of the resident's room, specifically mentioning spider webs on the window sill and a black substance under the sink. Photos submitted by the family corroborated these claims, showing spider webs and an exposed sink pipe with a black substance on the wall and under the sink counter. During the survey, the room previously occupied by Resident #134 and currently occupied by Resident #109 was inspected, revealing that the spider webs and black substance were still present, confirming the family's concerns. The Maintenance Director verified these findings, acknowledging that the issues had not been addressed. The facility's policy on routine cleaning, which aligns with CDC recommendations, was reviewed, indicating a failure to adhere to these standards. This deficiency was investigated under Complaint Number OH00155736.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Willoughby
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ohio Living Breckenridge Village | 1 mi | ★★★★★ | 1 | 0 |
| Kirtland Woods Of Journey | 3.6 mi | ★★★★★ | 16 | 0 |
| Mentor Ridge Health And Rehabilitation | 3.6 mi | ★★★★★ | 6 | 0 |
| Mentor Hills Post Acute | 3.7 mi | ★★★★★ | 0 | 0 |
| Wickliffe Country Place | 4.1 mi | ★★★★★ | 3 | 0 |
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