01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2023-08-03 | 7 | 2023-08-03 | 3 |
| Cycle 2 | 2019-11-21 | 8 | 2019-11-21 | 1 |
| Cycle 3 | 2018-10-04 | 6 | 2018-10-04 | 11 |
CMS CCN 3653052026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Willoughby Post Acute
37603 Euclid Ave · Willoughby, OH 44094 · Lake County
Certified beds157CMS provider file
Recent citation rows36current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
36 rows in the current release
2 rows carry G–L scope/severity codes; 0 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-04-23 · HEALTHF0740Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Correction field: Deficient, Provider has date of correction · 2026-05-01 · complaint2025-10-22 · HEALTHF0697Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-10-31 · complaint2025-08-05 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-08-29 · complaint2025-08-05 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-08-29 · complaint2025-08-05 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-08-29 · complaint2025-08-05 · HEALTHF0921Severity F · widespread; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2025-08-29 · complaint2024-11-20 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-11-29 · complaint2024-11-20 · HEALTHF0725Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Correction field: Deficient, Provider has date of correction · 2024-11-29 · complaint2024-11-20 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-11-29 · complaint2024-11-20 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2024-11-29 · complaint2024-11-20 · HEALTHF0921Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2024-11-29 · complaint2024-09-16 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-09-20 · complaint2024-08-07 · HEALTHF0584Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Correction field: Deficient, Provider has date of correction · 2024-09-16 · complaint2023-08-03 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Past Non-Compliance · 2023-07-062023-08-03 · FIREK0222Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Correction field: Deficient, Provider has date of correction · 2023-08-212023-08-03 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2023-08-212023-08-03 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2023-08-212019-11-21 · HEALTHF0582Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Correction field: Deficient, Provider has date of correction · 2019-12-102019-11-21 · FIREK0741Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2019-12-102018-10-04 · FIREE0018Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Establish procedures for tracking staff and patients during an emergency.
Correction field: Deficient, Provider has date of correction · 2018-11-272018-10-04 · FIREE0022Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures for sheltering.
Correction field: Deficient, Provider has date of correction · 2018-11-272018-10-04 · FIREE0024Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures for volunteers.
Correction field: Deficient, Provider has date of correction · 2018-11-272018-10-04 · FIREE0034Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Provide a means of sharing information on occupancy/needs.
Correction field: Deficient, Provider has date of correction · 2018-11-272018-10-04 · FIREE0035Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Provide family notifications of emergency plan.
Correction field: Deficient, Provider has date of correction · 2018-11-2703 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-10-22 | Fine | $39,840 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- 37603 EUCLID AVE OH OWNER LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 12/01/2024
- SNF OH HOLDCO LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 12/01/2024
- WELL INTEGRA MASTER JV LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 12/01/2024
- WELL PM HOLDCO JV LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 12/01/2024
- APT, FREDERICKIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 12/01/2024
- JERGENSEN, JOSHUAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 12/01/2024
- MITCHELL, JOHNIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 12/01/2024
- APT, FREDERICKIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/01/2024
- JERGENSEN, JOSHUAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/01/2024
- MITCHELL, JOHNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/01/2024
- PACS GROUP, INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2024
- PACS HOLDINGS, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2024
- PROVIDENCE GROUP NH, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2024
- RAMACCIATO, AMARILYSIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2024
- WELLTOWER INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/01/2024
- WELLTOWER OP, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 12/01/2024
- MEHTA, DHARMESHIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/01/2024
- RAMACCIATO, AMARILYSIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/01/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours2.99per resident day
RN hours0.52per resident day
Weekend nurse hours2.68per resident day
Staff turnover43.9%CMS reported field
06 / LOCAL RECORDS
Open the Willoughby ledger →