Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Willoughby Post Acute
WILLOUGHBY, OH · 157 certified beds · Last Life Safety survey August 3, 2023
CMS Certification Number 365305 · first certified May 1974
Ownership
Operated by PACS GROUP · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within OH
15 citations — more than 44% of the 922 certified nursing homes in OH. Compared within OH rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (March 2025 to March 2026), and past the point by which nine in ten OH facilities have been surveyed. This facility’s last Life Safety survey was August 2023. Facilities in OH are typically surveyed 20–32 months after the last one (median 26), measured over 889 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
5 of the 15 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0584 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.
How that compares
Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 15 |
| Median facility in OH | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 4, 2018 | 11 |
| November 21, 2019 | 1 |
| August 3, 2023 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2023-08-03 |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | 1 | 2018-10-04 |
| E-0034 | Provide a means of sharing information on occupancy/needs. | 1 | 2018-10-04 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2019-11-21 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2018-10-04 |
| E-0035 | Provide family notifications of emergency plan. | 1 | 2018-10-04 |
| E-0024 | Establish policies and procedures for volunteers. | 1 | 2018-10-04 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2018-10-04 |
What the citations cover
- Smoke Deficiencies 5
- Emergency Preparedness Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Miscellaneous Deficiencies 1
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 5 |
| Emergency Preparedness Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
| Services Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 3, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (August 21, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 21, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 21, 2023) |
November 21, 2019 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (December 10, 2019) |
October 4, 2018 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (November 27, 2018) |
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (November 27, 2018) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (November 27, 2018) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (November 27, 2018) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (November 27, 2018) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 27, 2018) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (November 27, 2018) |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | Deficient, Provider has date of correction (November 27, 2018) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 27, 2018) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (November 27, 2018) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (November 27, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.