Willoughby Post Acute

In the surveyor’s words

From the most serious findings on record at Willoughby Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF686May 7, 2021

  Based on observation, review of medical records, the facility policy and procedure for skin management, interviews with residents and staff, and interview with Nurse Practitioner (NP) Wound Nurse #621, the facility failed to implement a comprehensive and effective pressure ulcer prevention program to prevent and identify pressure ulcers in a timely manner for Resident's #22, #31, #72, #87 and #102. This resulted in Immediate Jeopardy that was Actual Harm on 03/12/21 when Resident #31, who was a quadriplegic and required two-staff assist with bed mobility and transfers was found with an unstageable (full thickness skin or tissue loss, depth unknown as wound is obscured by slough or eschar) pressure ulcer to his left buttock described with 100 percent slough to the wound bed, a Stage 3 (full… […]

• Actual harm, isolatedF697Oct 22, 2025

  Based on closed record review, policy review and interview, the facility failed to provide adequate and timely pain assessment and interventions following a fall with acute injury. This affected one resident (#148) of three residents reviewed for pain. The facility census was 146. Actual Harm occurred on 09/25/25 when Resident #148 was diagnosed with displaced fractures of the left lower leg bones (tibia and fibula) from a fall that had occurred on 09/24/25. Resident #148, who was admitted to the facility on [DATE] for respite care with hospice services was not adequately assessed or provided timely pain interventions following the fall on 09/24/25. […]

• Actual harm, isolatedF689Aug 3, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review and interview the facility failed to ensure Resident #49 was transferred safely between the bed and the wheelchair. Actual harm occurred on 07/02/23 when Resident #49 began complaining of pain in her right leg after her leg got caught between her bed and wheelchair during a staff assisted transfer. X-ray results dated 07/04/23 indicated Resident #49 had a right tibia and fibula fracture. The facility investigation determined this injury was caused from the staff assisted transfer. This affected one resident (#49) of six residents reviewed for accident hazards. […]

• Actual harm, isolatedF677May 1, 2023

  Based on observation, interview, record review and review of facility policy, the facility failed to ensure physician orders were followed, and care planned interventions for oral care were implemented for Resident #109, Resident #112, and Resident #126, and failed to ensure Resident #12, #29 and #94 were provided proper incontinence care timely Actual Harm occurred on 03/19/23 at 4:19 P.M. when Resident #126, who exhibited moderate cognitive impairment and required extensive staff assistance for personal care was assessed (by hospital staff upon transfer from the facility) to have poor oral/denture condition. The resident's upper dentures were stuck in place and coated in thick, white yellow mucous and coating. Resident #126 had dryness of the mouth, dry, cracked lips, teeth, and tongue. […]

• Actual harm, isolatedF686May 1, 2023

  Based on observation, record review, facility policy and procedure review, and interview, the facility failed to ensure interventions were implemented to prevent and timely identify the development of Resident #125's pressure ulcer and/or to ensure adequate treatments for Resident #47 were in place to promote healing. Actual Harm occurred on 02/21/23 when Resident #125, who required extensive assistance from two staff for bed mobility, developed a new, in-house acquired deep tissue injury (purple or maroon localized area of discolored, intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to the sacrum without evidence of adequate preventive interventions including turning and repositioning. […]