Willoughby Post Acute
Inspection Findings
F-Tag F0697
F 0697 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
assessments, pain interventions, medication offers or refusals and confirmed she did not contact hospice regarding the resident's condition during the night. Interview on 10/16/25 at 2:35 P.M. with the Director of Nursing (DON) verified Resident #148 had pain following the fall on 09/24/25 as noted in the nursing progress note on 09/25/25 at 6:44 A.M. and in a hospice note on 09/25/25 at 11:16 A.M. The DON verified there were no documented offers or refusals of pain medication, no facility attempts to obtain pain medication and no pain medication provided to the resident until 09/25/25 at 3:40 P.M. The DON stated she recalled seeing the resident's ankle and it was swollen but the DON denied remembering if the resident was acting like he was in pain. Interview on 10/21/25 at 11:48 A.M. with CNA #211, who worked night shift
on 09/24/25, revealed Resident #148 screamed once during the night when the CNA staff changed him early in the shift, and she believed it was because he was stiff. When she changed him again later she did not remember him yelling out but reported when the resident screamed the nurse came in to see what was wrong because Resident #148's room was right across from the nurse's station. Review of the nursing schedule for September 2025 revealed two additional staff members, CNA #212 and #213, worked while Resident #148 was at the facility. CNA #212 failed to return the surveyor's call and CNA #213 was no longer an employee and had no working telephone number. Review of the facility policy, Pain Assessment and Management, dated 2001, revealed the facility assessed residents for pain at admission and during ongoing assessments, and monitored residents for the presence of pain and the need for further assessment when there was a change of condition. This deficiency represents non-compliance investigated under Complaint Number 2636783.
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Willoughby Post Acute in WILLOUGHBY, OH inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WILLOUGHBY, OH, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Willoughby Post Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.