Cycle 1
Health 2023-08-03 · Fire 2023-08-03
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Willoughby, OH
Willoughby Post Acute
3-star overall rating with 2-star inspections with $52,600 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
37603 Euclid Ave, Willoughby, OH
(440) 951-5551
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
157
Certified beds
Average residents
140
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1974-05-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.75
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.04
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.73
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
2.94
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,897
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.27
Baseline 21.69% · Performance 19.47% · Measure score 4.27 · Achievement 4.24 · Improvement 4.27
Healthcare-associated infections
3.31
Baseline 5.36% · Performance 6.84% · Measure score 3.31 · Achievement 3.31 · Improvement 0
Total nurse turnover
2.56
Baseline 63.72% · Performance 53.23% · Measure score 2.56 · Achievement 2.56 · Improvement 2.20
Adjusted total nurse staffing
0
Baseline 3.27 hours · Performance 3 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.87% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 167 · Observed rate 8.98% · Lower 95% interval 7.25% |
| Discharge to community | 54.84% |
50.57%
4.3 pts better
|
No Different than the National Rate · Eligible stays 183 · Observed rate 48.63% · Lower 95% interval 48.29% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.88% |
95.27%
3.6 pts better
|
Numerator 88 · Denominator 89 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 89 |
| Discharge self-care score | 42.37% |
53.69%
11.3 pts worse
|
Numerator 25 · Denominator 59 |
| Discharge mobility score | 35.59% |
50.94%
15.3 pts worse
|
Numerator 21 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 89 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.84% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 112 · Observed rate 6.25% · Lower 95% interval 4.02% |
| Staff COVID-19 vaccination coverage | 0.83% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 120 |
| Staff flu vaccination coverage | 10.91% |
42%
31.1 pts worse
|
Numerator 18 · Denominator 165 |
| Discharge function score | 40.68% |
56.45%
15.8 pts worse
|
Numerator 24 · Denominator 59 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 39 · Denominator 39 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 39 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 28.21% |
25.2%
3 pts better
|
Numerator 11 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
92.4%
1.2 pts worse
|
93.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 93.8% · Q3 87.8% · Q4 88.7% · 4Q avg 91.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.8% |
94.5%
1.3 pts better
|
95.5%
0.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.3%
2.9 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.6% |
26.1%
16.5 pts better
|
11.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 2.8% · Q3 1.8% · Q4 27.0% · 4Q avg 9.6% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
6.2%
3.8 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.0% · Q3 2.2% · Q4 4.3% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
25.4%
4.2 pts better
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 22.7% · Q3 23.7% · Q4 19.4% · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.3% |
11.5%
5.2 pts better
|
16.7%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 5.1% · Q3 4.1% · Q4 6.4% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.7% |
7.7%
6 pts worse
|
16.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 41.2% · Q2 8.8% · Q3 5.5% · Q4 5.4% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
6.2%
3.5 pts worse
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 8.0% · Q3 3.4% · Q4 3.4% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.2%
0.5 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 0.0% · Q4 0.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.6% |
21.7%
7.9 pts worse
|
19.8%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.5% · Q2 36.2% · Q3 22.4% · Q4 26.8% · 4Q avg 29.6% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
3.7%
0.2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.8% · Q3 3.3% · Q4 4.1% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.9% |
78.1%
6.2 pts worse
|
81.7%
9.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.3% · Q2 69.9% · Q3 75.8% · Q4 69.9% · 4Q avg 71.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
12.5%
5.4 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 7.8% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.2%
0.3 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.8% · Q3 1.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.2% |
75.6%
25.4 pts worse
|
79.7%
29.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.2% |
25.1%
4.9 pts better
|
23.9%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.2% · Observed 23.4% · Expected 27.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-11-21 · Fire 2019-11-21
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2018-10-04 · Fire 2018-10-04
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-08-03
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-08-21
F · Potential for more than minimal harm
2023-08-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-21
F · Potential for more than minimal harm
2023-08-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-21
E · Potential for more than minimal harm
2019-11-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-12-10
F · Potential for more than minimal harm
2018-10-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-11-27
F · Potential for more than minimal harm
2018-10-04
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2018-11-27
F · Potential for more than minimal harm
2018-10-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-11-27
E · Potential for more than minimal harm
2018-10-04
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2018-11-27
D · Potential for more than minimal harm
2018-10-04
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-11-27
C · Minimal harm
2018-10-04
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2018-11-27
C · Minimal harm
2018-10-04
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2018-11-27
C · Minimal harm
2018-10-04
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2018-11-27
C · Minimal harm
2018-10-04
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2018-11-27
C · Minimal harm
2018-10-04
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2018-11-27
C · Minimal harm
2018-10-04
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2018-11-27
Inspection history
Recent health citations
G · Actual harm
2025-10-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-10-31
F · Potential for more than minimal harm
2025-08-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-08-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-29
F · Potential for more than minimal harm
2024-11-20
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-11-20
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-11-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-09-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-20
D · Potential for more than minimal harm
2024-08-07
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-09-16
G · Actual harm
2023-08-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-06
G · Actual harm
2023-05-01
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-12
G · Actual harm
2023-05-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-05-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-12
D · Potential for more than minimal harm
2019-11-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-12-10
D · Potential for more than minimal harm
2018-10-04
F555 · Resident Rights Deficiencies
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2018-11-27
D · Potential for more than minimal harm
2018-10-04
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-11-27
D · Potential for more than minimal harm
2018-10-04
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2018-11-27
D · Potential for more than minimal harm
2018-10-04
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2018-11-27
D · Potential for more than minimal harm
2018-10-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-11-27
D · Potential for more than minimal harm
2018-10-04
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2018-11-27
Penalties and ownership
What sits behind the stars
$14,680
2023-08-03
Fine
Fine · fine $14,680
Fine
$37,920
2023-05-01
Fine
Fine · fine $37,920
Fine
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
37603 Euclid Ave Oh Owner LLC
5% Or Greater Indirect Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Group, Inc.
Operational/Managerial Control · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
Operational/Managerial Control · Organization
Providence Group Nh, LLC
Operational/Managerial Control · Organization
Ramacciato, Amarilys
Operational/Managerial Control · Individual
Snf Oh Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Well Integra Master Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Well Pm Holdco Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Ohio Living Breckenridge Village
Willoughby, OH
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Kirtland Woods Of Journey
Kirtland, OH
1-star overall rating with 1-star inspections with Special Focus status with $314,178 in total fines with 21 recent health deficiencies with 22 fire-safety deficiencies in the latest cycle
#3
Mentor Ridge Health And Rehabilitation
Mentor, OH
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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