Health inspection·October 22, 2025

F 0697 Level of Harm - Actual harm Residents Affected - Few keep his gown on, and his gown and bed linens were changed three times. There was no evidence of hospice being notified of the resident's condition throughout the night. Review of the Hospice Visit Summary dated 09/25/25 from 11:16 A.M. to 12:32 P.M. revealed an unidentified hospice aide and nurse visited Resident #148 and upon arrival at the facility the resident was heard screaming down the hallway. The resident was seen in bed covered with urine, so they got him up into a chair, and changed him and the bed, during which Resident #148 screamed in pain again. The resident's left knee was swollen, bruised and red. The resident was unable to bear weight to left hip or straighten his left knee. The facility's Director of Nursing (DON) and Unit Manager (UM) #206 entered the room and stated they did not know the resident was hurt but had reports which indicated Resident #148 fell the previous day with no injuries and neurological checks within normal limits. The summary revealed this was the first hospice was informed of the fall that had occurred on the previous day. The hospice physician was notified and gave an order for an x-ray. The facility was notified of the new order and was obtaining it. The resident's power of attorney (POA) was in agreement, and the facility was to contact hospice with the x-ray results. Review of a nurse's note dated 09/25/25 at 3:12 P.M. by RN #211 revealed an unidentified hospice nurse notified the facility of Resident #148 having swelling to the left knee and it was red and warm to the touch. The resident was medicated with Morphine as ordered and it had positive effects. Additionally, an x-ray was ordered of the left ankle. The resident's mother was updated about the new order. Review of the medication administration record for September 2025 revealed no medication was documented as offered, refused or received to address pain from 09/24/25 until 09/25/25 at 3:40 P.M. when Resident #148 received one dose of Lorazepam for anxiety, and at 3:41 P.M. when the resident received one dose of Morphine for knee pain assessed at a seven out of 10 on a pain scale of one to 10 with 10 being the most severe. On 09/25/25 at 4:26 PM., the Lorazepam and Morphine doses were documented as ineffective as the resident was still in pain assessed at an eight out of 10 on a pain scale. Review of the radiology report dated 09/25/25 at 7:04 P.M. revealed the left ankle x-ray resulted in displaced fractures of the tibia and fibula. There was no evidence of hospice being notified of the results. Review of nurses' notes for September 2025 revealed no documentation of Resident #148's transfer to the hospital including a pain assessment for pain level or his condition at the time of discharge. Interview on 10/15/25 at 4:47 P.M. with LPN #201, who was present at the time of Resident #148's fall, revealed hospice was at the facility when the resident initially arrived (on 09/24/25). LPN #201 stated she had informed hospice of the resident's fall (although this was not noted in the nursing progress note). During the interview, the LPN revealed following the incident, the resident had required one on one care until about 10:00 P.M. at which time she stated staff were able to get him to stay in bed. The LPN did not provide additional information to support the resident's pain following the fall was assessed or adequately managed. Interview on 10/15/25 at 4:19 P.M. with Certified Nursing Assistant (CNA) #214 confirmed Resident #148 fell out of bed on 09/24/25 and broke his (unspecified) leg between the knee and the ankle, but an x-ray was not taken until the next day. CNA #214 stated all staff heard the resident scream throughout the shift and believed the nurse only gave him Tylenol for pain. Interview on 10/15/25 at 4:43 P.M. with RN #204, who cared for Resident #148 during the night of 09/24/25 and documented the resident was up all-night screaming, crying loudly and was aggressive, revealed Resident #148 had allowed the nurse to put ice on his knee after his fall. RN #204 described being in and out of the room because the resident kept sitting up, ready to get up, and his urinary catheter kept leaking so he needed changed and the bed was remade several times. During the interview RN #204 claimed Resident #148 would not take either the ordered Lorazepam or Morphine but verified she failed to document any pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365305 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365305 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Willoughby Post Acute 37603 Euclid Ave Willoughby, OH 44094 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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. Event ID: Facility ID: 365305 If continuation sheet Page 3 of 3