Wickliffe Country Place

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the facility to deliver the residents' medications, the nurse checks in and counts all the medications while

the driver is still there, then signs they received the medications. Account Manager #392 revealed the pharmacy had packing slips and the signature the nurse (LPN #275) signed it and confirmed she received

the clonazepam for (Resident #181). Director of Clinical Services Pharmacist #393 confirmed the clonazepam was delivered and signed received by the facility nurse. Interview and record review on 09/15/25 at 3:17 P.M. with LPN #275 of the Controlled Packing Slip dated 08/09/25 confirmed the controlled packing slip for Resident #181 was signed by her (LPN #275). LPN #275 revealed she did not see the clonazepam written directly under the tramadol on the packing slip when she signed for the medication.

LPN #275 revealed she was never asked to do a drug screen and confirmed she did not receive any further education on the proper procedure of receiving medications from the pharmacy after receiving the initial education in April 2025. LPN #275 confirmed on 08/10/25 Resident #181 did not have the A.M. dose of clonazepam available for administration. LPN #275 revealed during the nurse to nurse report the nurse told her the medication was already on order so she did not have to call the pharmacy or get a prescription from

the physician. Interview on 09/15/25 at 3:39 P.M. with the DON revealed due to the incident, nurses were in-serviced on controlled drugs. The DON confirmed the in-service log dated and initiated 08/13/25 titled Controlled Substance In-service was signed by 16 nurses. The DON confirmed LPN #275 did not sign the in-service. The DON stated, She was educated in April on controlled substances. On 09/15/25 at 4:40 P.M.

the DON revealed on 08/21/25 LPN #275 was given a final written warning. Review with DON of the final written warning dated 08/21/25 revealed employee name (LPN #275) was not adequately following policies and procedures for accepting controlled substances from pharmacy. On the form Previous Warnings were marked yes with a check mark and dated 04/18/25. The DON revealed this was when all nurses received initial training for the policy and procedures on pharmacy deliveries. The DON also stated LPN #275 was re-trained on the correct procedure when given the form. The DON confirmed the form did not indicate the training. Interview with the DON on 09/17/25 at 3:00 P.M. confirmed she did not see the note dated 08/11/25 at 9:29 A.M. completed by LPN #347 revealing the pharmacy has indicated that it is too soon to refill the requested medication supply below. Clonazepam oral tablet disintegrating 0.25 mg give one tablet by mouth two times a day for bipolar. Patient has requested refill too soon. Order will be dispensed on 08-21-2025. The DON confirmed the MAR and nursing notes were not in the investigation file provided to

the surveyor. The DON confirmed no investigation was initiated at that time, 08/11/25 to determine where

the medication was or why it was too soon to refill. The DON revealed she would have to look into it. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property reviewed 01/06/25 revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The initial response included staff should report all incidents /allegations immediately to the Administrator or designee. The Administrator or his or her designee will notify the Ohio Department of Health of all alleged violations involving mistreatment, neglect, abuse, exploitation, and misappropriation of resident property as soon as possible but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. If the accused is an employee, then review his or her employment records. Evidence of the investigation should be documented.

Complete staff training, if appropriate, as determined by the results of the investigation. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number 2612137.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wickliffe Country Place

1919 Bishop Rd Wickliffe, OH 44092

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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

supplies were. RN ADON #364 then looked on the assessment and revealed Resident #52 was to have a Shiley 7.5 trach. Central Supply Personnel #367 then entered and directed where the trach supplies would be located. Observation revealed at 10:50 A.M. RN ADON #364 found where trach supplies were located.

RN ADON #364 confirmed all the trach supplies were there that was needed for Resident #52 except trach ties and confirmed there were no trach ties available. RN ADON #364 took trach supplies to the nursing station. RN ADON #364 confirmed the amount of time taken to find the trach supplies could have been detrimental to the resident if the supplies were needed in an emergency. Interview on 09/15/25 at 10:55 A.M. with LPN #266 revealed Resident #52 did all of his own trach care and she did not have to do any of it.

LPN #266 confirmed she did not monitor Resident #52 do his trach care. Interview on 09/15/25 at 11:00 A.M. with Resident #52 and RN ADON #364 present revealed Resident #52 revealed his inner cannula had not been changed for weeks. Resident #52 revealed he made the nursing staff aware. Interview on 09/15/25 at 11:35 A.M. with Infection Preventionist Corporate RN #389 and DON revealed if a resident had

a trach, trach supplies should be readily available. Resident #52's trach cleaning supplies should be kept at

the bedside. The trach ties should be changed weekly and when visibly soiled and should also be kept at

the bedside. A spare trach can be kept at the bedside, but it may not be if he has behavior. The nurses should be aware where the spare trach is kept. The inner cannula needs to be cleaned or changed daily; nurses should be the ones doing it. The DON confirmed the nurses were signing the orders and revealed nurses should be completing the care per the physician orders. Phone interview on 09/15/25 at 11:58 A.M. with the RT confirmed she visited the facility two times a week and revealed she visited Resident #52 one of those two days. The RT revealed Resident #52 did not keep trach supplies in his room because he goes through them and would use them all. The RT revealed she did not provide any care for Resident #52 when

she visited, Resident #52 did his own trach care and revealed the nursing should give him his supplies when his trach care is due. The RT revealed trach ties should be changed at least once a week, and as needed, the inner cannula is disposable and should be changed daily and confirmed the trach care should be done twice daily. The RT revealed she usually checked Resident #52's supplies and ordered them. The RT revealed a spare trach should be kept with the nurse. Interview on 09/15/25 at 4:44 P.M. with LPN #292 confirmed he worked with Resident #52. LPN #292 revealed Resident #52 kept all his trach supplies in his room and did his own trach care. Interview on 09/15/25 at 5:11 P.M. with LPN #233 revealed Resident #52 liked to do his own trach care and she asks him if he did it then signs the orders confirming the treatment was completed. LPN #233 revealed the trach supplies were kept in the treatment or medication cart.

Review of the facility policy titled, Tracheostomy Care revealed to verify the physicians order, gather the assembled supplies, assess the condition of the stoma, remove the inner cannula, cleanse around the stoma, place the new inner cannula inside tracheostomy tube, replace trach ties if soiled, document the date and time and the skin integrity around the stoma. This deficiency represents non-compliance investigated under Complaint Numbers 2616221, 2620100.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Wickliffe Country Place

1919 Bishop Rd Wickliffe, OH 44092

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)

Federal health inspectors cited WICKLIFFE COUNTRY PLACE in WICKLIFFE, OH for a deficiency under regulatory tag F-F0725 during a complaint investigation conducted on 2025-11-17.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of WICKLIFFE COUNTRY PLACE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-18.