Wickliffe Country Place

Inspectors wroteBased on medical record review, facility self-reported incident (SRI) review, facility policy review, facility investigation review, hospital record review, interdisciplinary team (IDT) summary review, and staff interview, the facility failed to protect the resident's right to be free from physical abuse by another resident. This affected one resident (Resident #162) of four residents reviewed for abuse. The facility census was 128. Actual harm occurred on 10/26/25 when Resident #162 sustained nasal bleeding and fractures of the maxilla and nasal bone after being struck by Resident #161. Resident #162 experienced significant injury, and the facility did not implement timely interventions or notify a physician despite documented increases in Resident #161's behaviors on 10/18/25, 10/21/25, 10/24/25, and 10/25/25, failing to protect Resident #162 from foreseeable harm.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that food was prepared using methods that preserved its nutritional value, flavor, and appearance. This had the potential to affect all 124 residents who received meals from the kitchen, as four residents in the facility were not to receive nutrition by mouth (Residents #20, #30, #84, and #106). The facility census was 128.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that food was stored and prepared according to professional standards. This had the potential to affect all 134 residents who received meals from the kitchen as four residents had orders not to receive nutrition by mouth (Residents #20, #30, #84, and #106). The facility census was 128.

Inspectors wroteBased on record review and interviews the facility failed to ensure a licensed social worker worked full time in the facility. This had the potential to affect 127 residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident code statuses were accurately reflected in both the paper medical record and the electronic medical record (EMR). This affected six residents (Resident #1, #4, #7, #39, #43 and #152) of 35 residents reviewed for advanced directives. The census was 128.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure a, clean, sanitary, homelike environment. This affected two resident's (Resident's #111 and #113) out of three reviewed for clean and sanitary resident rooms and had the potential to affect all residents who used the common area and wanted to know the time. The facility census was 128.

Inspectors wroteBased on review of the medical record, staff interview, observation, and review of the facility policy the facility failed to ensure resident care conferences and revisions to comprehensive care plans were completed timely. This affected six residents (Resident's #6, #11, #61, #92, #140, and #159) of seven residents reviewed for care plan timing and revisions.

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure residents received their ordered adaptive devices during meals as required. This affected five residents (Residents #04, #85, #89, #91, and #104) of the seven residents who had physician orders for adaptive feeding devices. The facility census was 128.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure a dignified homelike environment by knocking on the resident's door before entrance. The affected one resident (Resident #149) with the potential to affect five additional residents (#10, #81,#20, #108, and #88) residents out of 22 residents observed for dignity. The census was 127. Findings Include:Review of the medical record for Resident #149 admitted on [DATE] with diagnosis of acquired absence of left leg below the knee, surgical amputation aftercare, posthemorrhagic anemia, severe protein calorie malnutrition, type two diabetes, hypertension, and pulmonary vascular disease. Resident #149 had a surgical wound to left leg and a wound on his coccyx. Resident #149 short-and long-term memory are intact and can make informed decisions. Resident #149 could make needs known. Observation on 06/22/26 at 2:13 P. [...]

Inspectors wroteBased on review of the medical record review, staff interview, and policy review, the facility failed to timely report an allegation of misappropriation to the stage agency. This affected one resident (Resident #140) of four residents reviewed for allegations of abuse, neglect, or misappropriation. The facility census was 128.

Inspectors wroteBased on the review of the medical record, the facility self-reported incident (SRI) report, facility policy, the facility investigation report, hospital records, interdisciplinary team (IDT) summary, Resident #161 Administrator summary, and staff interview, the facility failed to thoroughly investigate resident to resident physical abuse between Resident #161 and Resident #162. This affected two residents (#161 and #162) of four residents reviewed for abuse. The facility census was 128.

Inspectors wroteBased on record review and interview, the facility failed to ensure the interdisciplinary team addressed all of Resident #99's discharge needs to ensure a safe discharge. This affected one resident (Resident #99) of one resident reviewed for discharge.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure activity outings outside of the facility were provided for the residents. This affected one resident (Resident #95) of two residents reviewed for activities. The facility census was 128.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #22's blood glucose levels will properly monitored before administration of insulin in accordance with physician orders and care planned interventions, and failed to ensure Resident #113's cardiac medication was ordered and administered properly. This affected two residents (Resident #22 and Resident #113) out of five residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure reducing interventions were in place at all times. This affected two residents (Resident #20 and Resident #149) of four residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, record review, review of Occupational Therapy Evaluation and Plan of Treatment, and review of the facility policy the facility failed to ensure Resident #113's care planned fall preventive interventions. This affected one resident (Resident #113) out of three residents reviewed for falls. The facility census was 128.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #113 had a comprehensive evaluation and care planned interventions for a significant childhood trauma. This affected one resident (Resident #113) out of three residents reviewed for trauma. The facility census was 128.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure effective care planned interventions were implemented to promote Resident #161's highest practicable physical, mental, and psychosocial well-being. This affected one (Resident #161) of one residents reviewed for behavioral health. The facility census was 128. Review of the medical record revealed Resident #161 was admitted to the facility on [DATE] from an acute care hospital stay. The resident had relevant diagnoses of adult failure to thrive, focal traumatic brain injury (TBI), restlessness and agitation, hypertension (high blood pressure), and anemia. Review of the Minimum Data Set (MDS) 3.0 admission assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03 (severe cognitive impairment) and disorganized thinking. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly identify Resident #106's food allergies to ensure interventions were in place to provide the correct diet. This affected one resident (Resident #160) out of six residents reviewed for food.

Inspectors wroteBased on observation, interview, record review and review of the facility policy revealed the facility failed to ensure sufficient staff were available to timely serve meal trays for the 18 residents residing on the A unit and failed to provide timely incontinence care for three residents. This affected three (#80, #109, and #111) of three residents reviewed for incontinence care also residing on the A unit. This had the potential to affect all 18 residents (#80, #98, #99, #100, #101, #102, #103, #104, #105, #106, #107, #109, #110, #111, #112, #113, #114, and #115) residing on the A Unit. The facility census was 114.

Inspectors wroteBased on facility staff and pharmacy staff interview, medical record review, review of Self- Reported Incident (SRI) #264042 and facility policy review the facility failed to thoroughly investigate a missing controlled medication for one resident. This affected one (#181) of one resident reviewed for misappropriation of medications. The facility census was 114.

Inspectors wroteBased on observation, interview, record review and review of the facility policy revealed the facility failed to assure trach supplies were available and care and treatment was completed. This affected one (#52) of one resident reviewed for trach supplies and treatment. The facility census was 114.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to follow the renal diet menu. This affected two residents (#115 and #129) of three residents reviewed for nutrition, and affected ten additional residents (#3, #16, #22, #42, #46, #56, #64, #94, #99 and #105) who received a renal diet. The facility census was 129.

Inspectors wroteBased on observations and interview the facility failed to maintain a sanitary kitchen. This had the potential to affect all residents residing in the facility except for three residents (#9, #93, and #123) who did not receive nutrition by mouth. The census was 126.

Inspectors wroteBased on observations and interviews the facility failed to maintain a sanitary environment surrounding the dumpster area. This had to potential to affect all 126 residents residing in the facility.

Inspectors wroteBased on interview, record review and review of facility policy revealed the facility did not ensure Resident #32's advanced directives were accurate per the physician orders on her electronic medical record. This affected one resident (#32) out of 43 residents reviewed for advanced directives. The facility census was 126.

Inspectors wroteBased on interview, record review, and review of facility policies the facility failed to ensure the resident, physician, legal guardian and/ or responsible party was notified regarding significant weight changes. This affected two residents (#16 and #32) out of seven residents reviewed for proper notifications of significant weight change. The facility census was 126.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident received bathing as planned and/or as requested. This affected one resident (#180) of five residents reviewed for showers. The facility census was 126.

Inspectors wroteBased on record review, observation, and interview the facility failed to provide assistance to maintain personal hygiene. This affected one (Resident #69) of five residents reviewed for activities of daily living.

Inspectors wroteBased on interview, observation, record review, and review of facility policy revealed the facility failed to implement fall interventions as identified in the resident's plan of care. This affected one resident (#32) of four residents reviewed for falls and/ or accidents. The facility census was 126.

Inspectors wroteBased on interview, observation, record review, and review of facility policies the facility did not ensure weights were obtained and monitored timely. This affected two residents (#16 and #32) of seven residents reviewed for nutrition. The facility census was 126.

Inspectors wroteBased on interview, observation, record review, and review of facility policy the facility failed to ensure Resident #108's enteral tube feeding (a method of providing nutrition to patients who are unable to eat or drink safely by mouth) was infusing at the correct rate per physician order. This affected one resident (#108) of two residents reviewed for tube feeding.

Inspectors wroteBased on interview, observation, policy review and review of the medical record revealed the facility failed to ensure enteral feedings were labeled and dated appropriately. This affected one resident (#93) of two residents reviewed for enteral feedings. The facility census was 126.

Inspectors wroteBased on interview, observation, record review and review of facility policy revealed the facility failed to ensure enhanced barrier precautions were utilized for a resident during high contact resident care. This affected one resident (#108) of two residents observed for enhanced barrier precautions.

Inspectors wroteBased on observation, interview, menu spreadsheet review, and policy review the facility failed to serve palatable meals at appetizing temperatures. This affected 117 residents receiving meals from the kitchen as two residents (#67 and #108) were ordered nothing-by-mouth (NPO). The facility census was 119.

Inspectors wroteBased on observation, record review, interview, and policy review the facility failed to ensure appropriate interventions were implemented to timely identify pressure ulcers for Resident's #1 and #80. Actual Harm occurred on 09/08/22 when Resident #80, who required extensive assistance with two staff for bed mobility and transfers was observed to have a new unstageable pressure ulcer (full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar) to the right gluteal fold when first observed by Licensed Practical Nurse (LPN)/Wound Nurse #629. In addition Actual Harm occurred on 09/20/22 when Resident #1, who required extensive assistance of two staff for bed mobility, transfers, and toilet use was observed during wound rounds to have a new unstageable pressure ulcer across the bilateral glutei. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have sufficient staff to provide the necessary care and services including restorative nursing, getting assistance to bed per preference and timely manner, timely incontinence care, showers per schedule and preference, changing of clothing, and meeting the minimum daily staffing requirement of 2.50 hours per resident. This had the potential to affect all 137 residents residing in the facility.

Inspectors wroteBased on observation and interviews, the facility failed to serve hot and palatable foods. This had the potential to affect all 132 residents receiving food from the facility kitchen. Five (Resident's #25, #48, #38, #50, and #127) did not receive food from the facility. The facility census was 137.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to provide consistent and timely assistance with activities of daily living (ADL) for incontinence care and showers. This affected four (Resident's #17, #116, #441 and #453) of eight residents reviewed for ADL. The facility census was 137.

Inspectors wroteBased on observation, interview, record review, review of Centers for Disease Prevention and Control (CDC) guidance, and review of the facility policy the facility failed to ensure two (Resident's #1 and #450) were placed on contact precautions timely. The facility failed to ensure appropriate hand hygiene during and after care the of one (Resident #1) who was on contact precautions. The facility failed to ensure tuberculin screening tests were administered and read within the required time frame for two (Resident's #3 and #453). This affected two (Resident's #1 and #450) of three residents reviewed for transmission-based precautions, one (Resident #1) of three residents reviewed for hand hygiene, and two (Resident's #3 and #453) of five reviewed for tuberculin screening. The facility census was 137.

Inspectors wroteBased on interview, observation, record review, and facility policy review the facility failed to ensure water temperatures were maintained in a safe manner at or below 120 degrees Fahrenheit (F). This affected eight residents (Resident's #12, #15, #20, #45, #95 #109, #116 and #136) and had the potential to affect 101 residents who resided on the 100, 200, 300, and 500 halls (Resident's #1, #2, #3, #4, #5, #6, #7, #9 #12, #13, #15, #16, #17, #20, #21, #25, #27, #30, #31, #33, #35, #37, #38 #41, #43, #44, #45 #47, #48, #49, #51, #52, #54, #55, #57, #59, #60, #61, #62, #63, #65, #66, #67, #68, #89, #70 #71, #72, #73, #74, #75, #77, #79, #80, #82, #86, #87, #93, #95, #96, #97, #99, #102, #104, #106, #108, #109, #111, #114, #116, #117, #118, #119, #121, #123, #125, #127, #130, #131, #133, #134, #135, #136, #139, #140, #391, #392, #442, #443, #444, #445, #446, #447, #448, #449, #450, #451, [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure neglect did not occur. This affected two (Resident's #452 and #453) of three residents reviewed for neglect. The facility census was 137.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to implement a care plan intervention after a fall for Resident #122. This affected one (Resident #122) of two Resident #62 and Resident #122) reviewed for accuracy of care plan fall interventions. The facility census was 137.

Inspectors wroteBased on interview, observation, record review, and facility policy review the facility did not ensure Resident's #10 and #116 received their restorative programs per recommendation. This affected two (Resident's #10 and #116) of two (Resident's #10, and #116) reviewed for restorative nursing programs. This had the potential to affect 38 (Resident's #5, #10, #12, #14, #15, #16, #22, #23, #25, #28, #32, #35, #39, #40, #42, #43, #45, #51, #52, #53, #56, #59, #60, #64, #65, #70, #80, #87, #89, #99, #104, #106, #112, #116, #117, #121, #122, and #126) who received a restorative nursing programs. The facility census was 137.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #45 had orders in place to receive appropriate indwelling catheter care. This affected one (Resident #45) of three residents reviewed for indwelling catheter care orders. The facility census was 137.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure two (Resident's #136 and #450) were administered oxygen as ordered by the physician. This affected two (Resident's #136 and #450) of seven residents reviewed for oxygen administration. The facility census was 137.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to complete dialysis assessments before and after dialysis and send a dialysis communication form to dialysis. This affected one (Resident #93) of one resident reviewed for dialysis. This had the potential to affect 17 additional residents (Resident #2, #6, #26, #31, #35, #54, #74, #82, #84, #87, #111, #119, #133, #134, #139, #443, and #446) who received dialysis. The facility census was 137.

Inspectors wroteBased on observation, interview, record review, and review of facility training the facility failed to ensure appropriate supervision for one resident with dementia. This affected one (Resident #455) of three residents reviewed for supervision. The facility census was 137.