Health inspection·September 26, 2019

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide an individualized activity plan and activities for Resident #149. This affected one of three residents (Resident #25, Resident #107 and Resident #149) reviewed for activities. The census was 150. Residents Affected - Few Findings include: Review of the medical record revealed Resident #149 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, unspecified visual loss and end stage renal disease with dependence on dialysis. Review of the 5-day minimum data set (MDS) assessment dated [DATE] revealed the resident required extensive two-person assist for bed mobility, transfers, dressing, eating and personal hygiene. The resident was totally dependent on staff for locomotion and toilet use. The brief interview mental status (BIMS) score of 04 indicated severe cognitive impairment. A care plan, dated 08/09/19 and revised 08/25/19, relative to activities revealed generic interventions including: the resident will express satisfaction with type of activities and level of activity involvement when asked, assist with arranging community activities, arrange transportation, assure the activities the resident attends are compatible with physical and mental capabilities, known interests and preferences. Adapted as needed (large print, holders), and with individual needs and abilities and are age appropriate. Encourage ongoing family involvement. Invite family to attend special events, activities, meals. Establish prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. Explain the importance of social interaction, leisure activity time. Encourage participation. If resident chooses not to attend organized activities, turn on TV or music to provide sensory stimulation. Reassure resident that they may leave activities at any time for toileting and will be able to return to activity. Reassure resident that they may leave activities at any time, and that they are not required to stay for entire activity. The interventions also included Provide 1:1 bedside/in-room visits and activities if unable to attend out of room events. Review of the Recreation admission Assessment completed on 08/08/19 revealed it was very important for Resident #149 to listen to choice of music and to participate in religious services or practices. The resident had an interest in music, television and movies. Resident #149 needed one-to-one visits and conversation. Interview on 09/24/19 at 8:32 A.M. with Resident #149 revealed because she was blind there were no activities for her. She was not interested in group activities. Resident #149 did not know if there were any audio books available at the facility, but she might be interested in those. The resident could not think of any other activities she would enjoy. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 365381 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 365381 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2019 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)