Health inspection·July 11, 2023

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed ensure Resident #110 was appropriately discharged and failed to ensure Resident #110's durable medical equipment (DME) was delivered timely upon discharge. This finding affected one (Resident #110) of three residents reviewed for discharges. Residents Affected - Few Findings include: Review of Resident #110's medical record revealed he was admitted on [DATE] and discharged on 06/27/23 with diagnoses including encounter for other orthopedic aftercare, charcot's joint right ankle and foot and diabetes. Review of Resident #110's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited intact cognition. Review of Resident #110's Clinical Utilization Review form from the insurance company dated 06/26/23 at 12:00 P.M. stated the last covered day was 06/22/23 and clinical information was requested and due on 06/23/23. Review of Resident #110's social worker progress note dated 06/27/23 at 4:19 P.M. indicated he was discharged home with home health care (HHC). Upon discharge home, Resident #110 needed a hospital bed, commode and wheelchair. Interview on 07/10/23 at 10:41 A.M. with Licensed Social Worker #905 indicated on 06/26/23 she received an email which stated Resident #110 was cut from therapy services on 06/22/23. She stated when she received the email, she immediately started sending out referrals for home care which included skilled physical therapy (PT) and occupational therapy (OT) and she sent in a referral for durable medical equipment (DME) including a bariatric wheelchair, commode and hospital bed. She stated the DME was to be delivered on 06/30/23 and she was unable to find a HHC provider for PT and OT and she notified the resident. Interview on 07/10/23 at 11:29 A.M. with Resident #110 indicated he did not receive his DME equipment until 07/03/23 and he felt his HHC was not setup satisfactorily. Interview on 07/10/23 at 11:36 A.M. with the Medical Supply #980 indicated the facility sent over a referral for DME equipment but it required additional information. Interview on 07/10/23 at 1:30 P.M. with Insurance #982 with the Administrator, the Director of Nursing (DON) and Admissions Director #841 in attendance revealed Resident #110 was not issued a cut (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 3 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 07/11/2023 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)