Health inspection·January 30, 2025

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based 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. Findings include: Review of the medical record for Resident #115 revealed an admission date of 11/18/24. Diagnoses included end stage renal disease, peripheral vascular disease, and non-pressure chronic ulcers to the right and left lower leg. Physician orders effective January 2025 specified a renal diet with regular texture and thin consistency. Review of the medical record for Resident #129 revealed an admission date of 06/17/20. Diagnoses included severe chronic kidney disease, adult failure to thrive and severe protein calorie malnutrition. Physician orders effective January 2025 specified a renal diet, mechanical soft with pureed fruit texture and thin consistency with large portions. Interview on 01/29/25 at 7:55 A.M. with Resident #115 revealed a complaint about not receiving alternative food items during a meal which were not included in the renal diet. Observation on 01/29/25 at 8:20 A.M. revealed Certified Nursing Assistant (CNA) #337 entered the room for Residents #115 and #129 and delivered their breakfast trays. Resident #115's plate included scrambled eggs and one blueberry muffin. There were beverages included on the tray but no additional food items. Resident #129's plate included a large portion of scrambled eggs and one blueberry muffin. There were beverages included on the tray but no additional food items. Review of the meal ticket left on Resident #115's breakfast tray revealed a renal regular diet with no additional information or listed dislikes. Interview on 01/29/25 at 8:26 A.M. with CNA #337 verified both Residents #115 and #129 received only scrambled eggs and one blueberry muffin on their plate with no additional food items on the tray. Review of the facility menu for the week of 01/26/25 revealed the breakfast for 01/29/25 included the following food items: choice of hot or cold cereal, scrambled eggs with cheese, hash browns and a blueberry muffin. Interview on 01/29/25 at 8:29 A.M. with Dietary Manager (DM) #402 confirmed the breakfast menu (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 2 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 01/30/2025 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)