Health inspection·November 17, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Record review for Resident #181 revealed an admission date of 06/04/25 and a discharge date of 09/03/25. Diagnoses included bipolar disorder and schizoaffective disorder. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #181 was cognitively intact. Resident #181 had little interest or pleasure in doing things and was feeling down, depressed or hopeless. Resident #181 used a wheelchair for mobility and was independent for eating and personal hygiene. Resident #181 had non-traumatic brain dysfunction, bipolar disorder and schizophrenia. Review of the physician order for Resident #181 dated 07/19/25 revealed an order for clonazepam (classified as a Schedule IV prescription benzodiazepine) oral table disintegrating 0.25 milligrams (mg), give one tablet by mouth two times a day for bipolar disorder. The scheduled times to be administered were morning and evening. Review of the Resident #181's Medication Administration Record (MAR) for August 2025 revealed from 08/01/25 through 08/09/25 Resident #181 received 15 of the 18 ordered doses of clonazepam. On 08/04/25 the MAR revealed the evening dose had an R documented with initials. Review of the chart code on the MAR revealed the R indicated the resident refused the medication. Additionally, on 08/05/25 and 08/06/25 the morning dose had an R documented. On 08/10/25 the morning dose and the evening dose, had OT documented on the MAR. The chart code indicated OT indicated Other; On 08/11/25 the evening dose had an OT documented; 08/12/25, 08/13/25, and 08/14/24 the morning dose had an OT documented. An R was documented 08/12/25 and 08/13/25 for the evening dose. Review of the MAR indicated Clonazepam was administered from 08/14/25 evening dose as ordered through 08/24/25 when Resident #181 was admitted to the hospital. Review of the med pass note for Resident #181 dated 08/10/25 at 7:57 A.M. completed by Licensed Practical Nurse (LPN) #275 revealed clonazepam oral tablet disintegrating 0.25 mg give one tablet by mouth two times a day for bipolar (disorder) - medication on order. Review of the med pass note for Resident #181 dated 08/10/25 at 6:36 P.M. completed by LPN #346 revealed clonazepam oral tablet disintegrating 0.25 mg give one tablet by mouth two times a day for bipolar - on order. Review of the med pass note for Resident #181 dated 08/11/25 at 9:29 A.M. completed by LPN #347 revealed clonazepam oral tablet disintegrating 0.25 mg give 1 tablet by mouth two times a day for bipolar. 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 08/21/25. Review of the med pass note dated 08/11/25 at 6:27 P.M. completed by Nurse Manager Assistant Director of Nursing (ADON), Staff Development/Registered Nurse (RN) #355 revealed clonazepam oral tablet disintegrating 0.25 mg give one tablet by mouth two times a day for bipolar (disorder). Medication unavailable Residents Affected - Few Page 1 of 8 365381 365381 11/17/2025 Wickliffe Country Place 1919 Bishop Rd Wickliffe, OH 44092

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few however R (resident) refused all medications from this nurse. Review of the med pass note dated 08/14/25 at 8:59 A.M. completed by LPN #347 revealed clonazepam oral tablet disintegrating 0.25 mg give one tablet by mouth two times a day for bipolar - waiting on pharmacy. Review of the Certified Nurse Practitioner (CNP) Note for Resident #181 dated 08/14/25 at 11:51 P.M. completed by CNP #390 revealed chief complaint: N/V (nausea and vomiting), anxiety, follow up chest pain, and (congestive heart failure) CHF. She is resting quietly in bed. Reports feeling ok. No chest pain endorsed at time of exam. Continue current meds and treatments. Monitor. Addendum- anxious this afternoon. Per nurse, family called 911, but (Resident #181) refused to go. Did not leave facility. Awaiting klonopin (trade name for Clonazepam) from pharmacy. Review of the Self-Reported Incident (SRI) Tracking #264042 dated 08/14/25 at 1:36 P.M. with a date of discovery 08/14/25 and a category of Misappropriation and a brief description of the staff nurse identified medication unavailable. When calling pharmacy for medication, pharmacy stated the medication was delivered to the facility. Staff unable to locate medication at the facility. Alleged/suspected perpetrator was facility staff or other care provider. Resident remained at the facility at baseline. The Narrative Summary of the incident included interviewed the nurse that signed for receiving the medication when delivered to the facility. The report indicated the facility replaced the medication at the facility cost. Resident #181 was interviewed when asked if she refused medication, which medication she refused and why. The report indicated like residents were interviewed with no negative findings and staff were educated. The facility conclusion indicated the allegation was unsubstantiated and indicated evidence of abuse, neglect or misappropriation did not occur. Resident denied abuse occurred. No witnessed abuse, staff educated. The report was completed by the facility Administrator. Review of the typed Controlled Packing Slip titled Pharmacy #391 Controlled, revealed delivered to (Facility Name and address) shipping date 08/08/25. (Resident #181) Tramadol HCL tab 50 mg four of four and clonazepam ODT tab 0.25 mg 30 of 30. Under the listed medications revealed By signing below you acknowledge that the items above have been received. Under the statement was hand written name (LPN #275) with a hand written signature (LPN #275) dated 08/09/25. Review of the handwritten statement dated 08/14/25 at 12:13 P.M. signed by LPN #275 revealed on 08/09/25 she did not receive the narcotic medication clonazepam. On this date she only received and signed for tramadol 50 mg, four tablets for (Resident #181). No other medications for this resident were received or signed for by me. Interview on 09/15/25 at 1:04 P.M. with Administrator and DON revealed on 08/14/25 the nurse was passing medication, Resident #181's medication clonazepam was not available. The pharmacy was called and stated they delivered the clonazepam for Resident #181 on 08/09/25. The nurse, LPN #275 signed the packing slip confirming she received it. Interview with LPN #285 revealed her statement that she did not receive it. Administrator revealed she saw LPN #275's signature on the packing slip and stated, She signed she received it, but we were unable to locate the medication, could not find the form (the signature/count log used by nurses to sign off the medication after each dose was given to assure no missing doses) or medication. The nurse was suspended during the investigation. The DON confirmed the allegation was unsubstantiated because the nurse said she did not receive the medication. The Administrator and DON confirmed LPN #275 signed the packing slip on 08/09/25 used to deliver and confirmed the medication was received. The DON confirmed LPN #275 was never requested to take a drug screen. Record review of Resident #181's MAR and progress notes for 08/10/25 through 08/14/25 with the DON confirmed Resident #181's clonazepam was not available for administration and was documented. Phone interview on 09/15/25 at 3:09 P.M. with Pharmacy Staff #391, Account Manager #392, and Director of Clinical Services Pharmacist #393 revealed the pharmacy had packing slips for the medications delivered to the facility. When the driver arrives at 365381 Page 2 of 8 365381 11/17/2025 Wickliffe Country Place 1919 Bishop Rd Wickliffe, OH 44092

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 365381 Page 3 of 8 365381 11/17/2025 Wickliffe Country Place 1919 Bishop Rd Wickliffe, OH 44092

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings include: Record review for Resident #52 revealed an admission date of 03/06/24. Diagnoses included encounter for attention to tracheostomy (a direct opening or stoma through the neck into the windpipe (trachea) allowing a tube to be inserted to provide an airway), dysphagia, weakness, unspecified psychosis, obsessive compulsive disorder, post-traumatic stress disorder and obstructive sleep apnea. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #52 was moderately cognitively impaired. Resident #52 had no rejection of care and required set up or clean up assistants with eating and oral hygiene. Resident #52 had a tracheostomy and received tracheostomy care. Review of the care plan for Resident #52 dated 03/07/24 revealed Resident #52 has a trach (a common shorthand term for tracheostomy) and is at risk for ineffective breathing patterns as evidence by shortness of breath and labored respirations. Interventions included to administer medications and respiratory treatments as ordered; monitor for effectiveness and adverse reactions of medications/treatments. Review of the Physician orders for Resident #52 revealed an order dated 03/07/24 to change trach inner cannula daily and as needed every night shift. An additional order dated 03/07/24 revealed trach care BID (two times a day) and prn (as needed) every day and evening shift. Review of the Treatment Administration Record for 09/01/25 through 09/15/25 for Resident #52 revealed the treatments to Resident #52's trach (including to change trach inner cannula daily and trach care BID and prn every day and evening shift) were documented on the TAR by facility nurses as completed as ordered. Observation and interview on 09/15/25 at 10:30 A.M. with Resident #52 revealed Resident #52 was sitting up in bed. Observation revealed Resident #52 had a trach intact and secured with trach ties. Resident #52 revealed he ran out of trach ties for his trach about a month ago. Resident #52 revealed the staff were aware there were no trach ties available. Observation revealed Resident #52's trach ties were dingy in color and appeared to be soiled. Interview on 09/15/25 at 10:32 A.M. with Registered Nurse (RN) Assistant Director of Nursing (ADON) #364 revealed the Respiratory Therapist (RT) ordered Resident #52's trach supplies. RN ADON #364 revealed there were trach supplies available including trach ties kept in Resident #52's room. Observation revealed RN ADON #364 went to Resident #52's room and searched the room for trach supplies. RN ADON #364 confirmed there were no trach supplies in Resident #52's room. RN ADON #364 then went to the nurses station and approached Licensed Practical Nurse (LPN) #266. LPN #266 confirmed she was Resident #52's primary nurse. LPN #266 stated when asked about trach ties, I think we have some. Observation revealed LPN #266 looked in the medication cart and treatment cart and confirmed she was unable to find trach ties. LPN #266 also confirmed she was unable to find inner cannulas or a spare trach. RN ADON #364 revealed she would text RT to find out where the supplies were kept. Observation revealed RN ADON #364 went back into Resident #52's room and again looked for trach supplies. Resident #52 confirmed there were no supplies in the room. Resident #52 then removed his inner cannula in front of RN ADON #364 and revealed the inner cannula had not been changed in weeks. Observation revealed the inner cannula was soiled and discolored. RN ADON #364 confirmed the inner cannula was more soiled than usual and confirmed the neck ties were also soiled. RN ADON #364 confirmed there were no trach supplies on the hall and revealed there was some in the supply room downstairs in the basement. RN ADON #364 revealed Resident #52 was the only resident with a trach. Observation at 10:45 A.M. revealed RN ADON #364 searched the central supply room and revealed she was not sure where the trach Residents Affected - Few 365381 Page 4 of 8 365381 11/17/2025 Wickliffe Country Place 1919 Bishop Rd Wickliffe, OH 44092

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 365381 Page 5 of 8 365381 11/17/2025 Wickliffe Country Place 1919 Bishop Rd Wickliffe, OH 44092

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.Findings include: 1. Record review for Resident #80 revealed an admission date of 08/23/23. Diagnoses included multiple sclerosis, spinal stenosis, and muscle weakness. Review of the Annual Minimum Data Set (MDS) dated [DATE] for Resident #80 revealed Resident #80 had a Brief Interview of Mental Status (BIMS) score of 12 (moderately cognitively impaired). Resident #80 required set up or clean up assistance for eating, dependent for oral hygiene, toileting hygiene, and personal hygiene. Resident #80 was frequently incontinent with bowel and bladder. Review of the care plan for Resident #80 dated 08/26/23 revealed Resident #80's preferences have been identified. Resident #80 preferred showers two times a week. An additional care plan dated 07/28/24 revealed Resident #80 had an activity of daily living (ADL) self care performance deficit. Interventions included staff were to assist with completion of ADL's on a daily basis so needs were met. Review of the care plan for Resident #80 dated 08/29/23 revealed Resident #80 had bowel incontinence related to impaired mobility, physical limitations, and MS. Interventions included bladder toileting program, check for wetness before meals, after meals, every evening, and on rounds during the night. Check resident, if he or she is continent, offer to assist with toileting, if he/she is incontinent, provide incontinence care. Observation on 09/20/25 at 9:14 A.M. of the A Hall revealed Licensed Practical Nurse (LPN) #275 was passing medications. Certified Nursing Assistant (CNA) #374 was passing breakfast trays. Interview with LPN #275 revealed she was the only nurse on the hall for 18 residents and CNA #374 was the only aide. LPN #275 revealed CNA #374 was passing the breakfast trays by herself. LPN #275 stated, There's not enough staff, I am still passing medications so I can't help her much. Interview on 09/20/25 at 9:15 A.M. with CNA #374 confirmed the breakfast cart arrived about 7:40 A.M.; CNA #374 confirmed she was still passing breakfast trays. Observation revealed at 9:20 A.M. CNA #374 served the last tray on the cart, Resident #98's tray. CNA #374 did not heat the food on the tray before serving it. Observation revealed residents were served pancakes, sausage and oatmeal. Resident #98 stated, The food is cold, it's not even a little warm it's that way all time. Interview with Resident #114 stated, it is cold, its every meal. Resident #80 also confirmed his food was served cold. The facility identified the following residents resided on the A Unit and would be affected by the late meal trays, Residents #80, #98, #99, #100, #101, #102, #103, #104, #105, #106, #107, #109, #110, #111, #112, #113, #114, and #115. Interview on 09/20/25 at 9:30 A.M. with CNA #374 revealed she did the best she could. CNA #374 stated, I have not even started checking and changing (residents for incontinence), there's not enough help over here, I still have to collect trays. CNA #374 confirmed her shift started at 7:00 A.M. and confirmed she will not start checking on her residents or initiating her first set of rounds for incontinence until about 10:30 A.M. because she had to answer call lights and collect (meal) trays. Observation on 09/20/25 at 10:25 A.M. with CNA #374 revealed the CNA provided incontinence care for Resident #80. At the time of the observation, it was revealed that Resident #80's fingernails were very long and embedded with a dark substance. Resident #80 had food in his beard and crumbs and pieces of food on his sheets. CNA #374 revealed that (the crumbs and pieces 365381 Page 6 of 8 365381 11/17/2025 Wickliffe Country Place 1919 Bishop Rd Wickliffe, OH 44092

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some of food) was his pizza from the night before. Resident #80 revealed he was last changed sometime in the middle of the previous night. Resident #80's incontinence brief was saturated with urine. The brief tore apart when removing it. CNA #374 confirmed this was the first time her shift she checked Resident #80 for incontinence. Resident #80 confirmed he would not mind if his nails were trimmed and confirmed he would like them to be cleaned. CNA #374 confirmed Resident #80 did not have a history of refusing care and confirmed his nails were embedded with a dark substance. Observation revealed CNA #374 completed incontinence care for Resident #80 but did not provide nail care before confirming she completed his A.M. care. Interview on 09/20/25 at 10:52 A.M. with Dietary Manager (DM) #319 and [NAME] #340 revealed breakfast trays were delivered to the A Hall at 7:45 A.M.; DM #319 revealed she does get complaints of cold food but the staff can heat the food up in the microwave. Interview on 09/20/25 at 12:19 P.M. with Resident #115 revealed sometimes staff take two hours to answer a call light and stated, The food is cold when we get it, they will heat it up but it's not as good though when heated in a microwave. 2. Record review for Resident #111 revealed an admission date of 02/08/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction. Review of the quarterly MDS for Resident #111 dated 06/19/25 revealed Resident #111 had a BIMS score of 15 (cognitively intact). Resident #111 was frequently incontinent of bowel and bladder, was dependent for toileting hygiene and chair/bed to chair transfers. Review of the care plan for Resident #111 dated 02/09/24 revealed bladder incontinence BPH, urinary retention, malignant neoplasm of prostate. Place urinal/bedpan within resident's reach. Interventions included to check resident if he is continent, offer to assist with toileting, if he/she is incontinent, remove wet or soiled clothing, briefs, provide incontinence care. Observation on 09/20/25 at 11:05 A.M. revealed LPN #275 had linen in her arms and walking into Resident #111's room. Resident #111 revealed he would talk to the surveyor after he was changed. LPN #275 revealed she would be changing him because he had not been checked or changed at all this shift and the CNA was with other residents. Interview on 09/20/25 at 11:32 A.M. with Resident #111 revealed he was also Resident Council President. Resident #111 stated, My whole bed was wet (with urine) when she changed me, not enough staff, I was last changed sometime on third shift, we bring it up in Resident Council, it don't matter. Resident #111 revealed his concerns were changing residents timely, cold food and not getting assistance at night to go to bed until 10:00 P.M. or 11:00 P.M. Interview on 09/20/25 at 11:37 A.M. with LPN #275 confirmed she changed Resident #111 and stated, I did change (Resident #111), he was saturated, the sheets were saturated, the bed was also wet with urine, we still have four more residents for first rounds. Resident #109 will be our last resident for first rounds. 3. Record review for Resident #109 revealed an admission date of 02/19/25. Diagnoses included chronic obstructive pulmonary disease and muscle weakness. Review of the quarterly MDS dated [DATE] revealed Resident #109 was severely cognitively impaired. Resident #109 was frequently incontinent of bowel and bladder, was dependent (on staff), for toileting hygiene, and chair/bed to chair transfers. Review of the care plan for Resident #109 dated 02/20/25 revealed Resident #109 had bladder incontinence related to impaired mobility. Interventions included to check resident if he/she is continent, offer to assist with toileting, if he is incontinent, remove wet or soiled clothing, briefs, provide incontinence care. Observation on 09/20/25 at 11:55 A.M. of incontinence care for Resident #109 provided by LPN #275 and CNA #374 revealed Resident #109's incontinence brief was saturated (with urine). The pad under the brief was wet. Observation revealed Resident #109's buttocks were red with a small area of light purple discoloration near the crease of both the right and left buttocks. LPN #275 confirmed the red buttocks with the discolored areas. Interview on 09/20/25 at 1:43 P.M. with the DON revealed CNA's should be doing rounds every two hours and as needed. CNA's 365381 Page 7 of 8 365381 11/17/2025 Wickliffe Country Place 1919 Bishop Rd Wickliffe, OH 44092

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some start at 7:00 A.M.; as soon as they come in they get their report and start their rounds. The DON revealed that an hour to pass meal trays is definitely too long and revealed nail care should be done with showers and anytime personal care is needed. Review of the facility policy titled, Incontinence Care dated 01/06/25 revealed the purpose was to keep skin clean, dry, free of irritation and odor, to prevent skin breakdown and prevent infections. This deficiency represents non-compliance investigated under Complaint Number 2620100. 365381 Page 8 of 8