Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Wickliffe Country Place during CMS and state inspections, most recent first.
Insufficient staffing resulted in delayed meal service and untimely incontinence care for all residents on one unit. Only one LPN and one CNA were available, causing breakfast trays to be served late and food to be cold. Several residents were not checked or changed for incontinence until late morning, with saturated briefs and wet bedding observed. Staff and residents reported ongoing issues with delayed assistance and unmet care needs.
A resident with a history of bipolar and schizoaffective disorder did not receive several doses of a prescribed controlled medication due to it being unavailable, despite pharmacy records showing it was delivered and signed for by an LPN. The facility did not conduct a thorough investigation into the missing medication, failed to review all relevant documentation, and did not follow all required procedures for investigating potential misappropriation.
A resident with a tracheostomy did not have necessary trach supplies, such as trach ties and inner cannulas, readily available, and required care was not completed as ordered. Staff were unable to locate supplies when needed, and several LPNs reported that the resident performed his own trach care without monitoring, yet documented the care as completed. The resident confirmed his inner cannula had not been changed for weeks, and staff interviews revealed inconsistent practices and lack of adherence to facility policy regarding trach care.
The facility failed to follow the renal diet menu, affecting multiple residents. Two residents with severe kidney conditions received breakfast trays that did not align with their prescribed renal diets, as confirmed by staff interviews. The facility's menu included items not suitable for a renal diet, leading to non-compliance with therapeutic diet policies.
The facility's kitchen was found to be unsanitary, with dust and food debris on garbage can lids, floors, and equipment. Undated food items were found in the refrigerator, and potential cross-contamination occurred during food preparation. The Food Service Director verified these issues.
The facility failed to maintain a sanitary environment around the dumpster area, potentially affecting all 126 residents. Observations revealed garbage bags, soiled briefs, and other waste scattered around dumpsters. The Food Service Director confirmed the issue, but no policy was provided for maintaining cleanliness.
A resident's advanced directives were inaccurately recorded in the electronic medical record, showing a full code status, while a DNR Comfort Care-Arrest form was present in the hard chart. Interviews with an LPN and the DON confirmed the discrepancy, and the facility's policy lacked guidance on ensuring accurate documentation of advanced directives.
A resident with intact cognition and specific medical conditions was not offered showers as per their care plan and preferences, despite being cooperative. Facility records showed discrepancies in documentation, with no reattempts noted for recorded refusals and no showers offered since admission, contrary to the facility's policy.
A resident with impaired cognition and requiring maximum assistance for personal hygiene was observed to have facial hair, which she wished to be shaved. Despite staff acknowledging the need, the issue was not addressed promptly, as the facial hair remained during subsequent observations.
A resident at high risk for falls due to impaired mobility and other conditions did not have a floor mat placed next to her bed as required by her care plan. Despite being added as a fall intervention after a previous fall, observations and staff interviews confirmed the absence of the mat, highlighting a deficiency in implementing necessary fall prevention measures.
A resident with a feeding tube was receiving enteral nutrition at an incorrect rate of 65 ml per hour instead of the prescribed 50 ml per hour. This discrepancy was due to an LPN continuing the previous nurse's incorrect setting without verifying the physician's order, contrary to facility policy.
A facility failed to label and date enteral feeding bags for a resident dependent on tube feeding, despite physician orders requiring such labeling. An LPN confirmed the omission during an observation, and the DON acknowledged the labeling requirement. The facility's policy lacked instructions for labeling feeding bags, contributing to the deficiency.
A facility failed to implement enhanced barrier precautions for a resident with a feeding tube. An LPN provided high contact care without wearing a gown, despite signage indicating the need for enhanced precautions. The LPN misunderstood the requirements, believing they applied only to highly contagious conditions. The DON confirmed the need for gown use, as per facility policy and CMS guidelines, to prevent MDRO transmission.
The facility failed to notify relevant parties of significant weight changes for two residents. One resident experienced a 17.1% weight loss over three months without physician or guardian notification, and another had a 21% weight loss with no reweigh or notification. Facility policies lacked clear guidelines for such notifications, leading to non-compliance.
The facility failed to monitor and document weights for two residents, leading to significant weight loss. One resident lost 17.1% of her weight over three months without notification to her physician or guardian. Another resident experienced a 21% weight loss, with a reweigh not documented in the electronic record. The facility lacked a full-time dietician, and policies did not ensure notification of significant weight changes.
Insufficient Staffing Leads to Delayed Meals and Incontinence Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the daily needs of residents on the A unit, resulting in delayed meal service and untimely incontinence care for all 18 residents on the unit. Observations and interviews revealed that only one LPN and one CNA were assigned to the unit, which led to significant delays in serving breakfast trays, with the last tray being served nearly two hours after arrival. Multiple residents reported that their food was consistently cold, and staff confirmed that they did not have enough help to serve meals promptly or reheat food as needed. In addition to meal delays, incontinence care was not provided in a timely manner. Three residents reviewed for incontinence care had not been checked or changed until late in the morning, with one resident not receiving care until after 10:25 A.M. and another not being changed until after 11:00 A.M. Observations showed that residents' briefs were saturated with urine, bedding was wet, and one resident had red and discolored buttocks. Staff interviews confirmed that rounds for incontinence care were significantly delayed due to insufficient staffing, and that nail and personal hygiene care were also neglected. Residents and staff consistently reported that call lights were not answered promptly, and that assistance with personal care and meals was delayed. The facility's own policies required more frequent incontinence checks and timely meal service, but these were not followed due to inadequate staffing levels. The deficiency affected all residents on the A unit, as confirmed by the facility census and staff interviews.
Failure to Investigate Missing Controlled Medication
Penalty
Summary
A deficiency occurred when the facility failed to thoroughly investigate a missing controlled medication for a resident with diagnoses including bipolar disorder and schizoaffective disorder. The resident was cognitively intact and had an order for clonazepam, a Schedule IV controlled substance, to be administered twice daily. Medication Administration Records (MAR) showed that several doses of clonazepam were not administered over a period of days, with documentation indicating the medication was either refused, unavailable, or on order. On multiple occasions, nursing staff documented that the medication was not available, and pharmacy records indicated that the medication had been delivered and signed for by a nurse. The investigation revealed inconsistencies in the medication delivery and receipt process. The nurse who signed for the medication on the pharmacy packing slip later stated she did not receive the clonazepam, only another medication, and was not asked to complete a drug screen. The facility was unable to locate the medication or the signature/count log used to track controlled substances. The nurse involved had previously received training on controlled substance procedures, but there was no evidence of further education following the incident. Additionally, the facility's investigation did not include a review of the MAR and nursing notes that documented the medication's unavailability, nor was an investigation initiated when pharmacy notes indicated a refill was requested too soon. Interviews with facility administration and pharmacy staff confirmed that the medication was delivered and signed for, but the facility did not conduct a comprehensive investigation to determine the whereabouts of the missing medication or the circumstances leading to its disappearance. The facility's policy required immediate reporting and thorough investigation of such incidents, including review of employment records and documentation of investigative steps, but these actions were not fully carried out. The deficiency was identified as a failure to properly investigate the misappropriation of a controlled medication for one resident.
Failure to Provide Required Tracheostomy Supplies and Care
Penalty
Summary
A deficiency was identified when a resident with a tracheostomy did not have necessary trach supplies readily available, and required care and treatment were not completed as ordered. The resident, who had diagnoses including tracheostomy, dysphagia, and moderate cognitive impairment, was observed with soiled and dingy trach ties and reported that he had run out of trach ties about a month prior. Facility staff, including the RN Assistant Director of Nursing and LPN, were unable to locate trach ties, inner cannulas, or a spare trach in the resident's room, medication cart, or treatment cart. The search for supplies revealed that while some trach supplies were eventually found in the central supply room, trach ties were not available at all. Interviews with staff revealed inconsistent practices regarding trach care. Several LPNs stated that the resident performed his own trach care, and they did not monitor or assist him, but still documented the care as completed per physician orders. The resident confirmed that his inner cannula had not been changed for weeks and that he had informed nursing staff of this. The RN ADON and Infection Preventionist confirmed that trach supplies, including ties and cleaning materials, should be kept at the bedside and that nurses are responsible for performing and documenting trach care as ordered. Further interviews with the respiratory therapist and other staff indicated that the resident did not keep supplies in his room due to using them up quickly, and that the RT only visited twice a week and did not provide direct care. The facility's policy required verification of physician orders, gathering of supplies, assessment and cleaning of the stoma, changing of the inner cannula, and replacement of trach ties if soiled, with proper documentation. The failure to ensure supplies were available and care was completed as ordered resulted in non-compliance with required standards for respiratory care.
Non-Compliance with Renal Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed renal diet menu for residents, affecting two specific residents and ten additional residents on a renal diet. Resident #115, diagnosed with end-stage renal disease and other conditions, was observed to have received a breakfast tray that did not align with the renal diet requirements. Similarly, Resident #129, with severe chronic kidney disease and malnutrition, also received a breakfast tray that did not meet the specified renal diet. Both residents received scrambled eggs and a blueberry muffin, contrary to the renal diet menu that should have included scrambled eggs and pineapple instead of a muffin. Interviews with the Certified Nursing Assistant and the Dietary Manager confirmed the discrepancy between the meals served and the renal diet menu. The facility's menu for the day included items not suitable for a renal diet, such as hash browns and blueberry muffins, which were not supposed to be served to residents on a renal diet. The Dietary Manager acknowledged that the spreadsheet for renal diets was not followed, leading to the incorrect meal service for all residents requiring a renal diet. This oversight was documented under Complaint Number OH00161451, indicating non-compliance with the facility's policy on therapeutic diets.
Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, which had the potential to affect all residents except for three who did not receive nutrition by mouth. During observations, surveyors noted several deficiencies, including garbage can lids covered with dust and food debris, a paper inspection tag on the floor covered with brownish debris, and a kitchen floor littered with food debris and grime. Additionally, a shelving unit holding clean sheet pans was dusty, and a walk-in refrigerator contained a bag of green/brownish lettuce that was not dated. Food scoops were stored in a plastic container surrounded by food debris, and the microwave's exterior was covered with dust and debris. A mouse trap on the floor had a large fork, straws, and food debris on it, and a plastic container holding lids was covered with thickening powder. Further observations revealed juice dispenser nozzles covered with brown liquid, a reach-in cooler with an undated turkey sandwich, and containers of thickening agents and milk that were opened and not dated. A white liquid substance was found on the bottom shelf of the cooler, and the small refrigerator's door had white debris. The dry storage area had condiment packets and debris on the floor. An exhaust fan near the tray line was covered with blackish, brownish dust. During tray line preparation, a Regional District Manager sanitized a cutting board but then placed thawed turkey patties and a clean knife on it, leading to potential cross-contamination. The Food Service Director verified these findings and directed staff to address the issues.
Unsanitary Conditions Around Dumpster Area
Penalty
Summary
The facility failed to maintain a sanitary environment around the dumpster area, which had the potential to affect all 126 residents. Observations made on September 23, 2024, at 8:54 A.M. revealed that plastic garbage bags filled with food, soiled adult briefs, latex gloves, plastic utensils, and Styrofoam cups were scattered around three dumpsters in the parking lot. During the observation, the Food Service Director confirmed the state of the area and stated that the garbage would be cleaned up immediately. The facility did not provide a policy related to maintaining cleanliness around the dumpsters.
Inaccurate Advanced Directives for Resident
Penalty
Summary
The facility failed to ensure that Resident #32's advanced directives were accurately reflected in the electronic medical record, leading to conflicting information regarding the resident's code status. Resident #32, who had diagnoses including schizophrenia, diabetes, moderate protein-calorie malnutrition, and hypertension, was documented as having a Do Not Resuscitate (DNR) Comfort Care-Arrest status on a form completed by a Nurse Practitioner. However, the electronic medical record and physician orders indicated that the resident was to be a full code, creating a discrepancy in the resident's care instructions. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed the inconsistency between the electronic medical record and the hard chart. The facility's policy on Advanced Care Planning did not address the need for ensuring that advanced directives were accurately recorded in the electronic medical record or provide guidance on where staff should verify a resident's code status in the event of an emergency. This oversight affected the accuracy of Resident #32's care plan and could potentially impact the resident's treatment in critical situations.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident received bathing as planned and/or as requested, affecting one resident out of five reviewed for showers. The resident, who was admitted with diagnoses including type II diabetes mellitus, stage III chronic kidney disease, and a history of transient ischemic attacks, had a BIMS score indicating intact cognition and required set-up assistance for bathing. The care plan and facility records indicated a preference for showers, scheduled twice weekly. However, the resident reported never being offered a shower since admission, only being given a washcloth to wash up, despite being cooperative and not refusing care. Facility records showed shower refusals on two occasions, but there were no documented reattempts or progress notes indicating refusals. Interviews with the resident and staff confirmed the lack of shower offers and discrepancies in documentation. The facility's policy required scheduling showers to accommodate resident preferences and documentation of completed showers, which was not adhered to in this case.
Failure to Maintain Personal Hygiene for a Resident
Penalty
Summary
The facility failed to provide necessary assistance to maintain personal hygiene for Resident #69, who was one of five residents reviewed for activities of daily living. Resident #69, admitted with diagnoses including depression and type two diabetes, had impaired cognition and required maximum assistance for personal hygiene. The resident's care plan indicated a self-care performance deficit related to impaired mobility and generalized weakness, with interventions for staff to provide total oral care and extensive assistance with personal hygiene. Despite these interventions, observations on two separate occasions revealed that the resident had facial hair on her chin, which she expressed a desire to have shaved. Staff acknowledged the need to address the issue but failed to do so in a timely manner, as evidenced by the continued presence of facial hair during subsequent observations.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions as identified in the care plan for a resident, leading to a deficiency in ensuring a safe environment free from accident hazards. The resident, who was at high risk for falls due to impaired mobility, generalized weakness, schizophrenia, and neuropathy, was supposed to have a floor mat placed next to her bed as a fall intervention. Despite this intervention being added to her care plan after a fall, observations on multiple occasions revealed that the floor mat was not present, and staff interviews confirmed the absence of the mat. The resident's medical record indicated she was cognitively impaired and dependent on staff for assistance with mobility and other activities of daily living. After a fall incident where the resident was found on the floor, the interdisciplinary team decided to add a floor mat as a preventive measure. However, subsequent observations and staff interviews showed that this intervention was not implemented, indicating a failure to adhere to the care plan and facility policy regarding fall prevention.
Incorrect Enteral Tube Feeding Rate for Resident
Penalty
Summary
The facility failed to ensure that a resident's enteral tube feeding was administered at the correct rate as per the physician's order. The resident, who had a history of heart failure, diabetes, cerebral infarction, and protein-calorie malnutrition, was admitted with a feeding tube to assist in maintaining or improving nutritional status due to difficulty swallowing. The care plan specified that the feeding should be administered at 50 ml per hour continuously, as recommended by the dietician and ordered by the physician. However, during an observation, it was found that the feeding was running at 65 ml per hour, which was not in accordance with the physician's order. An interview with the LPN responsible for the resident's care revealed that the tube feeding was set at the incorrect rate by a previous nurse, and the LPN continued the same setting without verifying the order. This oversight was contrary to the facility's policy, which required checking the physician's order and programming the pump accordingly. The facility's policy also emphasized the importance of ensuring safe and effective administration of enteral tube feeding, which was not adhered to in this instance.
Failure to Label Enteral Feeding Bags
Penalty
Summary
The facility failed to ensure that enteral feedings were labeled and dated appropriately, affecting one resident who was dependent on tube feeding. The resident, who had severe cognitive impairment and was dependent for all activities of daily living, had a physician's order to change the enteral feeding bag and syringe every night shift and label it with the date. However, during an observation, it was found that the enteral feeding bag connected to the resident was unlabeled and undated, lacking the resident's name, product name, date, or time. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the facility's practice was to follow physician orders and label the tube feeding bags with the necessary information, as tube feeding products are only good for 24 hours. Despite this, the facility's policy on enteral tube feeding did not include instructions for labeling the bags with the product it contained and the date/time it was hung, contributing to the deficiency.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were utilized for a resident during high contact care. Resident #108, who had a feeding tube and was dependent on staff for most activities of daily living, was observed to have signage indicating enhanced barrier precautions. However, an LPN entered the resident's room and provided high contact care without wearing a gown, only donning gloves. This care included repositioning the resident, obtaining vital signs, and administering medications through the feeding tube. The LPN admitted to not wearing a gown and was under the impression that enhanced barrier precautions were only necessary for residents with highly contagious conditions. The Director of Nursing confirmed that the LPN should have worn a gown during the care provided. The facility's policy and a memorandum from the Centers for Medicare & Medicaid Services indicated that enhanced barrier precautions, including the use of gowns and gloves, were required for residents with indwelling medical devices, such as feeding tubes, to reduce the transmission of multidrug-resistant organisms.
Failure to Notify of Significant Weight Changes
Penalty
Summary
The facility failed to ensure proper notification of significant weight changes for two residents, which is a requirement for maintaining adequate care. Resident #32 experienced a significant weight loss of 17.1% over a period from February to May 2024, with no documentation indicating that the physician or legal guardian was informed. The resident's weight was not recorded for over three months, and there was no evidence of any reason for this lapse, such as hospitalization or refusal. Interviews with the dietician and the Director of Nursing confirmed the absence of notification and the failure to complete regular weight checks. Resident #16 also experienced a significant weight loss of 21% between July and August 2024, with no recorded notification to the resident, responsible party, or physician. The dietician questioned the validity of the weight and requested a reweigh, which was not completed or documented in the electronic medical record. A re-weight was eventually done in September, but it was not entered into the electronic system, leading to further confusion and lack of communication. The facility's policies on nutrition intervention and changes in a resident's condition did not adequately address the need for notifying relevant parties about significant weight changes. The lack of documentation and communication regarding these significant weight losses represents a deficiency in the facility's compliance with required notification procedures, as confirmed by interviews with staff and review of the facility's policies.
Failure to Monitor and Document Resident Weights
Penalty
Summary
The facility failed to ensure timely monitoring and documentation of residents' weights, which led to significant weight loss in two residents. Resident #32, who had diagnoses including schizophrenia, diabetes, moderate protein-calorie malnutrition, and dysphagia, experienced a 17.1% weight loss over three months without any recorded weights during that period. The facility did not notify the physician or legal guardian of this significant weight change, and there was no weight recorded for September 2024 at the time of review. The facility lacked a full-time dietician, and the interim dieticians were not aware of any other location for weight records besides the electronic medical record. Resident #16, diagnosed with dementia, emphysema, mild protein-calorie malnutrition, and dysphagia, experienced a 21% weight loss. The weight was questioned by the dietician, who requested a reweigh, but there was no evidence that a reweigh was completed in the electronic medical record. A reweigh was later found in a weight book, but it had not been communicated to the dieticians. The facility also failed to notify the physician or responsible party of the significant weight loss. The facility's policies on nutrition intervention and change in a resident's condition did not include procedures for notifying physicians or responsible parties of significant weight changes. The Director of Nursing confirmed the lack of timely weight monitoring and documentation, as well as the absence of a full-time dietician, which contributed to the oversight in managing the residents' nutritional needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wickliffe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highland Pointe Health & Rehab Center | 2.7 mi | ★★★★★ | 10 | 1 |
| Grande Pointe Healthcare Commu | 2.9 mi | ★★★★★ | 3 | 0 |
| Altercare Of Mayfield Village, Inc | 3 mi | ★★★★★ | 1 | 1 |
| Heritage Healthcare Of Euclid | 3 mi | ★★★★★ | 1 | 0 |
| Mount Saint Joseph Rehab Center | 3.2 mi | ★★★★★ | 0 | 0 |
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