The violations occurred when staff used g-tube de-clogger devices on at least one resident without physician orders, according to a January 31 inspection report. The devices were not part of facility policy, yet had been present at the 128-bed facility for an unknown period.
During the investigation, the director of nursing refused to participate and was terminated. The assistant director of nursing told inspectors she was unaware how long the de-cloggers had been at the facility — "they were just always here."
The immediate jeopardy citation was issued January 31 at 8:42 AM after inspectors discovered the unauthorized equipment during their annual survey. Federal regulations require nursing homes to follow physician orders precisely when caring for residents with feeding tubes, which deliver nutrition directly to the stomach through a surgically created opening.
Central Supply Tech revealed she had been ordering replacement de-cloggers when existing ones expired, with the most recent order placed in late 2024. She told inspectors the previous director of nursing had instructed staff to keep the devices on hand and had trained employees on their use, though no training materials or documentation could be located.
The facility immediately removed all de-clogger devices from the premises once they were identified during the survey. Central supply staff were instructed not to order any more devices regardless of who requested them and to notify the administrator if asked.
Three residents with feeding tubes were assessed head-to-toe by the assistant director of nursing immediately after the violations were discovered. No signs or symptoms of injury were found.
RN F, who was assigned to care for one of the affected residents, told inspectors she was unaware the resident lacked physician orders for tracheostomy care. She said she provided trach care every morning and as needed, including suctioning and daily cannula changes, but acknowledged the resident had no orders for these procedures.
"The potential risk of not having any physician orders would make it appear that they were not providing any care," RN F said.
The facility's policy required physician orders before performing tracheostomy care every 8 to 12 hours. The policy stated nurses must "verify physician's order, including: procedure to be done, frequency, physician's signature."
Multiple nurses interviewed after the immediate jeopardy was identified confirmed they had been re-trained on proper procedures. LVN K said she was told not to use de-cloggers and had "never used one before." She was instructed to call physicians for orders to send residents to hospitals for tube replacement or de-clogging.
RN N admitted she had used de-cloggers previously but "had not been trained at this facility." She said she knew how to use them from past experience but was now supposed to call physicians for hospitalization orders.
The facility's Regional Nurse Consultant said the previous director of nursing had ordered the devices to be kept on hand but could not locate any training materials or in-service documentation. She told inspectors the director "had refused to assist the investigation into de-clogger use, so she was termed."
All nursing staff received immediate re-training on the facility's policy prohibiting de-clogger use and requiring physician notification whenever feeding tubes become clogged. Staff who missed the initial in-services were required to complete training before their next scheduled shifts.
The immediate jeopardy was lifted January 31 at 3:30 PM after the facility's corrective actions, but violations remained at a lower level due to ongoing monitoring requirements.
Beyond the feeding tube violations, inspectors found the facility had operated without a full-time social worker since September 25, 2024, despite being required to employ one due to its capacity exceeding 120 beds. During a resident council meeting in October, residents mentioned they needed a social worker on staff.
Ten residents interviewed during the inspection confirmed the facility had been without a social worker "for months" and said they were being told administrators were actively searching for one. The new administrator, who started January 13, said interviews were conducted and an offer was made the day before the inspection ended.
Additional violations included improper food preparation and privacy curtain failures. The dietary manager prepared pureed mashed potatoes using a hand whisk instead of a blender, leaving chunks that created choking risks for residents requiring smooth, pudding-consistency foods.
"The risk if everything was not completely pureed, was the resident could choke," the dietary manager acknowledged after inspectors found lumps in the test tray.
Four residents lacked adequate privacy curtains in their shared rooms. Resident #3 said she "did not like not having privacy during incontinent care and the staff never bothered pulling that curtain." Her curtain hung by only four hangers while the rest draped to the floor.
Resident #47 had no privacy curtain at the foot of his bed and told inspectors "it bothered him to not have the curtain." He had requested staff provide a curtain or move him to a room with more privacy since being relocated to the room in September.
The housekeeping supervisor said she checked all curtains monthly, with the last inspection on January 13, but was unaware of the damaged and missing curtains. The maintenance supervisor revealed the facility lacked surplus curtains to replace ones being washed, leaving residents without privacy during cleaning cycles.
Infection control failures occurred when a medical assistant used the same blood pressure cuff on two residents without sanitizing it between uses. The assistant told inspectors she had sanitizing cloths in her cart but "forgot to use them."
"The risk of not sanitizing between resident uses could be spreading an infection from one resident to another," the medical assistant said.
The Regional Nurse Consultant initially told inspectors that reusable medical equipment only needed sanitizing between residents if visibly soiled. When asked about infection risks, she shrugged and provided no answer.
Wedgewood Nursing Home established weekly monitoring of nursing supply orders for one month to ensure de-cloggers were not being reordered. The director of nursing and administrator committed to reviewing nursing orders monthly at quality assurance meetings to maintain compliance.
The facility's response included updating policies for tube-fed resident care and implementing random checks of auto-flush pumps to ensure they matched physician orders. All corrective actions were documented as part of the plan to prevent future immediate jeopardy violations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wedgewood Nursing Home from 2025-01-31 including all violations, facility responses, and corrective action plans.