Wedgewood Nursing Home

F-F693 Plan of Removal

Immediate Actions taken

I. Resident specific

On [DATE REDACTED] resident was immediately assessed BY ADON head to toe without any noted signs or symptoms of injury.

On [DATE REDACTED] the 2 other g-tube residents with g-tubes were immediately assessed By ADON LVN head to toe without any noted signs or symptoms of injury.

II. System changes

On [DATE REDACTED] all g-tube de-clogger devices were immediate removed from the facility at the time they were identified during the annual survey as this is not part of our policy.

On [DATE REDACTED] all g-tube de-cloggers were brought to the DON office by Central supply for immediate destruction.

On [DATE REDACTED] Central supply and ADON's were immediately instructed to not order any g-tube de-cloggers moving forward no matter who requested them. And to notify the Administrator if asked.

On [DATE REDACTED] Director of Nurses was terminated for failure to participate in this investigation.

On [DATE REDACTED] Facility policy was updated by VP of clinical services to include problem solving to prevent g-tube clogging.

III. Education

On [DATE REDACTED] all licensed nurses were immediately in-serviced by ADON on the facility policy is not to use g-tube de-cloggers and on the facility policy on care of the tube fed resident (prevention of gastrointestinal complications, prevention of mechanical complications, prevention of dignity issues, observations and reporting)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 23 455572 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455572 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wedgewood Nursing Home 6621 Dan Danciger Rd Fort Worth, TX 76133

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)

F 0693 On [DATE REDACTED] all licensed nurses were immediately in-serviced by ADON on following physicians orders for administering flushes. This in-service included validating the pump was programmed to match the Level of Harm - Immediate physician's order at the beginning of their shift. jeopardy to resident health or safety On [DATE REDACTED] all nurses were in-serviced by ADON on the updated facility policy for care of the tube fed resident (which includes the notification of the physician anytime a g-tube is clogged). Residents Affected - Few All staff that did not attend the in-service's will be in-serviced on all education completed by ADON prior to their next scheduled shift.

IV. Monitoring

Nursing supply orders will be pulled weekly x 1 month to ensure de-cloggers are not being ordered.

DON/Designee will do random checks weekly x 4 weeks to ensure auto flush pumps are programmed to match the flush ordered by the physician.

DON and Administrator will review nursing orders monthly at the facility QAPI meeting to ensure continued compliance.

Monitoring of the Immediate Jeopardy continued:

Record review on [DATE REDACTED] at 9:20 AM of Resident #67's MAR indicated he had no medications via g-tube scheduled until bedtime.

Interview on [DATE REDACTED] at 9:25 AM a family member of Resident #67 was bedside, the family member stated

they were bedside the majority of the day. The family member described how the nurse administers the resident's medications via the g-tube. They described the medications being in separate cups, the nurse administers one cup at a time followed by some water. The medications were allowed to go in on their own,

they never used the syringe to force the medications in.

Observation on [DATE REDACTED] at 9:25 AM of Resident #67's feeding pump indicated he was receiving Glucerna at 65 ml/hr and a 100 ml water flush was scheduled every two hours.

Record review on [DATE REDACTED] at 9:30 AM of Resident #67's nursing notes indicated no issues with his g-tube clogging since [DATE REDACTED].

Record review on [DATE REDACTED] at 9:50 AM of Resident #70's MAR reflected she was not scheduled to receive any medications via g-tube until the next morning.

Record review on [DATE REDACTED] at 9:53 AM of Resident #70's nursing notes reflected there had been no issues with her g-tube clogging since [DATE REDACTED].

Observation on [DATE REDACTED] at 9:55 AM of Resident #70's feeding pump reflected her Glucerna was infusing at 50 ml/hr and a 125 ml water flush was scheduled every 4 hours.

Record review on [DATE REDACTED] at 10:00 AM of Resident #58's MAR revealed she was not scheduled to receive any medications via her g-tube until bedtime.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 23 455572 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455572 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wedgewood Nursing Home 6621 Dan Danciger Rd Fort Worth, TX 76133

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)

F 0693 Record review on [DATE REDACTED] at 10:03 AM of Resident #58's nursing notes reflected there were no issues with her g-tube clogging since [DATE REDACTED]. Level of Harm - Immediate jeopardy to resident health or Observation on [DATE REDACTED] at 10:05 AM of Resident #58's feeding pump reflected she was receiving Glucerna at safety 55 ml/hr with a 75 ml water flush every four hours.

Residents Affected - Few Attempts to interview RN G were made via phone on [DATE REDACTED] at 11:10 AM and 1:40 PM in an attempt to what size and length of de-clogger to use on Resident #67's g-tube.

Interview on [DATE REDACTED] at 11:20 AM with the ADON revealed she did not know how long de-cloggers had been

in the facility, they were just always here.

Interview on [DATE REDACTED] at 11:33 AM with the Central Supply Tech revealed she had been in the position since around [DATE REDACTED] and the de-cloggers were in stock at that time. Several were expired so she ordered more to replace them. The last time she ordered a de-clogger was on [DATE REDACTED]. She stated on [DATE REDACTED] all the de-cloggers were turned over to the Administrator. She was advised not to re-order them and to notify the DON if she was asked by anyone to order one.

Interview on [DATE REDACTED] at 11:40 AM with the RNC revealed the previous DON had refused to assist the investigation into de-clogger use, so she was termed. The RNC stated as far as she could determine the previous DON had ordered them to be kept on hand. The DON had stated she trained staff on the use of de-cloggers, but the RNC was unable to locate any training material, no in-services, or anything to indicate de-clogging training had been done with staff. The RNC stated on [DATE REDACTED] all nursing staff were in-serviced by herself and the ADONs that de-cloggers were not to be used on clogged g-tubes. The nurse was to contact the physician for orders to send the resident to the hospital to have the g-tube replaced or de-clogged.

Interview on [DATE REDACTED] at 12:22 PM with LVN K revealed she had been in-serviced by the ADON on g-tubes.

She stated she was not allowed to use the de-clogger, but she had never used one before. She stated she was to call the physician for orders to send the resident to the hospital. If the physician ordered it, they could try to milk or massage the tube to unclog it.

Interview on [DATE REDACTED] at 12:25 PM with LVN H revealed she had been recently in-serviced on g-tubes. She was to call the physician for orders to send them to the hospital. The physician could order them to attempt to unclog the tube by massaging or milking the tube. If the interventions were unsuccessful the resident was to go to the hospital.

Interview on [DATE REDACTED] at 12:30 PM with RN F revealed she had recently been in-serviced on g-tubes. If the resident's g-tube was clogged they were not to use the de-clogger, they were to call the physician for orders to send the resident to the hospital. The physician could order them to attempt to unclog the tube using water

on the pump like a bolus or massaging it.

Interview on [DATE REDACTED] at 12:39 PM with LVN L revealed she had been in-serviced on g-tubes recently. She stated it was made clear that de-cloggers were not to be used, and they had been removed from the facility.

They were to call the physician for orders to send the resident to the hospital for replacement of the g-tube.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 23 455572 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455572 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wedgewood Nursing Home 6621 Dan Danciger Rd Fort Worth, TX 76133

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)

F 0693 Interview on [DATE REDACTED] at 1:55 PM with RN-J revealed he had been in-serviced on g-tubes. He stated if the tube was clogged, he was to call the physician for orders to send them to the hospital, or to try massaging the Level of Harm - Immediate tube to unclog it. jeopardy to resident health or safety Phone interview on [DATE REDACTED] at 2:00 PM with LVN M revealed she had been in-serviced on g-tubes. She stated it was made clear that de-cloggers were not allowed to be used, and they had been removed from the Residents Affected - Few facility. She stated she had never used a de-clogger and had never been trained on them. She stated she was to call the physician for orders.

Interview on [DATE REDACTED] at 2:24 PM with RN N revealed she had been in-serviced on g-tubes recently. She stated de-cloggers had been removed from the facility. She stated she had used the de-clogger in the past, but she had not been trained at this facility. She stated she knew how to use them from past experience. She stated she was now supposed to call the physician for orders to send the resident to the hospital.

Interview on [DATE REDACTED] at 2:28 PM with LVN O revealed he had been in-serviced on g-tubes recently. He stated if the tube is clogged, he can try to massage it first, and if that didn't work he would call the physician for orders to send the resident out.

Telephone interview on [DATE REDACTED] at 3:10 PM with RN Q revealed she had been in-serviced on g-tubes. She stated if the tube was clogged, she was to call the physician for orders. The physician could order the resident sent out, or to try milking the tube before sending the resident out. She stated de-cloggers were not to be used.

Record review of the facility's monitoring tool Weekly Monitoring of G-tube Flush reflected it had been completed weekly since [DATE REDACTED].

Record review of the facility's Ad Hoc QAA meeting, held on [DATE REDACTED], reflected physician orders, g-tubes orders had been reviewed. Discussion of g-tube de-clogging process was held. All de-clogging tools were removed, and all nurses were to be educated on the new process.

An Immediate Jeopardy was identified on [DATE REDACTED] at 8:42 AM. While the Immediate Jeopardy was removed

on [DATE REDACTED] at 3:30 PM, the facility remained out of compliance at a scope of isolated with no actual harm with

a potential for more than minimal harm that is not immediate jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 23 455572 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455572 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wedgewood Nursing Home 6621 Dan Danciger Rd Fort Worth, TX 76133

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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44140 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that a resident who needed Residents Affected - Few respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 6 residents (Resident #67) reviewed for respiratory care.

The facility failed to ensure there was a physician order for Resident #67's tracheostomy care, suction tubing, and emergency trach kit.

This failure could place residents with a tracheostomy requiring tracheostomy care at risk for respiratory distress, hospitalization s, and a decline in their quality of life.

Findings included:

Record review of Resident #67's Admission Record dated 01/16/25 reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED].

Record review of Resident #67's quarterly MDS assessment dated [DATE REDACTED] reflected his diagnoses included cerebral artery (supplies blood to the bran), aphasia (language disorder) following cerebral infarction (stroke), tracheostomy status (procedure to help air and oxygen reach the lungs), gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach), dysphagia (swallowing difficulties) following cerebral infarction, respiratory failure, and renal failure. Resident #67's BIMS score was not complete. The MDS further revealed Section O - Special Treatments, Procedures, and Programs indicated resident received oxygen therapy and tracheostomy care.

Record review of Resident #67's care plan revised date 10/11/24 reflected:

Tracheostomy:

Resident has a tracheostomy and is at risk for potential complications such as weight loss, increased secretions, congestion, infection, and respiratory distress. Goal: Resident will have clear airways with adequate ventilation through the next review date. Interventions: Provide oxygen, humidity, tracheostomy care, and tubing changes as indicated by physician's orders.

Record review of Resident #67's January MAR revealed O2 @ 3 LPM via Trach. Notify MD if SpO2 falls below 90% while using O2. Perform resp . assess if O2 applied. every shift related to ACUTE RESPIRATORY FAILURE WITH HYPOXIA (lungs cannot effectively transfer oxygen from the air to the bloodstream, resulting in low blood oxygen levels). Start date 01/14/25. There were no physician orders for Trach care or Suction or Emergency supplies.

Observation on 01/14/25 at 11:02 AM revealed Resident #67 lying in bed. The resident had a tracheostomy and feeding tube. The resident was not able to answer questions. An emergency kit was at the resident's bedside. Resident #67's family member was in the room visiting. The Family Member stated Resident #67 had a stroke and admitted to the facility with a trach.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 23 455572 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455572 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wedgewood Nursing Home 6621 Dan Danciger Rd Fort Worth, TX 76133

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)

F 0695 Interview on 01/15/25 at 1:32 PM RN F stated she was the nurse assigned to Resident #67. She stated Resident #67 admitted to the facility with a trach. She stated she provided trach care every morning and as Level of Harm - Minimal harm or needed to Resident #67. She stated she completed suctioning and changes the cannula every day. RN F potential for actual harm reviewed Resident #67's physician orders and stated the resident did not have any trach care orders. She stated a couple of weeks ago, unknown of the exact date, Resident #67 had gone to the hospital. She stated Residents Affected - Few the orders might have been deleted. RN F stated the admitting nurse should have put in orders and if the orders were missing the admitting nurse should have contacted the doctor. She stated she was unaware Resident #67 did not have any trach care orders. She stated the potential risk of not having any physician orders would make it appear that they were not providing any care to Resident #67.

Record review of Resident #67's January MAR as of 01/15/25 1400 [2:00 PM] reflected the following:

Suction Q shift & PRN. Report abnormal secretions to MD every shift related to TRACHEOSTOMY STATUS.

Verify the following emergency supplies are at the bedside (above the HOB): Ambu bag Obturator Water-soluble lubricant, Trach in the size ordered, Trach in a size below and size above (preferably), E- cylinder at the bedside for emergency O2 use. every shift for Presence of Trach

Interview on 01/15/25 at 2:29 PM with ADON A revealed she was the ADON assigned to the North Station where Resident #67 resided. She stated she was unsure why Resident #67's trach care orders were not showing. She stated she could assure that Resident #67 had trach care physician orders and did not understand how they could disappear from the system. She stated it was the responsibility of the admitting nurse to put in orders. She stated during morning stand up the DON and the ADONs audit physician orders upon return from the hospital. She stated she was unsure if the physician orders were put in the system. However, she had seen the orders prior to today (01/15/25). ADON A stated Resident #67 had been receiving trach care every shift and PRN . She stated there was no potential risk if they did not have any physician orders due to the resident continued to receive care.

Interview on 01/16/25 at 2:17 PM with RNC revealed her expectations were for the nurses to obtain physician orders and put them in the system. She stated Resident #67 should have had orders for trach care. She stated she was unaware Resident #67 did not have any physician orders. She stated it was the responsibility of the DON and the ADON to ensure physician orders were obtained. She stated the potential risk of not having physician orders could lead to resident trach care not getting done.

Record review of the facility's Respiratory Care Services: Tracheostomy Care policy, review date 2020, reflected the following:

To aseptically clean a tracheostomy site and trach tube free from mucous buildup,

maintaining tube patency, reducing risk of infection and maintaining skin integrity at the stoma site.

Tracheostomy care should be provided every 8 to 12 hours or as indicated by order of physician.

1. Verify physician's order, including: procedure to be done, frequency, physician's signature

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 23 455572 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455572 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wedgewood Nursing Home 6621 Dan Danciger Rd Fort Worth, TX 76133

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)

F 0695 Record review of the facility's Following Physician Orders policy, dated 09/28/21, reflected the following:

Level of Harm - Minimal harm or The policy provide guidance on receiving and following physician orders. potential for actual harm .For consulting physician/practitioner orders received via telephone, the nurse will: Residents Affected - Few a. Document the order on the physician order form, notating the time, date, name and title of the person providing the order, and the signature and title of the person receiving the order.

b. Follow facility procedures for verbal or telephone orders including noting the order, submitting to pharmacy, and transcribing to medication or treatment administration record.

c. Carry out and implement physician orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 23 455572 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455572 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wedgewood Nursing Home 6621 Dan Danciger Rd Fort Worth, TX 76133

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)

F 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 44140

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 or 2 meals (lunch) reviewed for food meeting residents' needs.

The facility failed to prepare and serve pureed mash potatoes as a pudding consistency for residents who required pureed diets during the lunch meal on 01/15/25.

This deficient practice could affect residents and place them at risk of not receiving meals that meet their needs

Findings included:

Record review of Week-At-A-Glance Texas 4 Week 4 menu revealed the menu for the lunch service was . Boiled Potato .

Observation on 01/15/25 at 11:16 AM of the Dietary Manager pureed mashed potatoes with a hand whisk, was observed removing the potato skins and then proceeded to place it on the steam table. The Dietary Manager did not check the consistency or ensure it was all blended to have a pudding consistency.

Observation of the test tray on 01/15/25 beginning at 12:55 PM with the Dietary Manager, the test tray included the regular textured menu items and the pureed menu items. Pureed mashed potatoes did not have

a smooth/pudding consistency. The mashed potatoes had chunks of potato not fully mashed. The Dietary Manager stated when she prepared the mashed potatoes, it appeared it was smooth. She stated she used a whisk instead of the blender. She stated she thought it had the correct consistency. She stated the risk if everything was not completely pureed, was the resident could choke.

Follow-up interview on 01/15/25 at 3:43 PM with the Dietary Manager revealed her expectation was for pureed food to have a smooth/ pudding consistency. She stated when she was preparing the mashed potatoes, she thought it was smooth until she tried the test tray, and it was not. She stated the mashed potatoes had lumps in it. She stated she normally oversees her staff complete the puree meals; however,

she was the one who prepared the mashed potatoes. She stated the potential harm to residents was the possibility chocking.

Record review of the facility's current, undated Pureed Recipe Book General Guidelines policy reflected:

When processing foods to obtain a pureed consistency, it is important to know that we want a moist mashed potato consistency. If the product is too dry it may cause difficulty in swallowing too moist may cause aspiration or at the very least be too runny on the plate and give a poor appearance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 23 455572 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455572 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wedgewood Nursing Home 6621 Dan Danciger Rd Fort Worth, TX 76133

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)

F 0850 Hire a qualified full-time social worker in a facility with more than 120 beds.

Level of Harm - Minimal harm or 44140 potential for actual harm Based on interview and record review, the facility with more than 120 beds, failed to employ a qualified social Residents Affected - Some worker on a full-time basis for one of one Social Worker reviewed for qualifications.

The facility, licensed for more than 120 beds, had not employed a full-time, qualified Social Worker since 09/26/24.

This deficient practice could result in residents' social service needs not being met.

Findings included:

Record review of the facility's license revealed the facility had a licensed capacity of 128 residents.

Record review of the facility's Department Heads list revealed no Social Worker.

Record review of the Social Worker's electronic file revealed she was hired on 03/01/24 and was terminated 09/25/24.

During the confidential resident group interview 10 of the 10 residents in attendance revealed the facility had not had a social worker in months. Residents stated they were being told that the facility was actively looking for a social worker.

Record review of Resident Council Meeting for the months of October 2024 revealed Social Services: Resident mentioned that we need a staff member.

Interview on 01/16/25 at 12:29 PM with HR revealed the facility had not had a Social Worker since the end of September. She stated the facility was actively looking for a new Social Worker. She stated as of today (01/16/25) they hired someone but they had not started yet, she stated she was going to provide the hiring paperwork. She stated the previous Administrator, who was no longer employed, had SW license and the MDS Coordinators would assist with any social service's needs.

Interview on 01/16/25 at 2:36 PM with the Administrator revealed he had been employed since 01/13/25. He stated interviews were completed yesterday (01/15/25) and he made an offer, and the offer was accepted.

He stated the facility had been without a Social Worker for about 60 days. The Administrator stated the DON, Medical Records, MDS, and ADONs were following up with resident social service's needs. He stated a social worker was needed to advocate resident's rights, be part of the care plan team and make sure psychosocial needs were being met. The Administrator stated the facility did not have a policy for social services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 23 455572 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455572 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wedgewood Nursing Home 6621 Dan Danciger Rd Fort Worth, TX 76133

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43791 potential for actual harm Based on observations and interviews the facility failed to maintain an infection prevention and control Residents Affected - Few program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two resident (Residents #5 and #60) of five residents reviewed for infection control.

MA D failed to sanitize a re-useable blood pressure cuff between uses on Resident #5 and Resident #60.

This failure could place the residents at risk of exposure to infections.

Findings included:

Record review of Resident #5's undated Admission Record reflected he was an [AGE] year-old male admitted to the facility on [DATE REDACTED] with diagnoses which included kidney disease, diabetes, high blood pressure, and heart failure.

Record review of Resident #5's quarterly MDS assessment, dated 11/20/24, reflected a BIMS score of 12 indicating he was cognitively intact. His Functional Assessment indicated he required assistance with all of his ADLs.

Record review of Resident #5's care plan, dated 11/04/24, reflected he had an ADL self-care deficit, high blood pressure with interventions of administering medications and monitoring his vital signs.

Record review of Resident #60's undated Admission Record reflected he was a [AGE] year-old male admitted to the facility on [DATE REDACTED] with diagnoses which included complete paralysis, mild cognitive impairment, and personal care assistance.

Record review of Resident #60's quarterly MDS, dated [DATE REDACTED], reflected a BIMS score of 14 indicating he was cognitively intact. His Functional Assessment indicated he required assistance with all of his ADLs.

Record review of Resident #60's care plan, dated 12/02/24, reflected he had an ADL self-care deficit requiring total assistance with his ADLs.

Observation on 01/15/25 at 7:32 AM revealed MA D checked Resident #60's blood pressure with a re-useable blood pressure cuff and returned it to her cart without sanitizing it.

Observation on 01/15/25 at 7:45 AM revealed MA D checked Resident #5's blood pressure with the same re-useable blood pressure cuff used on Resident #60. MA D failed to sanitize the cuff prior to or after using it

on Resident #5.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 23 455572 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455572 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wedgewood Nursing Home 6621 Dan Danciger Rd Fort Worth, TX 76133

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)

F 0880 Interview on 01/15/25 at 12:32 PM with MA D revealed she was unaware she had not sanitized the blood pressure cuff between uses on the residents. She stated she had sanitizing cloths in her cart but she forgot Level of Harm - Minimal harm or to use them. She stated the risk of not sanitizing between resident uses could be spreading an infection from potential for actual harm one resident to another.

Residents Affected - Few Interview on 01/16/25 at 2:27 PM with the RNC revealed re-useable medical equipment only had to be sanitized between residents if it was visibly soiled. When asked the risks of not sanitizing equipment between use the RNC shrugged her shoulders and did not provide an answer. She stated staff follow the facility policies.

Record review of the facility's Blood Pressure-Obtaining policy, dated 01/01/24, reflected:

.5. Closing steps:

a. Clean and store re-useable items and discard disposables

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 23 455572 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455572 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wedgewood Nursing Home 6621 Dan Danciger Rd Fort Worth, TX 76133

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)

F 0914 Provide bedrooms that don't allow residents to see each other when privacy is needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43791 potential for actual harm Based on observation, interview, and record review, the facility failed to assure full visual privacy for four Residents Affected - Some (Residents #3, #46, #47, and #61) of twelve residents reviewed for privacy curtains.

The facility failed to provide privacy curtains that assured each resident had full visual privacy.

This failure could cause anxiety to residents during personal care.

Findings included:

Observation and interview on 01/14/25 at 10:10 AM revealed Resident #3 had a privacy curtain between the beds that was hanging by 4 hangers, the rest of the curtain hung down to the floor. Resident #3 stated she did not like not having privacy during incontinent care and the staff never bothered pulling that curtain. She stated anyone could walk in and see her when she was exposed.

Record review of Resident #3's undated Admission Record reflected she was a [AGE] year-old female admitted to the facility on [DATE REDACTED] with diagnoses which included emphysema, dementia, and muscle weakness.

Record review of Resident #3's quarterly MDS, dated [DATE REDACTED], reflected a BIMS score of 9, indicating she had moderate cognitive impairment, Her Functional Status indicated she required assistance with all her ADLs.

Record review of Resident #3's care plan, dated 12/04/24, reflected she had cognitive impairment, impaired visual function, and a communication deficit.

Observation and interview on 01/14/25 at 10:14 AM revealed Resident #47 had no privacy curtain at the foot of his bed. Resident #47 stated it bothered him to not have the curtain. He stated it had not been in place since he was moved to the room, and he had asked staff for a curtain or to move him to a room that had more privacy.

Record review of Resident #47's EHR reflected he had been moved to his current room on 09/06/24.

Record review of Resident #47's undated Admission Record reflected he was a [AGE] year-old male admitted to the facility on [DATE REDACTED] with diagnoses which included stroke, diabetes, and weakness.

Record review of Resident #47's quarterly MDS, dated [DATE REDACTED], reflected a BIMS score of 12 indicating he was moderately cognitively impaired. His Functional Status indicated he needed set-up assistance with his ADLs.

Record review of Resident #47's care plan, dated 12/19/24, reflected he had a communication impairment,

he was incontinent of bowel and bladder, and had a self-care deficit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 455572 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455572 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wedgewood Nursing Home 6621 Dan Danciger Rd Fort Worth, TX 76133

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)

F 0914 Observation and interview on 01/14/25 at 10:21 AM revealed Resident #61 had no privacy curtain between

the beds. Resident #61 stated it did not bother him now that he did not have a roommate, but when he had Level of Harm - Minimal harm or one, it was uncomfortable. potential for actual harm

Record review of Rfesident #61's undated Admission Reocrd reflected he was a [AGE] year-old male Residents Affected - Some admitted to the facility on [DATE REDACTED] wu=ith disgises which included stroke, anxiety, aand cataracts.

Record review of resident #61's quarterly MDS, dated [DATE REDACTED] reflecctrd A BIMS score of 14 indicating he was cognitively intact. His Functional Status indicated he requierd partial assistance with his ADLs.

Record review of Resident #61's care plan, dated 11/05/24 reflected he had a cognitive impairment, impaired communication, and an ADL self-care deficit.

Observation and interview on 01/14/25 at 10:55 AM revealed Resident #46 did not have a privacy curtain at

the foot of the bed and no track for hanging a curtain was present. Resident #46 stated it had been that way since being moved into the room.

Record review of Resident #46's undated Admission Record reflected he was admitted to the facility on [DATE REDACTED] with diagnoses of chronic kidney disease diabetes, and muscle weakness.

Record review of Resident #46's quarterly MDS, dated [DATE REDACTED], reflected a BIMS score of 15 indicating he was cognitively intact. His Functional Status indicated he was independent with his ADLs.

Record review of Resident #46's care plan, dated 1/12/25 reflected he had an ADL self-care deficit, depression and was a smoker.

Observations on 01/15/25 and 01/16/25 of the resident rooms revealed privacy curtains had not been addressed.

Interview on 01/16/25 at 10:45 AM with ADON A revealed housekeeping was responsible for changing and cleaning the privacy curtains. Maintenance would hang damaged curtains if needed.

Interview on 01/16/25 at 12:35 PM with CNA E revealed each resident should have a privacy curtain. She was unaware Resident #46 did not have a curtain in place. She stated privacy curtains were needed for privacy.

Interview on 01/16/25 at 12:38 PM RN F revealed she was the nurse assigned for Resident #46 and was not aware he did not have a privacy curtain. She stated Resident #46 did not have the tracks for a privacy curtain . She stated it was the responsibility of housekeeping staff and maintenance staff to change and put up privacy curtains.

Interview on 01/16/25 at 1:19 PM with the Housekeeping Supervisor revealed her staff were responsible for changing out privacy curtains when they were soiled. If the curtains needed to be re-hung because the hangers were damaged, maintenance was responsible for making the repairs. The Housekeeping Supervisor stated all curtains were checked monthly by her; the last check was on 01/13/25. She was unaware Resident #3's curtain was only hanging by four hooks, but she would address it with maintenance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 455572 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 455572 B. Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Wedgewood Nursing Home 6621 Dan Danciger Rd Fort Worth, TX 76133

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)

F 0914 Interview on 01/16/25 at 3:20 PM with the Maintenance Supervisor revealed he had been working at the facility for four years and he was not aware of all the curtains that needed to be replaced. He stated Level of Harm - Minimal harm or housekeeping took them down to be washed when needed but they did not have a surplus of curtains to potential for actual harm allow them to be replaced with a clean one while the other was being washed. He stated it was important to have a privacy curtain for each resident to ensure they had privacy. Residents Affected - Some

Interview on 01/16/25 at 3:06 PM with the Administrator revealed the facility had no policy addressing resident privacy or privacy curtains. There was only the Resident Rights policy stating the residents had the right to a clean, comfortable, home like environment.

44140

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 455572