Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Wedgewood Manor during CMS and state inspections, most recent first.
A dietary staff member measured the concentration of a sanitizing solution using expired test strips, which was confirmed during staff interview. This resulted in the kitchen environment not being maintained in accordance with professional standards.
Staff failed to accurately code the MDS for two residents: one was incorrectly documented as receiving antianxiety medication, and another was coded as using bed rails daily despite none being present. These errors were confirmed by administrative nursing staff and identified through record review and observation.
Staff did not follow infection control protocols during wound care for two residents, failing to wear gowns as required by Enhanced Barrier Precautions, and a nurse administered a medication that had been dropped and handled with bare hands, contrary to facility policy.
A facility failed to protect all residents after a suspected sexual abuse incident involving a resident whose urine sample contained non-motile sperm. Despite the finding, male staff continued providing care without additional supervision, except for the involved resident. The facility's policy mandates immediate safety measures, which were not implemented, leading to an Immediate Jeopardy situation.
A facility failed to report potential sexual abuse to law enforcement after a urinalysis sample from a cognitively impaired resident contained non-motile sperm. Despite the facility's policy requiring notification of the police, this was not done, placing residents at risk. The deficiency was confirmed during staff interviews, leading to an Immediate Jeopardy situation.
A facility failed to thoroughly investigate potential sexual abuse involving a resident whose urinalysis showed non-motile sperm. The investigation did not include all potential male perpetrators, and male staff continued to provide care without supervision. The facility's policy required immediate reporting and investigation, but these procedures were not followed, leading to an Immediate Jeopardy situation.
The facility failed to accurately code the MDS for five residents, omitting documented falls for one resident and incorrectly coding the use of 'other alarms' for four residents. An administrative nurse confirmed these discrepancies, which could impact resident assessments and care plans.
The facility failed to update the comprehensive care plans for two residents. One resident with dementia and frequent wandering did not have interventions for wandering/elopement in their care plan. Another resident's care plan was outdated, still indicating isolation for a communicable disease despite recovery and lacking information on anticoagulant and diuretic medications.
The facility failed to notify a physician when a resident's blood glucose levels exceeded set parameters and did not perform required neurological assessments following falls with suspected head injuries for another resident. These actions were not in accordance with the facility's policies.
Expired Sanitizer Test Strips Used in Kitchen
Penalty
Summary
During a kitchen observation, a dietary staff member was seen measuring the concentration of a premixed sanitizing solution using test strips that were expired, with the expiration date marked as 05/15/2021. The use of these expired test strips was confirmed during a staff interview, where the dietary staff member acknowledged that expired test strips should not be used. This failure to ensure the use of valid sanitizer test strips resulted in the facility not maintaining a clean and sanitary kitchen environment as required by professional standards.
Inaccurate MDS Coding for Medications and Restraints
Penalty
Summary
Facility staff failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, as identified through record review, reference to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, and staff interviews. For one resident, the quarterly MDS indicated that an antianxiety medication was administered during the seven-day look-back period; however, the medical record did not show any such medication being given during that time. An administrative nurse confirmed that the MDS was incorrectly coded in this instance. For another resident, the admission MDS coded the use of bed rails as being used daily, but observations revealed that no bed rails were present for the resident. This discrepancy was also confirmed by an administrative nurse, who acknowledged that the MDS was not coded correctly. These inaccuracies in MDS coding do not allow for an accurate reflection of the residents' current status and needs.
Failure to Follow Infection Control and Medication Handling Protocols
Penalty
Summary
Facility staff failed to adhere to infection prevention and control standards during wound care for two residents. For one resident with a pressure ulcer requiring dressing changes, both a CNA and a nurse assisted with toileting and wound care while wearing gloves but did not don gowns, as required by the facility's Enhanced Barrier Precautions (EBP) policy. The resident's room also lacked EBP identification. For another resident with an indwelling urinary catheter and heel ulcers, two nurses performed wound dressing changes while wearing gloves but did not use gowns, despite EBP signage and supplies being present at the room entrance. Administrative staff confirmed that gowns were expected to be worn during these high-contact care activities. Additionally, during a medication pass for the resident with an indwelling catheter and heel ulcers, a nurse dropped a Vitamin B complex capsule onto the medication cart, picked it up with a bare hand, and placed it into the medication cup for administration. Facility policy requires that any medication whose integrity or sanitation is compromised, such as being touched by hand after being dropped, must be destroyed. An administrative nurse confirmed that the expected practice was to discard such compromised medication.
Failure to Implement Safeguards After Suspected Sexual Abuse
Penalty
Summary
The facility failed to immediately implement safeguards for all residents after a suspected sexual abuse incident involving a resident. The incident was identified during a facility-reported incident (FRI) investigation, where a urinalysis sample from a resident, who was not sexually active, contained non-motile sperm. This finding was confirmed by three laboratorians and a medical doctor. The facility did not provide adequate protection from all potential perpetrators, placing all residents at risk for mental and emotional distress, and/or physical injury. During the investigation, it was revealed that a male CNA assisted the resident to the bathroom, where the urine sample was collected. The sample was initially unlabeled, and upon further examination by the lab, sperm was found in the urine. Despite this finding, the facility continued to allow other male staff members to provide personal care to residents without additional supervision, except for the resident involved in the incident, who required two staff members present. The facility's policy on resident abuse and neglect, which was reviewed during the investigation, mandates immediate safety measures and mental well-being assurance for residents in cases of suspected abuse. However, the facility failed to implement these measures for all residents after being notified of the sperm in the resident's urine sample. This oversight led to the identification of an Immediate Jeopardy situation by the State Survey Agency, highlighting the facility's failure to protect residents from potential sexual abuse.
Removal Plan
- No additional male travelers will be utilized for staffing until investigation is completed.
- All male staff on duty or scheduled, including non direct care staff, certified nurse aides (CNAs), and licensed staff will have a female staff member with them while in a resident's room.
- All staff informed of the changes in procedures for care provided by male caregivers and reviewed the abuse and neglect policy. Staff not present at the meeting will read, review, and sign the information provided prior to their next shift.
Failure to Report Potential Sexual Abuse
Penalty
Summary
The facility failed to report potential sexual abuse to law enforcement for a resident with cognitive impairment. The incident involved a urinalysis sample collected from the resident, which contained non-motile sperm, confirmed by three laboratorians and a Medical Doctor. Despite these findings, the facility did not notify law enforcement, placing the resident and all other residents at risk for possible abuse and/or injury. This deficiency was identified during an interview with administrative staff and a staff nurse, confirming the facility's failure to act appropriately. The facility's policy on Resident Abuse & Neglect, revised in June 2021, clearly stated that the Director of Nursing should contact the Police Department in such cases. However, this protocol was not followed. The progress note from the facility's final investigation indicated that a urine sample was brought to the lab without a name on it, and it was confirmed to contain sperm. An administrative staff member confirmed during an interview that the facility failed to notify law enforcement regarding the alleged sexual abuse, leading to an Immediate Jeopardy situation.
Removal Plan
- Chief of Police notified of potential sexual abuse of resident regarding potential improper contents of female urine specimen.
- Facility will cooperate with reporting and investigation per law enforcement.
- All staff meeting informed staff of the changes in procedures for care provided by male caregivers and reviewed the abuse and neglect policy. Staff not present at the meeting will read, review, and sign the information provided prior to their next shift.
Inadequate Investigation of Potential Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation of potential sexual abuse involving a resident, which placed all residents at risk. The incident involved a female resident who was not sexually active, yet a urinalysis sample collected from her contained non-motile sperm. This finding was confirmed by three laboratorians and a medical doctor. Despite this evidence, the facility's investigation was inadequate as it did not include all potential male perpetrators, such as male residents, visitors, and non-resident care staff members. Additionally, male facility staff members continued to provide care to all residents, except the involved resident, without any additional supervision or precautions. The facility's policy on resident abuse and neglect required immediate reporting and investigation of suspected abuse, including interviews with all relevant parties and protection of residents during the investigation. However, the facility did not adhere to these procedures. The investigation lacked evidence of thoroughness, as it did not include interviews with all potential witnesses or suspects, and failed to ensure the safety and mental well-being of all residents during the investigation. This oversight led to the identification of an Immediate Jeopardy situation by the survey team.
Removal Plan
- During investigation all male staff will be accompanied by another female at all times during cares and behind closed doors.
- A camera was placed in Resident #1's room and is stationed at the nurses station.
- All staff meeting informed staff of the changes in procedures for care provided by male caregivers and reviewed the abuse and neglect policy. Staff not present at the meeting will read, review, and sign the information provided prior to their next shift.
Inaccurate MDS Coding for Falls and Alarms
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for five residents. Specifically, Resident #30's annual MDS did not document falls that occurred between the previous and current assessments, despite the medical record indicating multiple falls, including one with injury. An administrative nurse confirmed the omission during an interview. This failure to document falls accurately could impact the resident's assessment and subsequent care planning. Additionally, the facility incorrectly coded the use of alarms for four residents. The MDS for Residents #3, #10, #15, and #28 indicated the daily use of 'other alarms,' but their medical records lacked evidence supporting this. An administrative nurse clarified that the alarms in question were exit alarms triggered by residents with wander guards, which do not meet the RAI manual's definition of 'other alarms.' This misclassification could lead to inaccurate assessments and care plans for these residents.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to review and revise the comprehensive care plan to reflect the current status for two residents. Resident #15, diagnosed with dementia with behavior disturbance, was observed with a wanderguard and frequently wandering throughout the building. Despite multiple episodes of exit seeking and/or elopement documented in the nurses' notes, the care plan did not include interventions to address wandering/elopement. An administrative nurse confirmed the care plan's lack of relevant interventions during an interview. Resident #28's care plan was also found to be outdated and incomplete. The quarterly MDS identified the resident received anticoagulant and diuretic medications but failed to note the resident's isolation status for an active infection. The care plan still indicated isolation for a communicable disease, even though the resident had recovered from the disease months earlier. Additionally, the care plan did not include side effects or interventions related to the anticoagulant and diuretic medications.
Failure to Follow Professional Standards of Care and Perform Neurological Assessments
Penalty
Summary
The facility failed to follow professional standards of care regarding physician orders for a resident selected for medication review. Specifically, the facility did not notify the physician when the resident's blood glucose levels exceeded the parameters set by the physician. The resident's blood sugar levels were recorded as being over 400 mg/dl multiple times between 05/01/24 and 05/15/24, but there was no documentation that the physician was informed of these elevated levels. An administrative nurse confirmed that the facility's policy required staff to notify the physician of such changes, but this was not done in this case. Additionally, the facility failed to perform neurological assessments following falls experienced by another resident. The resident's medical record showed instances of falls with suspected head injuries, but the required neurological checks were either not documented or not completed as per the facility's policy. For example, after a fall on 02/28/24, the record lacked documentation of the initial and subsequent neurological checks. Similarly, after a fall on 03/18/24, staff failed to complete eight of the required neurological checks. An administrative nurse verified these deficiencies during an interview.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cavalier
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pembilier Nursing Center | 15.8 mi | ★★★★★ | 5 | 0 |
| Lutheran Sunset Home | 27.8 mi | ★★★★★ | 8 | 0 |
| Good Samaritan Society - Park River | 30.9 mi | ★★★★★ | 20 | 0 |
| Kittson Healthcare | 31.5 mi | ★★★★★ | 0 | 0 |
| Maple Manor Care Center | 34.1 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Wedgewood Manor.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.