Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Nursing Home during CMS and state inspections, most recent first.
A facility failed to keep bedside call lights within reach for three residents who were observed in bed with the call light hanging down from the wall and out of reach. The residents had significant cognitive and functional impairments, including dementia, hemiplegia, legal blindness, and dependence for ADLs. Staff interviews confirmed that all employees were responsible for ensuring call lights were accessible, and the facility policy required call lights to be placed near the resident and never on the floor or bedside stand.
Failure to Provide Routine Fingernail Care: Multiple residents who were dependent on staff for ADLs were observed with long, dirty fingernails that had not been trimmed or cleaned despite care plans directing routine nail care. Residents with stroke, dementia, CVA, paraplegia, and cognitive impairment were found with nails extending beyond the fingertips, and several stated they wanted their nails cleaned and trimmed. Staff interviews confirmed that CNAs and nurses were responsible for nail care as part of personal hygiene.
Uncovered Food Items in Kitchen Storage: Food storage practices were not followed in the kitchen when tortillas were found open and exposed to air in dry storage and a box of lettuce was found open in the walk-in refrigerator. The Dietary Manager stated that all food items were expected to be covered at all times, and another staff member stated that uncovered food could lead to cross-contamination and illness.
Dignity During Meal Assistance: A resident with CVA, muscle weakness, and severe cognitive impairment was observed in bed while a CNA stood and assisted with feeding instead of sitting beside him. The CNA stated she should have sat while helping with the meal because standing could make a resident uncomfortable and lead to loss of dignity; the DON also stated staff should be seated when assisting residents with meals to maintain dignity.
A facility failed to ensure a resident's Temazepam blister pack on a nurses' cart was properly handled when 2 blister seals were broken and one was taped over with pills still inside. An LPN stated the shift count was correct but the blister packs were not checked, and the DON stated broken blister packs should not be kept with medication inside and that taping over them was unacceptable.
Improper hand hygiene and glove use occurred during incontinent care for a resident with an indwelling catheter and severe cognitive impairment. Two CNAs performed care, but one CNA sanitized gloved hands instead of changing gloves with hand hygiene while moving between contaminated and clean tasks, and the DON confirmed staff were expected to change gloves and not sanitize gloved hands. The facility policy stated gloves do not replace hand washing and hands should be washed after removing gloves.
A resident with COPD, respiratory failure, and severe cognitive impairment was sent to the ER after a fall and injury, and the facility treated the event as an AMA discharge when the family called 911 and the resident went to the hospital by ambulance. Facility notes stated the resident would not be accepted back, while the hospital record documented that the facility said the resident left AMA and would not return. The record also showed no documentation that the physician or designee contacted the resident or family and no Ombudsman involvement, despite the facility policy addressing AMA discharge and return procedures.
During a lunch meal, pureed rice pilaf was served with chunks and not at the required pudding-like consistency for residents on pureed diets. The DM did not verify the texture of the pureed food, and the staff member responsible acknowledged the rice was not smooth but served it anyway, contrary to facility policy.
A resident with multiple complex medical conditions experienced a change in condition resulting in hypoglycemia and hospital transfer. The facility failed to document the times for blood glucose monitoring, medication administration, and contacts with the NP and EMS. Staff interviews confirmed the importance of timely and complete documentation, and facility policy required such entries to be objective, chronological, and include all relevant details.
A facility failed to ensure proper treatment for a resident receiving enteral feeding, leading to a deficiency. A nurse used a de-clogger tool on a g-tube without physician orders, and the facility did not follow the prescribed water flush schedule, risking g-tube clogging. The resident had multiple medical conditions, requiring careful management of his feeding tube.
A facility with over 120 beds failed to employ a full-time social worker since late September 2024, as confirmed by resident interviews and record reviews. The absence of a social worker was acknowledged by the new Administrator, who stated that other staff members were addressing social service needs in the interim. The facility did not have a policy for social services.
The facility failed to provide adequate privacy curtains for several residents, leading to a lack of visual privacy during personal care. Observations showed that a resident had a curtain hanging by only four hangers, while another had no curtain at the foot of the bed. Staff interviews revealed a lack of awareness and responsibility for ensuring curtains were in place, and the facility lacked a specific policy on resident privacy.
A resident with severe cognitive impairment and physical limitations did not receive necessary nail care, resulting in untrimmed, jagged nails with a black substance underneath. Despite the resident's care plan indicating a need for extensive assistance with personal hygiene, observations showed her nails remained untrimmed over consecutive days. Staff interviews revealed that CNAs were responsible for nail care unless the resident had diabetes, but the facility's nail care policy was not followed.
A resident with a right hand contracture did not receive appropriate treatment as the facility failed to ensure the use of a splint or palm guard. The resident, with a history of aphasia and hemiplegia, was observed without a contracture management device for several days. Staff interviews revealed a lack of awareness and documentation regarding the use of the splint, and there was no physician's order in place, contrary to facility policy.
A facility failed to ensure physician orders for a resident's tracheostomy care, including suction tubing and an emergency trach kit. The resident, with a history of cerebral artery issues and respiratory failure, was admitted with a tracheostomy, but necessary orders were missing. Nursing staff continued care without orders, potentially leading to inadequate care. Facility policies requiring verification of physician orders were not followed.
The facility failed to prepare pureed mashed potatoes to the required pudding consistency for residents on pureed diets. The Dietary Manager used a whisk instead of a blender, resulting in lumpy potatoes, which could pose a choking risk. The facility's guidelines require a smooth consistency to prevent swallowing difficulties.
A facility failed to maintain an effective infection control program when a medical assistant did not sanitize a reusable blood pressure cuff between uses on two residents. Both residents required assistance with ADLs and had cognitive awareness. The medical assistant admitted to forgetting to sanitize the cuff, and the RNC showed a lack of understanding of the facility's policies, which required cleaning reusable items after use.
The facility failed to maintain a safe and sanitary environment in several resident rooms, with vent covers covered in dark debris resembling mold and a hanging ceiling rail posing injury risks. Staff interviews revealed a lack of communication and responsibility in addressing these issues, with the Maintenance Director ordering new vents only after being notified. The facility's Housekeeping Standards policy was not adhered to, placing residents at risk for infection and decreased quality of life.
A resident with multiple health conditions, including dementia and hemiplegia, was left in a soaked brief and bedding for about six hours without receiving necessary incontinence care. Despite the facility's policy requiring regular checks, the CNA responsible did not perform timely rounds, leaving the resident at risk for skin breakdown and infection. The facility's policy lacked specific guidelines on the frequency of incontinence checks.
A medication cart was found unlocked and unattended in a facility, with two residents nearby, one of whom was cognitively intact and on psychotropic medications. The ADON left the cart unsecured due to distraction, and the facility lacked a specific policy for medication cart security, as confirmed by the DON.
A facility failed to update a resident's care plan quarterly, as required. The resident, who was cognitively intact and had a history of stroke, cataracts, depression, and anxiety, had a care plan that had not been revised for several months. Interviews revealed that the DON was unfamiliar with the care plan update process, and the Administrator was unaware of the risks of not updating care plans.
Call Lights Left Out of Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that bedside call lights were adequately equipped and within reach for 3 of 5 residents reviewed for the resident call system. During observation on 04/21/2026, Resident #43 was lying in bed with the call light hanging down from the wall and away from him; he stated he could not reach it. Resident #43 had an admission date of 12/06/2014 and diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, cognitive communication deficit, and vascular dementia, with a BIMS score of 03 and a need for moderate assistance with showering and toileting hygiene. Resident #79 was also observed lying in bed with the call light hanging down from the wall and out of reach, and he stated he could not reach it. His record reflected an admission date of 11/01/2024, diagnoses including depression and cognitive communication deficit, a BIMS score of 00, and dependence on staff for toileting hygiene and showering. His care plan identified ADL self-care performance deficits, risk for not having needs met in a timely manner, functional limitations in range of motion, and hemiplegia/hemiparesis secondary to stroke, with ADL assistance required. Resident #92 was observed lying in bed with the call light hanging down from the wall and away from her, and she stated she could not reach it. Her record reflected an admission date of 02/25/2022, diagnoses including unspecified dementia and legal blindness, a BIMS score of 03, and dependence on facility staff for toileting hygiene and showering. Her care plan identified legal blindness, a high fall risk, and an ADL self-care performance deficit. Interviews with the charge nurse, CNA, and DON confirmed that staff were responsible for ensuring call lights remained within reach, and the facility policy stated call lights should be placed near the resident and never on the floor or bedside stand.
Failure to Provide Routine Fingernail Care
Penalty
Summary
The facility failed to provide necessary ADL assistance to maintain good grooming and personal hygiene for 7 residents who were unable to carry out those activities independently. During observation, interview, and record review, residents were found with fingernails that were long, dirty, and in need of trimming and cleaning, despite care plans that included nail care as part of routine personal hygiene support. Resident #1 had a history of stroke, arthritis, paraplegia, and a contracture of the right hand, and his BIMS score indicated intact cognition. His care plan directed staff to check nail length and trim and clean nails on bath day. On observation, his fingernails on both hands were long and dirty, and he stated staff had not offered nail care for the last few weeks and that he was unable to trim them himself because of his contracture. CNA A also observed that his fingernails were long and dirty. Resident #9 had a CVA, muscle weakness, severe cognitive impairment, and was dependent on staff for personal hygiene. His care plan directed staff to provide shower, shave, oral care, hair care, and nail care per schedule and when needed. On observation, his fingernails were long with discoloration and dark residue under the nails, and he stated he wanted them trimmed and cleaned. RN D later observed the nails and stated they needed to be trimmed and cleaned. Resident #22 had dementia and cognitive communication deficit and needed moderate assistance with personal hygiene. His care plan directed staff to provide shower, shave, oral care, hair care, and nail care per schedule and when needed. On observation, he had long, dirty fingernails with dark residue under several nails and stated he liked them trimmed short and cleaned. Resident #48, Resident #57, Resident #79, and Resident #87 were also observed with fingernails extending beyond the fingertips, and some had dirt or dark residue under the nails. Each of these residents stated they wanted their fingernails trimmed and/or cleaned, and their records reflected ADL self-care deficits with staff responsibility for personal hygiene and nail care.
Uncovered Food Items in Kitchen Storage
Penalty
Summary
The facility failed to store food in accordance with professional standards in its only kitchen observed for food service safety. During observation of the dry storage area on 04/21/2026 at 10:18 AM, about 3/4 of a packet of tortillas was found left open and exposed to air in a cardboard box. During observation of the walk-in refrigerator on 04/21/2026 at 10:22 AM, a cardboard box containing about 5-6 heads of lettuce was found open to cold air. During interview on 04/22/2026, the Dietary Manager stated that all food items in the kitchen were expected to be covered at all times and that cooks, dietary aides, and she herself were responsible for ensuring proper coverage. She stated that not covering food items could lead to cross-contamination and decreased food quality, and that she provided frequent in-services on appropriate food storage practices. Another staff member stated that everyone working in the kitchen was responsible for ensuring food items were properly covered at all times and not exposed to air, and that uncovered food could result in cross-contamination and residents becoming sick. Facility policy and the FDA Food Code were reviewed and reflected that dry goods and refrigerated foods were to be stored properly in covered containers to prevent cross-contamination.
Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with respect and dignity and to care for the resident in a manner that promotes maintenance or enhancement of quality of life when the resident was assisted with eating while the CNA stood instead of sitting. Resident #9 was a male admitted with diagnoses including CVA and muscle weakness, and his quarterly MDS dated 03/11/26 reflected a BIMS score of 00/15 indicating severe cognitive impairment. His functional abilities for eating were listed as setup or clean-up assistance, and his care plan identified eating interventions as setup. During an observation on 04/22/26 at 08:54 AM, Resident #9 was in bed with the head of the bed elevated while CNA I stood and assisted him with his meal. The resident was unable to state how he felt about staff standing during the meal. During interview, CNA I stated she was supposed to sit next to the resident while assisting with the meal and said she should have gotten a chair and sat because standing could make a resident uncomfortable and lead to loss of dignity. The DON stated that all staff were responsible for maintaining resident dignity and that staff should be seated when assisting with meals to prevent residents from being uncomfortable. The facility policy on Resident Rights stated that residents have the right to a dignified existence, self-determination, and communication.
Broken blister pack medication left on nurses' cart
Penalty
Summary
The facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, including appropriate accessory and cautionary instructions and expiration dates when applicable. During observation of the 100/200 Hall nurses' cart, LVN F was found with Resident #29's Temazepam 15 mg capsule blister pack containing 2 broken blister seals with pills still inside the broken blisters, and one of the broken blisters had tape over it. LVN F stated the medication count had been completed at shift change and was correct, but she had not checked the blister packs during the count and did not know when the seals were broken or who damaged them. She stated it was not acceptable to tape over the broken seal and that the risk would be potential for drug diversion. The DON stated that if a blister pack medication seal was broken, the pill should be discarded and that it was not acceptable to keep a pill in an opened blister pack or to tape over the broken blister with medication inside. The DON also stated the risk would be potential for drug diversion and infection control issues. The facility policy titled Storage of Medications stated that medication carts are routinely inspected for discontinued, outdated, defected, or deteriorated medications with worn, illegible, or missing labels, and that these medications are removed and destroyed in accordance with facility policy.
Improper Hand Hygiene and Glove Use During Incontinent Care
Penalty
Summary
Provide and implement an infection prevention and control program was cited after staff failed to maintain proper infection control during incontinent care for a resident with an indwelling urinary catheter and severe cognitive impairment. The resident’s record reflected a quarterly MDS assessment with a BIMS score of 00/15, bladder continence with an indwelling catheter, and bowel continence frequently incontinent. The care plan identified the resident as at risk for urinary tract infections and catheter-related trauma and complications, with catheter care interventions and monitoring for signs and symptoms of infection. During observation, two CNAs entered the room, performed hand hygiene, donned gowns and gloves, and began incontinent care. CNA E cleaned the resident’s front area and catheter tubing, then sanitized her gloved hands while continuing care. After turning the resident to the side, CNA E again sanitized her gloved hands before cleaning the buttocks area and handling the brief, and CNA H later changed gloves with hand hygiene. In interview, CNA E stated she was supposed to change gloves with hand hygiene after cleaning the resident and was not supposed to sanitize gloved hands. The DON stated staff were expected to change gloves with hand hygiene and not sanitize gloved hands, and the facility policy stated gloves do not replace hand washing and hands should be washed after removing gloves.
Failure to Follow Return-to-Facility Policy After Hospital Transfer
Penalty
Summary
The facility failed to establish and follow its written policy for permitting a resident to return to the facility after hospitalization. Resident #38 was a female admitted with diagnoses including hypertension, asthma, COPD, and respiratory failure, and her discharge MDS reflected a BIMS score of 03/15, indicating severe cognitive impairment. Her care plan documented ADL self-care deficits related to chronic COPD and physical debility, fall risk, and hospice/terminal prognosis needs. On 04/21/26, after a fall and injury, the resident’s family was upset about the injuries and called 911. The resident was transported by ambulance to the hospital ER. Facility documentation stated the resident refused to sign an AMA form, took her personal belongings, and stated she would not be back. The DON notified the physician by telehealth and documented that the resident was in no distress before discharge. The facility later documented that the resident left AMA and would not be accepted back. Record review showed no documentation that a facility physician or designee contacted the resident or family after the event, and no documentation that the Ombudsman was contacted to help the resident find placement or assist with discharge. The hospital record documented that hospital staff called the facility and were told the resident left AMA and would not be accepted back. The facility’s own policy stated that residents leaving AMA are to be allowed to discharge at their own risk, with physician and DON notification, documentation of the circumstances, and completion of the AMA process. During interviews, the Administrator and DON stated the family taking the resident to the hospital was treated as a discharge and that the resident would need to go through readmission to return.
Failure to Prepare Pureed Food to Required Consistency
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet individual resident needs during a lunch meal. Specifically, pureed rice pilaf was not prepared to a pudding-like consistency as required for residents on pureed diets. Observation of a sample tray revealed that the pureed rice contained chunks of rice grains and was not fully pureed. The dietary manager (DM) acknowledged that the rice should have been smoother and easier to swallow, but did not check the texture of the pureed food items, citing that she had just started working at the facility and assumed the staff member responsible for preparing the pureed foods was knowledgeable about the requirements. The staff member who prepared the pureed foods confirmed that she made the pureed rice and believed it became chunky due to the addition of thickener. She admitted that the rice was not pudding-like or smooth but served it regardless. Review of the facility's policy indicated that meals should be provided according to physician orders and the facility diet manual, but this was not followed for the pureed rice during the observed meal.
Incomplete Clinical Documentation During Resident Change of Condition
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident who experienced a significant change in condition. On the date in question, the resident, a male with multiple complex diagnoses including Type 1 Diabetes, End Stage Renal Disease, and Congestive Heart Failure, was transferred to the hospital after experiencing hypoglycemia. Documentation in the clinical record was incomplete, as the times for five blood glucose monitoring tests, three medication administrations, and contacts with the nurse practitioner and emergency medical services were not recorded. Interviews with facility staff confirmed that it is required practice to document the date, time, drug, and dose when administering medications, and to record the timing of significant events in the medical record. Staff acknowledged that failure to document these details could result in confusion for subsequent shifts and potentially lead to medication errors. The nurse responsible for the resident's care on the day of the incident admitted to usually documenting at the end of the shift and was unable to explain the omission of documentation for that day. Review of the facility's policy on clinical documentation emphasized the importance of objective, chronological, and complete entries, including the time of care and services provided. The policy also outlined procedures for late entries and corrections, underscoring the expectation that all significant events and care provided should be documented promptly and accurately. The lack of complete documentation in this case was inconsistent with both facility policy and accepted professional standards.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to ensure that a resident receiving nutrition via enteral feeding received appropriate treatment and services to prevent complications. Specifically, a nurse used a de-clogger tool to unclog a resident's g-tube without obtaining prior physician orders, despite the facility not training nurses on the use of such tools. The facility had de-clogger tools on-site, although they were not an approved method for de-clogging g-tubes, and the nurse did not follow the protocol of notifying the physician before using the tool. Additionally, the facility did not adhere to the physician's orders regarding the flushing of the resident's enteral feeding tube. The orders specified that the tube should be flushed with 100 ml of water every 2 hours, but observations revealed that the water flush rate was set at 200 ml every 4 hours. This discrepancy was identified by a nurse during her shift, who then adjusted the feeding pump to the correct settings. The failure to follow the physician's orders posed a risk of the g-tube clogging, which could lead to serious complications for the resident. The resident involved was an elderly male with multiple medical conditions, including cerebral artery issues, aphasia, tracheostomy status, gastrostomy status, dysphasia, respiratory failure, and renal failure. The resident was unable to answer questions during observations, and his care plan indicated a need for careful management of his feeding tube to prevent aspirations, weight loss, and dehydration. The facility's failure to follow proper procedures and physician orders for enteral feeding placed the resident at risk for serious harm.
Facility Lacks Full-Time Social Worker for Over 60 Days
Penalty
Summary
The facility, which is licensed for more than 120 beds, failed to employ a qualified social worker on a full-time basis since September 26, 2024. This deficiency was identified through interviews and record reviews, revealing that the facility had not had a full-time social worker since the previous one was terminated on September 25, 2024. The absence of a social worker was confirmed by a confidential resident group interview, where all ten residents in attendance stated that the facility had been without a social worker for months. The residents were informed that the facility was actively searching for a new social worker. Further investigation showed that the facility's HR department confirmed the lack of a social worker since the end of September and mentioned that a new hire had been made, but the individual had not yet started. The newly employed Administrator, who began on January 13, 2025, confirmed that the facility had been without a social worker for approximately 60 days. During this period, the Director of Nursing (DON), Medical Records, MDS Coordinators, and Assistant Directors of Nursing (ADONs) were addressing residents' social service needs. However, the Administrator acknowledged the necessity of a social worker to advocate for residents' rights, participate in care planning, and ensure psychosocial needs were met. The facility did not have a policy for social services in place.
Failure to Ensure Resident Privacy Due to Inadequate Curtains
Penalty
Summary
The facility failed to ensure full visual privacy for four residents due to inadequate privacy curtains in their rooms. Observations and interviews revealed that Resident #3 had a privacy curtain hanging by only four hangers, leaving her exposed during personal care. She expressed discomfort with the lack of privacy, especially during incontinent care. Resident #47 had no privacy curtain at the foot of his bed and had requested either a curtain or a room change for more privacy, but his request had not been addressed. Resident #61, who currently had no roommate, noted discomfort when he previously shared the room without a privacy curtain between the beds. Resident #46 also lacked a privacy curtain at the foot of the bed, and there was no track for hanging one. He had been in this situation since moving into the room. Interviews with staff, including the ADON, CNA, RN, and supervisors of housekeeping and maintenance, revealed a lack of awareness and responsibility for ensuring privacy curtains were in place and functional. The housekeeping staff was responsible for changing and cleaning the curtains, while maintenance was tasked with repairs, but there was no surplus of curtains to replace those being washed. The facility did not have a specific policy addressing resident privacy or privacy curtains, only a general Resident Rights policy stating the right to a clean, comfortable, home-like environment. The lack of a clear policy and communication among staff contributed to the deficiency, as evidenced by the unaddressed issues with privacy curtains in multiple residents' rooms.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living to a resident with severe cognitive impairment and physical limitations. The resident, an elderly female with diagnoses including myopathy, reflux, unsteadiness on feet, and failure to thrive, required extensive assistance for personal hygiene as indicated in her care plan. Despite this, observations revealed that her fingernails were uneven, jagged, and had a black substance underneath, which the resident expressed dissatisfaction with, stating that her nails often got caught in her bedding. Interviews with facility staff indicated that nail care was the responsibility of CNAs unless the resident had diabetes, in which case a nurse would perform the task. However, despite the resident's need for assistance, her fingernails remained untrimmed over consecutive days. The facility's nail care policy outlined specific procedures for nail care, but these were not followed, leading to the resident's unkempt nails and potential risk for infections or injuries.
Failure to Provide Contracture Management for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a right hand contracture, which is a permanent tightening of the muscles. The resident, who is an elderly male with a history of aphasia, hemiplegia, and memory problems, was observed without a contracture management device in place over several days. Interviews with staff revealed that the resident had a splint for his hand contracture, but it was not applied because it was likely in the laundry. Staff members, including a CNA, LVN, and the Occupational Therapist, were unaware of the resident's current use of the splint, and there was no physician's order for the splint or palm guard. The Occupational Therapist noted that the palm guard had not been located for about two weeks, and there was no clear documentation or order for its use. The facility's policy on splinting requires a physician's order and an Occupational Therapist evaluation, which were not in place for this resident. The absence of the splint or palm guard could lead to further tightening of the contracture, skin breakdown, and pain from stiffness, as noted by the ADON. The lack of consistent application of the contracture management device and the absence of a formal order contributed to the deficiency in care for the resident.
Failure to Ensure Physician Orders for Tracheostomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, as there were no physician orders for tracheostomy care, suction tubing, or an emergency trach kit. This deficiency was identified for a resident who was admitted with a tracheostomy and had a history of cerebral artery issues, aphasia, respiratory failure, and renal failure. The resident's care plan indicated the need for tracheostomy care, but the necessary physician orders were missing, which could lead to inadequate care. Observations revealed that the resident had a tracheostomy and feeding tube, and an emergency kit was present at the bedside. However, interviews with nursing staff indicated that the admitting nurse failed to input the necessary orders into the system, and the orders might have been deleted after the resident's hospital visit. The nurse assigned to the resident was unaware of the missing orders and continued to provide care without them, which could give the impression that care was not being provided. The facility's policies required verification of physician orders for tracheostomy care, but these were not followed. The ADON and RNC were unaware of the missing orders and emphasized the importance of obtaining and entering physician orders into the system. The lack of physician orders could potentially lead to the resident not receiving the necessary tracheostomy care, as outlined in the facility's policies.
Failure to Prepare Pureed Food Consistently
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet individual needs for residents requiring pureed diets. During a lunch meal, the facility did not prepare and serve pureed mashed potatoes with the required pudding consistency. Instead, the mashed potatoes contained chunks and were not fully mashed, which was observed during a test tray review. The Dietary Manager used a hand whisk instead of a blender to puree the mashed potatoes and did not verify the consistency before serving. The Dietary Manager acknowledged that the mashed potatoes were not smooth and contained lumps, which could pose a choking risk to residents. The facility's Pureed Recipe Book General Guidelines policy specifies that pureed foods should have a moist mashed potato consistency to prevent swallowing difficulties or aspiration. The Dietary Manager admitted to normally overseeing staff in preparing pureed meals but was directly involved in preparing the mashed potatoes on this occasion.
Inadequate Sanitization of Medical Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medical assistant (MA D) who did not sanitize a reusable blood pressure cuff between uses on two residents. Resident #5, a male with kidney disease, diabetes, high blood pressure, and heart failure, required assistance with all activities of daily living (ADLs) and had a BIMS score indicating he was cognitively intact. Resident #60, a male with complete paralysis and mild cognitive impairment, also required total assistance with ADLs and was cognitively intact. Observations revealed that MA D used the same blood pressure cuff on both residents without sanitizing it between uses, which could expose residents to infections. Interviews with MA D and the Registered Nurse Coordinator (RNC) highlighted a lack of awareness and understanding of the facility's infection control policies. MA D admitted to forgetting to use sanitizing cloths, despite having them available, and acknowledged the risk of spreading infections. The RNC incorrectly stated that reusable medical equipment only needed to be sanitized if visibly soiled and was unable to articulate the risks of not sanitizing equipment between uses. The facility's policy required cleaning and storing reusable items after use, which was not followed in this instance.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in four of the five rooms reviewed for environmental conditions. Observations revealed that the vent covers in Rooms 221, 225, 229, and 231 were covered with dark debris, resembling mold, dust, and dirt. The vents appeared to have thick black dust and debris both inside and outside. Additionally, a silver ceiling rail was found hanging from the ceiling in one of the rooms, posing a risk of injury to residents and staff. Interviews with staff members, including a housekeeper, a CNA, an LVN, and the Maintenance Director, indicated a lack of communication and responsibility in addressing the environmental issues. The housekeeper was aware of the dirty vents but had not reported them to the Maintenance Director, assuming he would have checked all vents. The CNA acknowledged the potential health risks posed by the dirty vents but had not reported them either. The LVN was informed of the issues but had not yet observed the vents herself. The Maintenance Director stated that he was responsible for cleaning the vents and had ordered new ones after being notified of the problem. The facility's Administrator acknowledged the deficiencies and stated that staff conducting Angel Rounds should have reported the issues. The facility's Housekeeping Standards policy emphasized the importance of maintaining a clean and sanitary environment to prevent the spread of disease and infection. However, the lack of adherence to these standards resulted in the identified deficiencies, placing residents at risk for infection and decreased quality of life.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance to a resident who was unable to perform activities of daily living, specifically incontinence care. The resident, a female with a history of stroke, hypertension, peripheral artery disease, hemiplegia, dementia, seizure disorder, and anxiety disorder, was found to be frequently incontinent of bowel and bladder. Despite requiring partial/moderate assistance with toileting, showering, bathing, and personal hygiene, the resident was left in a soaked brief and bedding for approximately six hours without being changed. Observations and interviews revealed that the resident had been in bed since the start of the 6:00 AM-2:00 PM shift and had not received incontinence care until 11:50 AM. The resident expressed discomfort and dissatisfaction with being left wet. CNA A, responsible for the resident's care during this shift, admitted to not checking on the resident for incontinence care since around 10:00 AM, as the resident was sleeping. The CNA acknowledged the importance of ensuring residents are clean and dry to prevent skin damage and irritation. The facility's Director of Nursing (DON) confirmed that CNAs are responsible for conducting rounds every two hours to ensure residents are clean and dry, and that nurses should also check on residents. The facility's incontinence care policy outlined procedures for cleaning after an incontinence episode but did not specify the frequency of checks. The failure to provide timely incontinence care placed the resident at risk for skin breakdown, infection, and pressure sores.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required by State and Federal laws. During an observation on the 100 halls, a medication cart was found unlocked and unattended. This occurred on 04/30/24 at 9:20 AM, with residents in close proximity to the unsecured cart. Resident #3 was sitting next to the cart, and Resident #1 was observed moving independently in his wheelchair near the cart multiple times. The medication cart remained unsupervised until 9:34 AM when another employee locked it, indicating that ADON A was responsible for the cart. Resident #1, a male with a history of cerebral infarction, depression, and anxiety, was cognitively intact with a BIMS score of 15. He required supervision for activities of daily living and was on psychotropic medications. Despite his cognitive status, he was observed near the unlocked medication cart, which posed a risk given his behavioral history of physical and verbal aggression. Resident #2, a female with severe cognitive impairment and dementia, was also near the cart, asleep in her wheelchair, and moving closer to it intermittently. Interviews with staff revealed that ADON A left the cart unlocked due to being distracted by another task. Both the DON and the Administrator acknowledged the expectation that medication carts should be locked when unattended to prevent unauthorized access. However, the facility lacked a specific medication cart security policy, as confirmed by the DON. This oversight in securing medication carts could potentially lead to residents accessing medications, posing risks of overdosing or adverse reactions.
Failure to Update Resident Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. This deficiency was identified for one resident, a cognitively intact male with a history of cerebral infarction, cataracts, depression, and anxiety. The resident's care plan, dated several months prior, had not been updated as required, despite the resident's ongoing need for supervision with activities of daily living and the use of psychotropic medications for depression and anxiety. Interviews with facility staff revealed a lack of familiarity and training regarding the care plan update process. The Director of Nursing (DON), who had been in the position for two weeks, acknowledged that the care plans should have been updated quarterly and was not aware of the facility's process for updating them. The facility's Administrator was aware of a backlog of care plans that had not been updated by previous nursing staff and had hired new nurse managers to address the issue. However, the Administrator was unaware of the risks associated with not updating care plans.
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What surveyors actually found near you
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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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ft. Worth Southwest Nursing Center | 0.5 mi | ★★★★★ | 6 | 0 |
| Avir At Fort Worth | 0.7 mi | ★★★★★ | 6 | 2 |
| Ignite Medical Resort Fort Worth, Llc | 0.8 mi | ★★★★★ | 17 | 0 |
| Cityview Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 12 | 0 |
| Garden Terrace Healthcare Center Of Fort Worth | 1.3 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.