Wedgemere Healthcare

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident # 1), the Facility failed to ensure they developed and implemented a comprehensive person-centered care plan with interventions, treatment goals, and outcomes that addressed his/her individual recreational activity needs. Findings Include: Review of the Facility's Policy titled, Care Plans, Comprehensive Person-Centered, dated as revised 01/2024, indicated the following:-A comprehensive, person-centered care plan will be developed for each resident; [...]

Inspectors wroteBased on interviews and review of the Activity Director's (AD) personnel file, the facility failed to ensure the activity program was directed by a qualified activities professional.

Inspectors wroteBased on review of Resident Council Minutes, a resident group meeting, interviews, and record reviews, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely and included the facility response to the group.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident was developed to include the minimum healthcare information necessary to properly care for a resident including, initial goals based on admission orders, and failed to ensure the resident and/or their representative were provided with a summary of the baseline care plan for three Residents (#21, #36, and #33), out of a total sample of 18 residents. Specifically, the facility failed:1. For Resident #21, to address a left femur fracture and surgical wound care on the Baseline Care Plan and failed to ensure the Resident and/or their representative were provided copies of the Medication list and Baseline Care Plan;2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a person-centered individualized comprehensive care plan was developed and implemented for one Resident (#36), out of a total sample of 18 residents. Specifically, the facility failed for Resident #36, to develop a care plan to address bilateral lower extremity contractures for 11 months and to develop a care plan for the potential for skin breakdown for two months.

Inspectors wroteBased on observation and interview, the facility failed to provide an ongoing program of individual and group activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of Residents on 4 out of 4 units and for one Resident (#23), out of 18 sampled residents. Specifically, the facility failed:1. For Resident #23, to ensure that staff offered and encouraged engagement in activities according to their comprehensive assessment and identified preferences; and 2. To ensure staff provided a meaningful and engaging activity program, including materials for self-directed activity, for residents on Sunday in the month of March.

Inspectors wroteBased on document review and interview, the facility failed to ensure that services were provided in accordance with professional standards for one Resident (#3) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of a total sample of two residents with G-tubes in the facility, to maintain patency and prevent complications of the G-tube. Resident #3 had to have their G-tube replaced four times between January and March 2026 due to clogging.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) program with documentation of the development, implementation, and evaluation of corrective actions or performance improvement activities. Specifically, the facility failed to:1. Develop and implement appropriate plans of action for resident concerns communicated at Resident Council; and2. Identify, develop, and implement appropriate plans of action for one Resident (#3) hospitalized four times in the past three months due to a clogged feeding tube.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the Resident Representative (Guardian) was not extended authority of decision making beyond the extent required by the court to consent to the administration of an antipsychotic medication for one Resident (#33), from a total sample of 18 residents. Specifically, Resident #33 was administered Olanzapine (Zyprexa) after the legal guardian did not retain authority to consent to the medication.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the call bell device was operational and in reach on the Resident's functional side for one Resident (#3), out of 18 sampled residents.

Inspectors wroteBased on observation, document review, and interview, the facility failed to ensure for one Resident (#14), out of a total sample of 18 residents, that their wheelchair was maintained in a clean and safe manner.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one Resident (#23), out of a total sample of 18 residents, was provided the right to participate in their care plan process. Specifically, the facility failed to ensure that Resident #23 was invited to participate in their individual care plan meeting or provide a rationale as to why the participation of the Resident/Resident Representative was determined not practicable for the development of the care plan.

Inspectors wroteBased on record review and interview, the facility failed to ensure for one Resident (#21), out of a total sample of 18 residents with an alteration in skin integrity, specifically post-op surgical incisions, received necessary treatment and services to promote healing. Specifically, the facility failed to transcribe and implement wound care per the Hospital Discharge Summary, to develop and implement a care plan for the alteration in skin integrity, to ensure specific bathing/showering requirements related to the surgical incision were on the Kardex, to complete accurate admission, re-admission, and weekly skin assessments, and to monitor, assess and identify signs/symptoms of an infection until he/she was seen by the Wound Care Physician two weeks after admission for unrelated wounds and the clinical signs of infection were identified and a treatment implemented.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had a Physician's order for an x-ray of his/her sacrum/pelvis, the Facility failed to ensure that he/she was provided with radiology services consistent with his/her Physician's Orders, when the x-ray was not obtained. Findings Include:Review of Resident #1's Physician Progress Note, dated 12/07/25, indicated that his/her Stage 3 (full-thickness skin loss that extends through the dermis and into the subcutaneous tissue) sacral pressure injury appeared necrotic (tissue death within the wound) and to obtain an x-ray of his/her sacrum/pelvis to evaluate for osteomyelitis (serious bone infection). Review of Resident #1's Physician Orders, dated 12/07/25, indicated to obtain x-ray of the pelvis and sacrum. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), who had developed open areas to his/her sacrum and left buttocks, and who was dependent on the physical assistance of staff with Activities of Daily Living (ADL), the Facility failed to ensure they maintained a complete and accurate medical record, when 1) there was conflicting nursing documentation related to his/her wounds and 2) Certified Nurse Aide (CNA) ADL Flow Sheets, daily documentation by CNA's (for all three shifts) were not consistently completed, with flow sheets left blank.

Inspectors wroteBased on interviews and record review, the facility failed to ensure staff maintained accurate documentation for four Residents (#37, #50, #32, and #23), out of a total of 18 sampled residents. Specifically, the facility failed to: 1. For Resident #37, ensure November 2024 through January 2025 Medication Administration Records (MAR) were accurate and reflected the administration of multiple medications according to physician's orders; 2. For Resident #50, ensure December 2024 and January 2025 MAR were accurate and reflected the administration of multiple medications according to physician's orders; 3. For Resident #32, ensure November 2024 through January 2025 Treatment Administration Records (TAR) accurately reflected the administration of multiple treatments according to physician's order; and 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections for three Residents (#50, #61, and #46), out of a total sample of 18 residents. Specifically, the facility failed: 1a. For Resident #50, to ensure staff performed hand hygiene when indicated, adhered to Contact Precautions, and sanitized shared medical equipment (blood pressure cuff) after use; and b. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe and clean environment in the designated smoking area by not properly disposing of cigarette butts in designated safe ashtrays.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for one Resident (#23), out of 18 sampled residents. Specifically, the facility failed to ensure a comprehensive care plan was developed and implemented to address the care and management of Resident #23's Diabetes Mellitus (non-insulin dependent diabetes).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for two Residents (#54 and #23), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #54, to ensure the facility implemented the consultant eye doctor's recommendations for eye drops; and 2. For Resident #23, to ensure physician requested/recommended treatments were entered into the electronic medical record and implemented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ankle foot orthosis (AFO) brace and to ensure left arm sling was worn for one Resident (#66), out of a total of 18 residents, so that he/she could carry out their activities of daily living, specifically regarding mobility and left shoulder support.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure staff provided appropriate care and services for one Resident (#46) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 18 sampled residents. Specifically, the facility failed to administer the prescribed enteral (form of nutrition that is delivered into the digestive system as a liquid) feeding, document administration tubing set changes every 24 hours and ensure the labels included the accurate Resident name, date, start time and rate of infusion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles for two Residents (#31 and #67), out of 18 sampled residents. Specifically, the facility failed: 1. For Resident #31, to ensure a bottle of Tylenol was not left unsecured in the Resident's room; and 2. For Resident #67, to ensure two bottles of Latanoprost eye drops (decreases pressure in the eye) and one bottle of Timolol eye drops (decreases pressure in the eye) were not left unsecured in the Resident's room.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled Employee Files, the Facility failed to ensure they implemented and followed their Abuse Policy when a Massachusetts Nurse Aide Registry (NAR) check was not conducted on Nurse #1 prior to her date of employment at the Facility as required, and in accordance with the Facility's Abuse Policy.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one Resident (#30), out of a total sample of 20 residents, received care and treatment in accordance with professional standards. [...]

Inspectors wroteBased on observation, interviews, policy review, and record review, the facility failed to ensure one Resident (#30), out of a total sample of 20 residents, received care and treatment to prevent and promote healing of pressure injuries. [...]

Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to ensure staff served food in accordance with professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to: 1. Maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections; and 2. Follow infection control guidelines during a wound dressing treatments for two Residents (#51 and #30), out of two observed wound dressing changes.

Inspectors wroteBased on observations, interviews, and records reviewed, the facility failed to ensure a comprehensive care plan was developed and/or implemented for three Residents (#4, #11, and #30), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #4, a. to develop a comprehensive care plan related to a left-hand splint, and b. to develop a comprehensive care plan related to a Foley catheter; 2. For Resident #11, to develop a comprehensive care plan related to antipsychotic and anticoagulant medications; and 3. For Resident #30, to develop a comprehensive care plan related to a pressure area.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure refrigerator temperatures were recorded in the medication storage refrigerators to ensure safe storage for both medications and vaccines in accordance with the facility policy.

Inspectors wroteBased on observation and interviews, the facility failed to ensure drinks, specifically milk, were served at an appetizing temperature for residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to implement an Antibiotic Stewardship Program to measure and improve how antibiotics are prescribed by clinicians and failed to complete antibiotic usage audit tools, which are used to track, report and evaluate antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to assess Resident #20 prior to staff moving the Resident after an unwitnessed fall. The total resident sample was 20.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to implement fall interventions indicated in the fall care plan for one Resident (#20), resulting in a fall, out of a total sample of 20 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards of care for Residents with indwelling urinary catheters for two Residents (#54 and #67), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #54, to ensure the catheter drainage bag was maintained in a manner to prevent the potential of germs entering the urinary tract system and potential urinary complications; and 2. For Resident #67, to implement and follow physician's orders for catheter care.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to provide necessary respiratory care and services for one Resident (#74), out of a total sample of 20 residents. Specifically, the facility failed to ensure oxygen tubing was changed weekly.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure ongoing communication, assessment and collaboration was maintained with the dialysis center for one Residents (#29), out of one Resident on dialysis in the facility.

Inspectors wroteBased on interview, policy review, and record reviews, the facility failed to ensure monthly medication regimen reviews (MRR) were maintained as part of the permanent medical record and failed to ensure irregularities were addressed by physician, pharmacy, and facility for two Residents (#26 and #29), out of a total sample of 20 residents.

Inspectors wroteBased on interview, policy review, and record reviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs without adequate monitoring for one Resident (#26), out of a total sample of 20 residents.

Inspectors wroteBased on interview, policy review, and record reviews, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic drugs without adequate monitoring for two Residents (#11 and #26), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #11, to monitor for side effects of an antipsychotic medication; and 2. For Resident #26, to monitor for behaviors related to the use of antianxiety and antidepressant medications and to ensure as needed (PRN) orders for psychotropic drugs are limited to 14 days except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

Inspectors wroteBased on record reviews, policy review, and interviews, the facility failed to provide a written notification of the intent to transfer or discharge to the Resident or responsible party prior to discharge to the hospital for two Residents (#49 and #11), in a total sample of 20 residents.

Inspectors wroteBased on record reviews, policy review, and interviews, the facility failed to provide a written notification of the bed hold policy to the Resident or Resident representative prior to discharge to the hospital, for two Residents (#49 and #11), in a total sample of 20 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately completed to reflect the status for three Residents (#21, #54, and #11), in a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #21, to ensure the MDS accurately reflected the hospice status; 2. For Resident #54, to ensure the MDS reflected the correct status regarding a restraint; and 3. For Resident #11, to ensure the MDS accurately reflected the use of anticoagulants (blood thinner).

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated he/she required two staff members to assist with and be present the entire time while providing care and services, the Facility failed to ensure nursing staff consistently implemented and followed interventions from his/her Plan of Care while meeting his/her care needs. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated to perform passive range of motion (ROM) with activities of daily living and to monitor and report changes in range of motion, the Facility failed to ensure that he/she was provided with the necessary care and potential need for treatment, when he/she experienced a sudden change in condition during the performance of range of motion by staff, that was not immediately reported to his/her nurse, as required. On 10/07/23, Certified Nurse Aide (CNA) #1 performed passive range of motion exercises to Resident #1's left leg and heard a popping sound while performing range of motion to his/her left leg, however CNA #1 never reported the incident to Resident #1's nurse. [...]

Inspectors wroteBased on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer Pneumococcal Vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for four Residents (#1, #2, #3, and #4), out of a total sample of five residents reviewed for immunizations.

Inspectors wroteBased on interview, policy review, and document review, the facility failed to maintain and consistently implement an infection prevention and control program during a current COVID-19 outbreak in the facility. Specifically, the facility failed to: 1. Consistently implement a system for staff surveillance of COVID-19 within the facility; and 2. Ensure staff followed infection control guidelines for doffing (taking off) personal protective equipment (PPE) when exiting a COVID-19 positive resident's room.