Wedgewood Manor

Inspectors wroteBased on observation and staff interviews, the facility failed to provide housekeeping services to maintain a safe, clean, comfortable and homelike environment for 3 of 3 sampled residents (Residents #11, #12, and #14's) and 1 of 1 commons area (Hall B) with circulating fans. Failure to ensure the residents' environment and equipment (fans) are kept clean and sanitary does not promote a homelike living environment.

Inspectors wroteBased on record review, review of facility policy, and staff interviews, the facility failed to notify the resident's medical provider for 1 of 1 sampled resident (Resident #15) with high blood glucose readings. Failure to notify the provider of high blood glucose levels as ordered may result in adverse outcomes for the resident and delay in treatment.

Inspectors wroteBased on record review and staff interview, the facility failed to develop a comprehensive care plan for 1 of 14 sampled residents (Resident #8). Failure to develop a comprehensive care plan that includes opioid medication use and pain may negatively impact the resident's quality of care.

Inspectors wroteBased on observation, record review, review of facility policy, and resident and staff interview, the facility failed to utilize the assistive devices necessary to prevent accidents for 1 of 1 sampled resident (Resident #6) observed during a transfer. Failure to use a gait belt during transfers placed residents at risk for injuries and falls.

Inspectors wroteBased on observation, record review, review of facility policy, and resident and staff interview, the facility failed to provide the necessary care and services for 1 of 1 sampled resident (Resident #11) receiving oxygen. Failure to administer oxygen according to the physician's order may result in complications and compromise the resident's respiratory status.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the safety of equipment for 1 of 2 sampled resident (Resident #12) observed with a nebulizer machine. Failure to maintain equipment in safe operating conditions may result in equipment short circuiting, fires, and injuries to the residents or staff.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean and sanitary kitchen environment for 1 of 1 facility kitchen. Failure to ensure the sanitizer test strips used to measure the concentration of sanitizing solution are not expired has the potential for inadequate sanitization and may result in foodborne illness.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.19.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 2 of 12 sampled residents (Resident #19 and #31). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wrote1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 3 sampled residents (Resident #14 and #32) observed during wound care. Failure to practice infection control standards related to enhanced barrier precautions (EBP) has the potential to spread infection throughout the facility.

Inspectors wroteBased on review of the facility reported incident (FRI) investigation, review of facility policy, and staff interviews, the facility failed to immediately implement safeguards for all residents after suspected sexual abuse occurred for 1 of 1 sampled resident (Resident #1). Failure to immediately protect all residents from the potential of sexual abuse placed them at risk for mental and emotional distress, and/or physical injury. During the on-site FRI survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 10/07/24. The IJ was identified during an interview with three administrative staff members (#1, #2, and #5) and a staff nurse (#4) on 10/07/24 at approximately 9:55 p.m. [...]

Inspectors wroteBased on review of the facility reported incident (FRI) investigation, review of facility policy, and staff interviews, the facility failed to report potential sexual abuse to law enforcement for 1 of 1 sampled resident (Resident #1) with cognitive impairment. Failure to report potential sexual abuse placed Resident #1 and all other residents at risk for possible abuse and/or injury. During the on-site survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 10/07/24. The IJ was identified during an interview with three administrative staff members (#1, #2, and #5) and a staff nurse (#4) on 10/07/24 at approximately 9:55 p.m. [...]

Inspectors wroteBased on review of the facility reported incident (FRI) investigation, review of facility policy, and staff interviews, the facility failed to conduct a thorough investigation of potential sexual abuse for all residents after suspected sexual abuse for 1 of 1 sampled resident (Resident #1). Failure to investigate alleged violations of sexual abuse and ensure all residents were protected during the investigation, placed Resident #1 and all other residents at risk for possible abuse, mental and emotional distress, and/or physical injury. During the on-site survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 10/07/24. The IJ was identified during an interview with three administrative staff members (#1, #2, and #5) and a staff nurse (#4) on 10/07/24 at approximately 9:55 p.m. [...]

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 5 of 12 sampled residents (#3, #10, #15, #28, and #30). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plan to reflect the current status for 2 of 12 sampled residents (Resident #15 and #28). Failure to review and revise the care plan limited staff's ability to communicate needs and ensure continuity of care.

Inspectors wrote1. Based on record review, facility policy review, and staff interview, the facility failed to follow professional standards of care regarding physician orders for 1 of 5 sampled residents (Resident #17) selected for medication review. Failure to follow professional standards and contact the physician when blood glucose levels are higher than the practitioner's parameter has the potential to prevent the provider from altering medications to control residents blood sugar and/or result in adverse events.