Deficiencies (last 4 years)
Deficiencies (over 4 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
186% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 1
Jun 18, 2025
Visit Reason
The inspection was conducted to assess whether the facility ensured that food was prepared in a form designed to meet individual resident needs, specifically reviewing the lunch meal on 06/18/25.
Findings
The facility failed to prepare and serve pureed rice pilaf with a pudding-like consistency for residents requiring pureed diets during the lunch meal on 06/18/25, which could place residents at risk of choking or not receiving meals that meet their needs.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to prepare and serve pureed rice pilaf as a pudding consistency for residents requiring pureed diets during the lunch meal on 06/18/25. | Level of Harm - Minimal harm or potential for actual harm |
Inspection Report
Complaint Investigation
Deficiencies: 1
Apr 23, 2025
Visit Reason
The inspection was conducted due to a complaint regarding incomplete and inaccurate clinical record documentation for Resident #1, specifically related to blood sugar monitoring, medication administration, and communication with healthcare providers during a change in condition on 02/02/25.
Findings
The facility failed to maintain complete and accurate clinical records for Resident #1, including missing documentation of times for blood glucose tests, medication administration, Nurse Practitioner contacts, and EMS calls. Interviews with staff confirmed the importance of timely and accurate documentation, and the facility's policy outlines proper clinical documentation procedures.
Complaint Details
The complaint was substantiated as the facility failed to properly document significant clinical events and care for Resident #1 on 02/02/25, leading to potential risks for delays and errors in care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain complete and accurate clinical records for Resident #1, including missing times for blood glucose monitoring tests, medication administration, Nurse Practitioner contacts, and EMS calls on 02/02/25. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Blood glucose monitoring tests missing time documentation: 5
Medications missing time documentation: 3
Nurse Practitioner contacts missing time documentation: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in findings for failure to document blood sugar monitoring, medication administration, and contacts with NP and EMS on 02/02/25. |
| LVN B | Licensed Vocational Nurse | Interviewed regarding importance of timely documentation of medication administration. |
| Medication Aide | Interviewed about medication documentation requirements. | |
| Administrator | Administrator | Interviewed about expectations for documentation of significant events. |
| Assistant Director of Nurses | Assistant Director of Nurses (ADON) | Interviewed about documentation expectations and review of Resident #1 progress notes. |
Inspection Report
Annual Inspection
Capacity: 128
Deficiencies: 8
Jan 31, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements across multiple areas including resident care, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide adequate ADL care, contracture management, enteral feeding care, respiratory care, infection control, privacy, and staffing. An Immediate Jeopardy was identified related to improper management of enteral feeding tubes and use of unapproved de-clogger devices. Other deficiencies included failure to maintain privacy curtains, failure to sanitize reusable equipment, and lack of a full-time qualified social worker.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure residents unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene, including failure to keep fingernails trimmed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care for a resident with limited range of motion, including failure to provide contracture management device for right hand. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents receiving enteral feeding received appropriate treatment and services to prevent complications, including failure to follow physician orders for water flushes and unauthorized use of de-clogger device. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to provide safe and appropriate respiratory care, including lack of physician orders for tracheostomy care, suction tubing, and emergency trach kit. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was prepared in a form designed to meet individual needs, including serving pureed mashed potatoes with lumps instead of pudding consistency. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to employ a qualified full-time social worker in a facility with more than 120 beds. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain an infection prevention and control program, including failure to sanitize reusable blood pressure cuff between residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide bedrooms that assure full visual privacy for residents, including lack of privacy curtains or damaged curtains for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Licensed capacity: 128
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN F | Registered Nurse | Named in enteral feeding and respiratory care deficiencies |
| ADON B | Assistant Director of Nursing | Named in enteral feeding and respiratory care deficiencies |
| RN G | Registered Nurse | Named in enteral feeding deficiency related to unauthorized use of de-clogger |
| MA D | Medical Assistant | Named in infection control deficiency for failure to sanitize blood pressure cuff |
| Dietary Manager | Named in food preparation deficiency for improper pureed food consistency | |
| Administrator | Named in social worker staffing and privacy deficiencies | |
| Housekeeping Supervisor | Named in privacy deficiency related to curtain maintenance | |
| Maintenance Supervisor | Named in privacy deficiency related to curtain maintenance |
Inspection Report
Routine
Deficiencies: 2
Oct 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to environmental conditions and resident care, including the safety and sanitation of resident rooms and the provision of assistance with activities of daily living.
Findings
The facility failed to maintain a safe, clean, and sanitary environment in resident rooms, specifically dirty vents covered with debris and a hanging ceiling rail posing risk of injury. Additionally, the facility failed to provide timely incontinence care to a resident, placing her at risk for skin breakdown and infection.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to maintain Rooms 221, 225, 229, and 231 in a safe and sanitary condition with vents covered in dark debris and dust, posing risk for infection and decreased quality of life. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide Resident #1 timely assistance with incontinence care, resulting in the resident being wet for approximately 6 hours, risking skin breakdown and infection. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 4
Residents affected: 1
Vent cover size: 10
Ceiling rail length: 2.5
Time resident wet: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper C | Aware of dirty vents and hanging ceiling rail, responsible for alerting Maintenance Director | |
| CNA A | Observed vents with mold, responsible for alerting Maintenance Director and providing incontinence care to Resident #1 | |
| LVN B | Licensed Vocational Nurse | Notified about dirty vents and hanging rail, responsible for resident care and reporting |
| Maintenance Director | Notified of vents and hanging rail, ordered new vents and repaired rail | |
| Administrator | Ordered new vents and emphasized staff responsibility for reporting concerns | |
| DON | Director of Nursing | Alerted to Resident #1 being soaked, stated CNAs responsible for rounds every 2 hours |
Inspection Report
Routine
Deficiencies: 2
Apr 30, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care plan updates and medication storage security at Wedgewood Nursing Home.
Findings
The facility failed to ensure that comprehensive care plans were reviewed and updated quarterly for residents, specifically Resident #1, and failed to secure medication carts, leaving them unlocked and unattended, posing risks of medication access by residents and others.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure comprehensive care plans were reviewed and revised quarterly by the interdisciplinary team for Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure medications were secured inside the medication cart on 100 halls; medication cart was found unlocked and unattended. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| ADON A | Assistant Director of Nursing | Responsible for medication cart on 100 halls; admitted leaving cart unlocked |
| DON | Director of Nursing | Interviewed regarding care plan updates and medication cart security; new to position |
| Administrator | Interviewed about care plan backlog and medication cart security policies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 14, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide Resident #1 with an admission packet upon admission, and failure to establish and implement policies addressing resident admission.
Findings
The facility failed to provide Resident #1 with an admission packet upon admission, which could place residents at risk of not being aware of the services provided. Interviews and record reviews confirmed missing admission paperwork for Resident #1 and other residents, with efforts underway to complete missing documentation.
Complaint Details
The complaint investigation found that Resident #1 was not given admission paperwork or an admission packet upon admission. The Business Office Manager and Administrator confirmed missing admission paperwork for some residents due to previous staff issues.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide Resident #1 with an admission packet upon admission. | Level of Harm - Minimal harm or potential for actual harm |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 7, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication administration error involving Resident #1, where a licensed nurse administered an entire bottle of nitroglycerin instead of the ordered single tablet.
Findings
The facility failed to ensure licensed nurses had the appropriate competencies in medication administration, resulting in a significant medication error where Resident #1 was given 25 nitroglycerin tablets instead of one, leading to an emergency room visit. The facility corrected the noncompliance prior to the survey and implemented staff in-services and disciplinary actions.
Complaint Details
The complaint investigation was substantiated. The Immediate Jeopardy (IJ) began on 2024-02-04 and ended on 2024-02-05. The facility corrected the noncompliance before the survey began by suspending and terminating the nurse involved, conducting medication cart audits, and providing in-services to all staff on medication administration and abuse and neglect policies.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure licensed nurses had appropriate competencies and skills to provide nursing services, resulting in a medication error where an entire bottle of nitroglycerin was administered instead of one tablet. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to ensure residents were free from significant medication errors, specifically the overdose of nitroglycerin to Resident #1. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Nitroglycerin tablets administered: 25
Nitroglycerin dosage per tablet: 0.4
Blood pressure at ER admission: 86
Blood pressure at ER admission: 42
BIMS score: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Nurse who administered the entire bottle of nitroglycerin to Resident #1, resulting in medication error and subsequent suspension and termination. |
| DON | Director of Nursing | Contacted after the medication error, conducted in-services, suspended LVN C, and ensured corrective actions were implemented. |
| WCN | Wound Care Nurse / Charge Nurse | Supervised LVN C during the incident, instructed on medication administration, and responded to the medication error. |
| ADON A | Assistant Director of Nursing | Completed medication cart audit with no issues found. |
| ADON B | Assistant Director of Nursing | Completed medication cart audit with no issues found. |
Inspection Report
Routine
Deficiencies: 2
Feb 1, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards regarding clinical record maintenance and wound care documentation for residents at Wedgewood Nursing Home.
Findings
The facility failed to maintain complete and accurate wound care documentation for two residents on multiple dates in January 2024, despite wound care being provided. Staff acknowledged completing care but not documenting it, resulting in deficient practice that could lead to misinformation about care provided.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure Resident #1's wound care was documented on the TAR for 01/13/24, 01/14/24, and 01/21/24. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident #2's wound care was documented on the TAR for 01/15/24 and 01/29/24. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Missing documentation dates for Resident #1: 3
Missing documentation dates for Resident #2: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Reviewed TARs, wrote up nurses responsible for missing documentation, and conducted in-service training |
| ADON | Assistant Director of Nursing | Responsible for Resident #2's wound care on 01/15/24; admitted to completing care but forgetting documentation; was written up |
| LVN A | Licensed Vocational Nurse | Worked on 01/13/24, 01/14/24, and 01/21/24; assigned to Resident #1; completed wound care but failed to document; was written up |
| WCN | Wound Care Nurse | Responsible for Resident #2's wound care on 01/29/24; completed care but did not document due to laptop connectivity issues |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 25, 2024
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Wedgewood Nursing Home following a survey completed on January 25, 2024.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Census: 83
Deficiencies: 2
Dec 20, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident call light systems and pest control programs in the nursing home.
Findings
The facility failed to adequately equip two residents with call light systems, potentially delaying staff response. Additionally, the facility failed to maintain an effective pest control program, resulting in the presence of gnats in multiple areas, posing a risk of foodborne illness or disease spread.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to provide working call light systems in residents' bathrooms and bathing areas for 2 of 83 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to maintain an effective pest control program to prevent presence of gnats in multiple areas. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for call lights: 83
Residents affected by call light deficiency: 2
Stations reviewed for pests: 2
Conference rooms reviewed for pests: 1
Dining rooms reviewed for pests: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA F | CNA assigned to Residents #45 and #65, noted absence of call lights | |
| RN D | Nurse assigned to Residents #45 and #65, noted absence of call lights | |
| ADON C | Assistant Director of Nursing, unaware of missing call lights, planned to move residents until fixed | |
| DON | Director of Nursing, unaware of missing call lights, planned to move residents until fixed | |
| LVN E | Nurse assigned to part of North Station, reported gnats issue during summer | |
| Maintenance Manager | Reported no complaints of gnats, pest control visits monthly | |
| Administrator | Reported no complaints regarding gnats, confirmed pest control visits |
Inspection Report
Routine
Deficiencies: 11
Dec 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, call light accessibility, homelike environment, physician orders, assessment accuracy, care planning, respiratory care, pain management, call system availability, and pest control.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity by not covering catheter bags, failure to provide accessible call lights, lack of warm water and clean air vents in some rooms, missing physician orders for catheter use and dialysis, inaccurate MDS assessments, incomplete care plans, improper respiratory care including undated oxygen equipment and incorrect oxygen administration, inadequate pain management, missing call lights for some residents, and ineffective pest control program resulting in presence of gnats.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 11
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to ensure resident dignity by not covering urinary catheter collection bag with a privacy bag for Resident #23. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident #11's call light was accessible, placing resident at risk of falls and injury. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide warm water to sinks in multiple rooms and clean air vents in others, risking resident discomfort. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to have physician orders for indwelling catheter for Resident #23 and dialysis for Resident #60 upon readmission. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure MDS assessment accurately reflected dialysis treatment status for Resident #36. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to refer residents #20 and #68 for PASARR Level II review despite diagnoses indicating need. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement comprehensive care plans for Residents #23, #40, and #53 including catheter use and wound care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to date oxygen tubing and humidifier bottle for Resident #75 and failure to ensure accurate oxygen administration for Resident #72. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain pain control at acceptable levels for Resident #10, with inadequate alternative pain management. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide working call light systems in rooms of Residents #45 and #65. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain an effective pest control program, resulting in presence of gnats in multiple facility areas. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for dignity: 8
Residents reviewed for call lights: 83
Rooms reviewed for homelike environment: 25
Residents reviewed for PASARR requirements: 5
Residents reviewed for comprehensive care plans: 8
Residents reviewed for respiratory care: 6
Residents reviewed for pain management: 7
Pest control visits: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA K | Certified Nursing Assistant | Mentioned in relation to catheter care and call light accessibility |
| LVN L | Licensed Vocational Nurse | Mentioned in relation to catheter care and physician orders |
| LVN M | Licensed Vocational Nurse | Mentioned in relation to catheter care and physician orders |
| ADON C | Assistant Director of Nursing | Mentioned in relation to catheter care, call light responsibility, and care plan accuracy |
| DON | Director of Nursing | Mentioned in relation to catheter care, call light responsibility, care plan accuracy, and respiratory care |
| LVN A | Licensed Vocational Nurse | Mentioned in relation to call light accessibility and pain management |
| RN D | Registered Nurse | Mentioned in relation to respiratory care and call light accessibility |
| LVN I | Licensed Vocational Nurse | Mentioned in relation to oxygen administration |
| RN J | Registered Nurse | Mentioned in relation to oxygen administration |
| Treatment Nurse | Mentioned in relation to wound care and care plan updates | |
| Social Worker | Mentioned in relation to PASARR referrals and care plan updates | |
| Maintenance Manager | Mentioned in relation to air vent maintenance and pest control | |
| CNA F | Certified Nursing Assistant | Mentioned in relation to call light accessibility and pest control |
| LVN B | Licensed Vocational Nurse | Mentioned in relation to dialysis orders |
| LVN E | Licensed Vocational Nurse | Mentioned in relation to dialysis orders and pest control |
| Administrator | Mentioned in relation to pest control and facility oversight |
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 24, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to reasonably accommodate the needs and preferences of residents, specifically focusing on Resident #1 who was not assisted to get out of bed despite multiple requests due to lack of a wheelchair.
Findings
The facility failed to assist Resident #1 to get out of bed when requested, lacked completed admission MDS assessment and care plan for Resident #1, and did not have physician orders for the resident's immediate care upon admission. Resident #1 was found unresponsive and later pronounced deceased. The facility also had 20 bedfast residents. Staff interviews revealed communication and procedural deficiencies related to Resident #1's care.
Complaint Details
The complaint investigation focused on Resident #1 who repeatedly requested to get out of bed but was not assisted due to lack of wheelchair and absence of therapy evaluation. Resident #1 was found unresponsive and later pronounced deceased. Interviews revealed conflicting staff statements about the resident's yelling and agitation during the night. The facility lacked completed admission assessments and care plans for Resident #1 and did not have physician orders upon admission.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to reasonably accommodate the needs and preferences of Resident #1 by not assisting her to get out of bed due to lack of wheelchair availability. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to have physician orders for Resident #1's immediate care at the time of admission. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for services and needs: 12
Residents bedfast: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Licensed Vocational Nurse | Named in findings related to Resident #1's care and observations during the night shift |
| CNA D | Certified Nursing Assistant | Named in findings related to Resident #1's care and observations during the night shift |
| RN N | Registered Nurse | Named in interview regarding admission and care of Resident #1 |
| DON | Director of Nursing | Named in interviews regarding facility policies and Resident #1's care |
| ADON A | Assistant Director of Nursing | Named in interviews regarding Resident #1's care and staff communication |
| ADON B | Assistant Director of Nursing | Named in interviews regarding Resident #1's care and staff communication |
| Administrator | Named in interviews regarding facility policies and Resident #1's care | |
| MD | Medical Doctor | Named in interviews regarding Resident #1's admission and care orders |
Inspection Report
Routine
Deficiencies: 2
Sep 8, 2023
Visit Reason
The inspection was conducted to assess compliance with nursing home regulations, focusing on accident prevention and infection control practices.
Findings
The facility failed to ensure adequate supervision during a Hoyer lift transfer for one resident, resulting in a safety risk. Additionally, the facility failed to maintain proper infection prevention and control practices for a COVID-19 positive resident, including improper use of PPE and failure to keep the isolation room door closed.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure each resident received adequate supervision and assistance devices to prevent accidents during a Hoyer lift transfer. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to establish and maintain an infection prevention and control program, including improper PPE use and failure to keep isolation room door closed for a COVID-19 positive resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for accidents: 3
Staff reviewed for infection control practices: 4
Days of isolation for Resident #1: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hospitality Aide D | Hospitality Aide | Failed to transfer Resident #2 with assistance during Hoyer lift transfer. |
| CNA A | Certified Nursing Assistant | Failed to don proper PPE and perform hand hygiene when caring for COVID-19 positive Resident #1. |
| Restorative Aide | Assisted Hospitality Aide D during Hoyer lift transfer after noticing lack of assistance. | |
| LVN E | Licensed Vocational Nurse | Confirmed requirement for two staff during Hoyer lift transfers. |
| LVN B | Licensed Vocational Nurse | Nurse assigned to Resident #1, confirmed PPE and isolation protocols. |
| DON | Director of Nursing | Stated expectations for two-person Hoyer lift transfers and proper PPE use during isolation. |
| ADON | Assistant Director of Nursing | Confirmed PPE and hand hygiene protocols for COVID-19 isolation. |
| CNA C | Certified Nursing Assistant | Trained CNA A and denied instructing CNA A to omit PPE use. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Sep 8, 2023
Visit Reason
The inspection was conducted due to concerns about infection prevention and control practices, specifically related to COVID-19 precautions for a resident on isolation.
Findings
The facility failed to maintain an effective infection prevention and control program, as staff did not consistently wear proper PPE or perform hand hygiene when caring for a COVID-19 positive resident. The resident's isolation door was left open, increasing risk of infection spread.
Complaint Details
The complaint investigation focused on infection control practices related to COVID-19 isolation precautions for Resident #1. The complaint was substantiated as staff failed to follow PPE and hand hygiene protocols, and the resident's isolation door was left open.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| The facility failed to ensure Resident #1's door was closed while on isolation for COVID-19. | Level of Harm - Minimal harm or potential for actual harm |
| CNA A failed to don proper PPE prior to entering Resident #1's room, who was on isolation for COVID-19. | Level of Harm - Minimal harm or potential for actual harm |
| CNA A failed to perform hand hygiene when passing out lunch trays for residents on the North Hall. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Isolation duration: 10
Resident isolation day: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Failed to don proper PPE and perform hand hygiene when caring for Resident #1. |
| LVN B | Licensed Vocational Nurse | Nurse assigned to Resident #1 who described proper PPE and isolation procedures. |
| CNA C | Certified Nursing Assistant | Trained CNA A and stated staff should always don PPE when entering isolation rooms. |
| ADON | Assistant Director of Nursing | Provided information on PPE requirements and infection control policies. |
| DON | Director of Nursing | Stated expectations for staff PPE use and hand hygiene during Resident #1's isolation. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 20, 2022
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to timely report suspected abuse involving two residents, specifically an incident of possible sexual abuse involving one resident taking pictures of her roommate.
Findings
The facility failed to report alleged abuse incidents to the State Survey Agency and other officials within 5 working days as required by state law. The investigation revealed conflicting accounts, with residents and responsible parties denying the incident and no evidence found on the phone. The Administrator did not report the incident, believing it did not constitute abuse.
Complaint Details
The complaint involved alleged sexual abuse where Resident #12 was reported to have taken pictures of Resident #33's private parts. The facility failed to report this incident to the State Survey Agency within 5 working days. Both residents and their responsible parties denied the incident, and no pictures were found on the phone. The Administrator did not consider the incident reportable.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse and the results of investigations to proper authorities for two residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for reportable incidents: 24
Residents involved in the incident: 2
Pictures seen: 4
BIMS score Resident #12: 10
BIMS score Resident #33: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA | Reported seeing pictures on Resident #12's phone and reported to DON and Administrator | |
| DON | Interviewed regarding the incident and Resident #12's room change | |
| Administrator | Did not report the incident to the State Survey Agency, interviewed staff and residents |
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