Inspection·February 1, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A record review of Resident #1's TAR, dated January 2024, reflected Clean right great toe wound with NS (normal saline), pat dry, apply [anasept] gel with collagen, and cover with dry drsg (dressing) daily until resolved. Every day shift. Start date 12/27/23. The TAR was blank without initials or check marks on 01/13/24, 01/14/24, and 01/21/24. In an interview on 01/31/24 at 11:58 AM, Resident #1 stated he received wound care daily. He stated he would raise hell if he did not receive wound care because he had already lost one foot and he would be damned if he lost the other foot. Resident #1 stated he had no concerns with the wound care he received at the facility, and he saw the WCD once a week. Resident #2 A record review of Resident #2's electronic face sheet, dated 01/31/24, reflected Resident #2 was a [AGE] year-old female, who admitted to the facility on [DATE]. Her diagnoses included which included dementia, diabetes, muscle weakness, unsteadiness on feet, cognitive communication deficit, and need for assistance with personal care. A record review of Resident #2's Optional State Assessment MDS dated [DATE], reflected Resident #2's BIMS score was 3, which indicated her cognition was severely impaired. The MDS assessment indicated the Resident #2 required treatment for pressure ulcer injury. A record review of Resident #2's Care Plan, dated 12/13/2023, reflected Resident #2 had a pressure ulcer and the interventions included Provide wound care per physician's order. Keep dressing clean, dry, and intact. A record review of Resident #2's physician order summary for January 2024 reflected the following wound care order: Clean pressure ulcer to coccyx/sacral with NS, pat dry, apply [anasept] gel with collagen, and cover with foam drsg QOD [every other day] until resolved. Start date 12/14/23. A record review of Resident #2's TAR, dated January 2024, reflected Clean pressure ulcer to coccyx/sacral with NS, pat dry, apply [anasept] gel with collagen, and cover with foam drsg QOD until resolved. Every day shift every other day. Start date 12/14/23. The TAR was blank without initials or check marks on 01/15/24 and 01/29/24. In an interview on 02/01/24 at 11:24 AM, Resident #2 was asked if she was receiving wound care and she said she did not know. Resident #2's FM was bedside and said Resident #2 probably did not understand. The FM stated he came to the facility daily for about 6 hours to sit with Resident #2. The FM stated Resident #2 was receiving wound care every other day. He stated he had no concerns with wound care and the nurses provided good care. In an interview on 02/01/24 at 1:55 PM, the WCN stated she worked Monday thru Friday and does not provide wound care on the weekends. She stated on the weekends the floor nurses were responsible for providing the wound care. She stated when staff called in for work, she would fill in for them, so on those days the floor nurses were responsible for wound care. The WCN stated when she was assigned to a hall, she would let the floor nurses know they had to complete wound care. The WCN confirmed she was responsible for Resident #2's wound care on 01/29/24. She stated she completed the wound care but did not document it on the TAR. The WCN stated her laptop frequently loses internet connection and she must wait for it to return before she can document on the TAR. She stated she must have forgot to go back and document it on the TAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455572 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455572 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wedgewood Nursing Home 6621 Dan Danciger Rd Fort Worth, TX 76133 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm In an interview on 02/01/24 at 3:05 PM, the DON stated was made aware today that there were missing days on the TARs for wound care. She stated she had spoken to staff, and they were saying that they did complete the wound care but did not document. The DON stated her expectation was for staff to complete wound care and document it immediately . She stated she had reviewed the TARs and wrote up the nurses who were responsible for the wound care on the days it was not documented. Residents Affected - Some In a phone interview on 02/08/24 at 10:48 AM, the ADON stated she was responsible for Resident #2's wound care on 01/15/24. She stated they had a couple of nurses call out that day, so she had to fill in on the floor. The ADON stated she did complete Resident #2's wound care but had got so busy and forgot to document it. She stated wound care was on a separate TAR than the other treatments and she forgot to open it and document. She stated she knew she was expected to document wound care and all other treatments, but she made a mistake. The ADON stated she was written up for not completing the documentation. In a phone interview on 02/08/24 at 11:01 AM, LVN A stated she was PRN at the facility and mainly worked on the weekends. She stated she did work on 01/13/24, 01/14/24, and 01/21/24 and was assigned to Resident #1. LVN A stated she was familiar with Resident #1 and knew for sure she completed wound care on those days, because if she did not, Resident #1 would say something. LVN A stated she was new to the facility and still learning their system. She stated wound care was on a different TAR and she believed that was the reason she missed documenting. LVN A stated she had access to the TARs but she made a mistake. She stated she was written up by the DON for this and was now well aware how and were to document. A record review of the facility's in-service titled Skin Management, dated 02/01/24, and conducted by the DON reflected Charge nurses LVNs and RNs are responsible for providing wound care and to perform skin assessments to assigned residents when the wound care nurse is off or whenever he/she is working on the floor as a charge nurse. Every nurse has access to treatment orders in the EMAR. There is no excuse for not providing resident care per physician orders. If you provide care but not document then it was not done, you cannot prove you provided care. Failure to provide wound care and/or skin assessment will result in disciplinary actions. If there is no initial in the MAR. A record review of the facility's policy titled Medication-Treatment Administration and Documentation Guidelines, dated 02/02/14, reflected Anticipated Outcome: To provide a process for accurate, timely administration and documentation of medication and treatments .Fundamental Information: .The Medication - Treatment Administration Documentation Guideline applies to licensed nurses and certified medication aides according to licensure or certification scope of practice .Process . 5. Document initials and/or signature for medications and treatments administered on the MAR or TAR immediately following administration FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455572 If continuation sheet Page 3 of 3