Health inspection·February 7, 2024

F 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Sublingual Tablet 0.4 MG Give 1 tablet sublingually every 5 minutes as needed for chest pain x 3 does, if no relief call MD, send to ER for further Evaluation. A record review of Resident #1's Care Plan, dated 09/08/22, indicated a focus area of has altered cardiovascular (relating to the heart and blood vessels) status r/t ASHD/CAD and the interventions included .Monitor for complaint of chest pain. Enforce the need to call for assistance if pain starts .Monitor/document/report to MD PRN any s/sx of CAD: chest pain or pressure especially with activity, etc Further review of Resident #1's Care Plan indicated a focus on area of Hypertension (when the pressure in your blood vessels is too high), and an intervention included Administer antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension, headache, vertigo, chest pain, and decreased heart rate. A record review of Resident #1's Progress Notes, dated 02/04/24 at 2:27 PM, by LVN C, reflected Data: Resident complained of chest pain. Resident was observed sitting in his wheelchair, appeared not to be in any distress. Vital signs were taken and this nurse looked at resident's chart to see if anything was available to be given. Resident did not have an order for nitroglycerin. [Telehealth] was called. Action: Before Resident left he stated he was not having chest pain and that I'm alive. Response: Vitals signs taken BP 118/70 P (pulse) 78 O2 (oxygen) 97% Room Air. [Telehealth] gave an order to give Nitroglycerin 0.4mg 1 tablet sublingual (situated or applied under the tongue) every 5 minutes times 3 doses. If no relief to call 911. Medication retrieved from Nexsys (secure technology to manage controlled medications, STAT/first doses and electronic E-Kits). This nurse gave the entire bottle misinterpreting the order and thought that the whole bottle was 0.4mg. Then realizing the error, Assessed resident, vitals taken again BP 159/108 P 102, No SOB noted, No respiratory distress. Resident was alert and oriented at this time. This nurse then called 911 and then reported it to the DON and called [telehealth]. EMT's arrived, while being taken out on the stretcher, Resident was alert, stable and talking to the nurse and stated he was not having chest pain and that I'm alive. [telehealth MD] asked if Resident was alert and stable and if he was having any adverse reactions. Resident was stable and did not appear to have any adverse reactions. [telehealth MD] stated ok, it's good he went to the hospital and is not having any reactions. [FM] notified at [phone number]. Stated to let her know when we hear back from the hospital. A record review of Resident #1's hospital records, dated 02/04/24, reflected Resident #1 entered the ER on [DATE] at 3:20 PM. The ER records reflected Chief Complaint Patient presents with Drug Overdose per EMS Accidental overdose of nitroglycerine, give 25 -0.4 mg nitro tablets by nursing home staff over a period of 20 minutes . Initial pressure 86 over 42 presently 115 over 68 after 1 liter of fluid. Sinus bradycardia (a slow heart rate) on the monitor at a rate of 56. Further review of the ER records reflected Resident #1 was given a physical exam and his cardiovascular rate and rhythm was Bradycardia present. The ER records reflected Resident #1's final diagnosis included acute chest pain, bradycardia, hypothyroidism, and overdose of nitroglycerin. Resident #1 was admitted to the hospital on [DATE] at 5:47 PM. In an interview on 02/06/24 at 9:10 AM, the DON stated on Sunday (02/04/24) she was contacted by the WCN and told that LVN C gave Resident #1 an entire bottle of nitroglycerin and was sent out to the hospital. The DON stated she went to the facility and LVN C told her that Resident #1 complained of chest pain, so she contacted the MD and was provided an order for 0.4 mg of nitroglycerin. The DON stated, LVN C told her she got confused and thought the entire bottle was 0.4mg and not each tablet. The DON stated LVN C told her she gave Resident #1 the entire bottle, which was 25 tablets. The DON stated the MD and Resident #1's FM were notified. The DON stated she in-serviced and suspended LVN C. She stated she ensured the other residents who had orders for nitroglycerin were not administered (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455572 If continuation sheet Page 2 of 8 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 02/07/2024 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the medication and confirmed when they were administered nitroglycerin it was administered per the orders. The DON stated the ADONs audited the medication carts and found there were no issues. The DON stated following the incident, she immediately in-serviced staff on medication administration, nitroglycerin administration, and abuse & neglect. She stated staff were not able to start their shift until they were in-serviced. The DON stated all in-services were completed by 02/05/24. She stated LVN C would be terminated. The DON stated her expectation was for Med Aides and nurses to administer medications per the physician orders, and if they have questions about the orders or medications, they were supposed to get clarification before administering the medication. In an interview on 02/06/24 at 10:17 AM, LVN C stated on Sunday (02/04/24) about noon, Resident #1 started complaining of chest pain, so she notified the WCN, who was the charge nurse. LVN C stated the WCN told her to take Resident #1's vitals and contact the MD. LVN C stated she contacted the MD and was given an order for 0.4 mg of nitroglycerin and if resident continued to have chest pain, then she needed to send Resident #1 to the ER. LVN C stated the WCN pulled the medicine for the emergency kit. She stated the bottle was small and the pills were tiny, so she misinterpreted the dosage amount. LVN C stated she thought the entire bottle was 0.4 mg, so she gave the entire bottle to the Resident #1, which was 25 tablets. She stated it was her first-time administering nitroglycerin. LVN C stated as she was about to leave Resident #1's room, she realized her mistake, but the pills were in his mouth and dissolved. LVN C stated she notified the WCN of her mistake and was told to call 911. She stated 911 was called and she notified the MD and Resident #1's family of the incident. LVN C stated the EMS arrived about 10 minutes after they were contacted. She stated Resident #1's vitals were normal while he was at the facility. LVN C stated she was in-serviced and suspended. In an interview on 02/06/24 at 10:28 AM, the WCN stated on 02/04/24, Resident #1 was complaining of chest pain. The WCN stated LVN C contacted the MD and received an order for nitroglycerin. She stated she pulled the Nitroglycerin from Nexsys and told LVN C to put Resident #1's name and date on the bottle. The WCN stated she told her to give Resident #1 one tablet and then wait to see if the chest pain stopped. She stated about 30 minutes later, LVN C came to her office crying saying she messed up and gave Resident #1 the entire bottle. The WCN stated LVN C stated she thought the entire bottle was 0.4 mg. The WCN stated she told LVN C to call 911 and to take Resident #1's vitals. In a follow up interview on 02/06/24 at 5:11 PM, the DON stated LVN C was a new nurse and got her license in September 2023. The DON stated a licensed nurse skills competency was completed when LVN C was initially hired in October 2023. The DON stated medication administration is a skill that is observed and completed during the competency check. She stated she did not believe any other evaluations had been completed after her initial skills check in October 2023. 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: Medication are administered according to manufacturer's guidelines unless otherwise indicated by physician order. Point Click Care (PCC) times codes are assigned to medication in order to administer according to manufacturers' guidelines, physician orders or patient choice . Process: 1. Verify labels accurately reflect the physician orders on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) prior to administering patient medications and treatments. 2. Verify administration accuracy by checking the medication with the MAR three (3) times . 4. Administer the medication according to the physician orders . A policy regarding nursing competency was requested and the facility provided a policy titled (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455572 If continuation sheet Page 3 of 8 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 02/07/2024 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 0726 Level of Harm - Immediate jeopardy to resident health or safety Training Requirements, dated 11/29/22. A record review of the policy reflected Policy: It is the policy of this facility to develop, implement, and maintain an effective training program for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. Policy Explanation and Compliance Guidelines: . 3. Competencies and skill set for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers must be consistent with their expected roles . Residents Affected - Few An IJ was identified to have existed from 02/04/24 through 02/05/24. On 02/06/24 the IJ was determined to be past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. The facility took the following actions to correct the non-compliance prior to the investigation: A record review of the facility's document titled Associate Disciplinary Memorandum, dated 02/04/24 and completed by the DON, reflected LVN C was suspended due to medication error. A record review of the facility's document titled Termination Report, dated 02/06/24, reflected LVN C was terminated due to safety violations. A record review of the facility's document titled Medication Cart Audit, dated 02/04/24 and completed by ADON A, reflected the medication carts for the 100 hall was audited and had no issues. A record review of the facility's document titled Medication Cart Audit, dated 02/04/24 and completed by ADON B, reflected the medication carts for the 200 hall was audited and had no issues. A record review of the facility's in-services titled Medication Pass Policy and Nitroglycerin uses and directions, dated 02/04/24, reflected all Med Aides and nursing staff, were educated on the facility's policy titled Medication- Treatment Administration Documentation Guidelines, dated 02/02/14 and training document Nitroglycerin Oral: Uses, Side Effects, Interactions, Pictures, Warning & Dosing, undated. A record review of the facility's documents titled Validation Checklist Medication Pass, dated 02/04/24, reflected Purpose: To determine if the nurse is performing a medication pass procedure in accordance with the facility's standard of practice. Enter Nurse/Nurse Aide Initial Record observation below. Review findings with the nurse. Provide correction action as needed. The documents reflected ADON A and ADON B completed observations of medication pass on all Med Aides and nurses, which revealed there were no issues. A record review of the facility's in-services titled Abuse and Neglect, dated 02/04/24, reflected all staff were in-serviced on the facility's policy titled Abuse Policy, dated 02/01/21, and completed a posttest titled Resident Abuse Prevention and Reporting, which reflected no issues. Interviews were conducted from 02/06/24 between 11:40 AM and 2:20 PM to 02/07/24 between 10:10 and 10:30, with 3 Med Aides, 4 RNs, 5 LVNs, and two ADONs, from various shifts. The staff all stated they had been in-serviced on medication administration, nitroglycerin administration, and abuse and neglect. The staff were able to identify and define medication errors, and were knowledgeable on procedures for administering all medications, specifically nitroglycerin. The staff were knowledgeable of abuse & neglect policy and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455572 If continuation sheet Page 4 of 8 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 02/07/2024 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 5 residents (Resident # 1) reviewed for significant medication errors. Residents Affected - Few On 02/04/24, LVN C failed to ensure Resident #1 was administered nitroglycerin (medication used to prevent or relieve chest pain caused by coronary artery disease by relaxing blood vessels), as ordered by the physician. LVN C dispensed an entire bottle of nitroglycerin, which consisted of 25 (0.4 mg) tablets to Resident #1, when the physician order was for 1 (0.4 mg) tablet. Resident #1 was transferred to the emergency room, his initial blood pressure at the ER was 86/42. The noncompliance was identified as PNC. The IJ began on 02/04/24 and ended on 02/05/24. The facility corrected the noncompliance before the survey began. This failure could place residents at risk for inaccurate drug administration resulting in a decline in health, hospitalization, or death. The findings included: A record review of the American Heart Associations' guidance on Understanding Blood Pressure Readings, last reviewed on 05/30/23, reflected a normal blood pressure reading would be 120/80. Accessed on 02/16/24 from https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings A record review of Resident #1's electronic Face Sheet dated 02/06/24 reflected Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #1 had diagnoses that included need for assistance with personal care, muscle weakness, unsteadiness on feet, and atherosclerotic heart disease of native coronary artery (caused by plaque buildup in the wall of the arteries that supply blood to the heart). A record review of Resident #1's Optional State Assessment MDS, dated [DATE] indicated Resident #1 had a BIMS score of 11, which indicated the resident's cognition was moderately impaired. A record review of Resident #1's Physician Orders, dated 02/04/24, reflected Nitroglycerin Sublingual Tablet 0.4 MG Give 1 tablet sublingually every 5 minutes as needed for chest pain x 3 does, if no relief call MD, send to ER for further Evaluation. A record review of Resident #1's Care Plan, dated 09/08/22, indicated a focus area of has altered cardiovascular (relating to the heart and blood vessels) status r/t ASHD/CAD and the interventions included . Monitor for complaint of chest pain. Enforce the need to call for assistance if pain starts . Monitor/document/report to MD PRN any s/sx of CAD: chest pain or pressure especially with activity, etc. Further review of Resident #1's Care Plan indicated a focus on area of Hypertension (when the pressure in your blood vessels is too high), and an intervention included Administer antihypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension, headache, vertigo, chest pain, and decreased heart rate. A record review of Resident #1's Progress Notes, dated 02/04/24 at 2:27 PM, by LVN C, reflected Data: Resident complained of chest pain. Resident was observed sitting in his wheelchair, appeared not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455572 If continuation sheet Page 5 of 8 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 02/07/2024 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to be in any distress. Vital signs were taken and this nurse looked at resident's chart to see if anything was available to be given. Resident did not have an order for nitroglycerin. [Telehealth] was called. Action: Before Resident left he stated he was not having chest pain and that I'm alive. Response: Vitals signs taken BP 118/70 P (pulse) 78 O2 (oxygen) 97% Room Air. [Telehealth] gave an order to give Nitroglycerin 0.4mg 1 tablet sublingual (situated or applied under the tongue) every 5 minutes times 3 doses. If no relief to call 911. Medication retrieved from Nexsys (secure technology to manage controlled medications, STAT/first doses and electronic E-Kits). This nurse gave the entire bottle misinterpreting the order and thought that the whole bottle was 0.4mg. Then realizing the error, Assessed resident, vitals taken again BP 159/108 P 102, No SOB noted, No respiratory distress. Resident was alert and oriented at this time. This nurse then called 911 and then reported it to the DON and called [telehealth]. EMT's arrived, while being taken out on the stretcher, Resident was alert, stable and talking to the nurse and stated he was not having chest pain and that I'm alive. [telehealth MD] asked if Resident was alert and stable and if he was having any adverse reactions. Resident was stable and did not appear to have any adverse reactions. [telehealth MD] stated ok, it's good he went to the hospital and is not having any reactions. [FM] notified at [phone number]. Stated to let her know when we hear back from the hospital. A record review of Resident #1's hospital records, dated 02/04/24, reflected Resident #1 entered the ER on [DATE] at 3:20 PM. The ER records reflected Chief Complaint Patient presents with Drug Overdose per EMS Accidental overdose of nitroglycerine, give 25 0.4 mg nitro tablets by nursing home staff over a period of 20 minutes . Initial pressure 86 over 42 presently 115 over 68 after 1 liter of fluid. Sinus bradycardia (a slow heart rate) on the monitor at a rate of 56. Further review of the ER records reflected Resident #1 was given a physical exam and his cardiovascular rate and rhythm was Bradycardia present. The ER records reflected Resident #1's final diagnosis included acute chest pain, bradycardia, hypothyroidism, and overdose of nitroglycerin. Resident #1 was admitted to the hospital on [DATE] at 5:47 PM. In an interview on 02/06/24 at 9:10 AM, the DON stated on Sunday (02/04/24) she was contacted by the WCN and told that LVN C gave Resident #1 an entire bottle of nitroglycerin and was sent out to the hospital. The DON stated she went to the facility and LVN C told her that Resident #1 complained of chest pain, so she contacted the MD and was provided an order for .4 mg of nitroglycerin. The DON stated, LVN C told her she got confused and thought the entire bottle was .4mg and not each tablet. The DON stated LVN C told her she gave Resident #1 the entire bottle, which was 25 tablets. The DON stated the MD and Resident #1's FM were notified. The DON stated she in-serviced and suspended LVN C. She stated she ensured the other residents who had orders for nitroglycerin were not administered the medication and confirmed when they were administered nitroglycerin it was administered per the orders. The DON stated the ADONs audited the medication carts and found there were no issues. The DON stated following the incident, she immediately in-serviced staff on medication administration, nitroglycerin administration, and abuse & neglect. She stated staff were not able to start their shift until they were in-serviced. The DON stated all in-services were completed by 02/05/24. She stated LVN C would be terminated. The DON stated her expectation was for Med Aides and nurses to administer medications per the physician orders, and if they have questions about the orders or medications, they were supposed to get clarification before administering the medication. In an interview on 02/06/24 at 10:17 AM, LVN C stated on Sunday (02/04/24) about noon, Resident #1 started complaining of chest pain, so she notified the WCN, who was the charge nurse. LVN C stated the WCN told her to take Resident #1's vitals and contact the MD. LVN C stated she contacted the MD and was given an order for .4 mg of nitroglycerin and if resident continued to have chest pain, then she needed to send Resident #1 to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455572 If continuation sheet Page 6 of 8 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 02/07/2024 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few ER. LVN C stated the WCN pulled the medicine for the emergency kit. She stated the bottle was small and the pills were tiny, so she misinterpreted the dosage amount. LVN C stated she thought the entire bottle was .4 mg, so she gave the entire bottle to the Resident #1, which was 25 tablets. She stated it was her first-time administering nitroglycerin. LVN C stated as she was about to leave Resident #1's room, she realized her mistake, but the pills were in his mouth and dissolved. LVN C stated she notified the WCN of her mistake and was told to call 911. She stated 911 was called and she notified the MD and Resident #1's family of the incident. LVN C stated the EMS arrived about 10 minutes after they were contacted. She stated Resident #1's vitals were normal while he was at the facility. LVN C stated she was in-serviced and suspended. In an interview on 02/06/24 at 10:28 AM, the WCN stated on 02/04/24, Resident #1 was complaining of chest pain. The WCN stated LVN C contacted the MD and received an order for nitroglycerin. She stated she pulled the Nitroglycerin from Nexsys and told LVN C to put Resident #1's name and date on the bottle. The WCN stated she told her to give Resident #1 one tablet and then wait to see if the chest pain stopped. She stated about 30 minutes later, LVN C came to her office crying saying she messed up and gave Resident #1 the entire bottle. The WCN stated LVN C stated she thought the entire bottle was .4 mg. The WCN stated she told LVN C to call 911 and to take Resident #1's vitals. 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: Medication are administered according to manufacturer's guidelines unless otherwise indicated by physician order. Point Click Care (PCC) times codes are assigned to medication in order to administer according to manufacturers' guidelines, physician orders or patient choice . Process: 1. Verify labels accurately reflect the physician orders on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) prior to administering patient medications and treatments. 2. Verify administration accuracy by checking the medication with the MAR three (3) times . 4. Administer the medication according to the physician orders . An IJ was identified to have existed from 02/04/24 through 02/05/24. On 02/06/24 the IJ was determined to be past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. The facility took the following actions to correct the non-compliance prior to the investigation: A record review of the facility's document titled Associate Disciplinary Memorandum, dated 02/04/24 and completed by the DON, reflected LVN C was suspended due to medication error. A record review of the facility's document titled Termination Report, dated 02/06/24, reflected LVN C was terminated due to safety violations . A record review of the facility's document titled Medication Cart Audit, dated 02/04/24 and completed by ADON A, reflected the medication carts for the 100 hall was audited and had no issues. A record review of the facility's document titled Medication Cart Audit, dated 02/04/24 and completed by ADON B, reflected the medication carts for the 200 hall was audited and had no issues. A record review of the facility's in-services titled Medication Pass Policy and Nitroglycerin uses and directions, dated 02/04/24, reflected all Med Aides and nursing staff, were educated on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455572 If continuation sheet Page 7 of 8 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 02/07/2024 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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few facility's policy titled Medication- Treatment Administration Documentation Guidelines, dated 02/02/14 and training document Nitroglycerin Oral: Uses, Side Effects, Interactions, Pictures, Warning & Dosing, undated. A record review of the facility's documents titled Validation Checklist Medication Pass, dated 02/04/24, reflected Purpose: To determine if the nurse is performing a medication pass procedure in accordance with the facility's standard of practice. Enter Nurse/Nurse Aide Initial Record observation below. Review findings with the nurse. Provide correction action as needed. The documents reflected ADON A and ADON B completed observations of medication pass on all Med Aides and nurses, which revealed there were no issues. A record review of the facility's in-services titled Abuse and Neglect, dated 02/04/24, reflected all staff were in-serviced on the facility's policy titled Abuse Policy, dated 02/01/21, and completed a posttest titled Resident Abuse Prevention and Reporting, which reflected no issues. Interviews were conducted from 02/06/24 between 11:40 AM and 2:20 PM to 02/07/24 between 10:10 AM and 10:30 AM, with 3 Med Aides, 4 RNs, 5 LVNs, and two ADONs, from various shifts. The staff all stated they had been in-serviced on medication administration, nitroglycerin administration, and abuse and neglect. The staff were able to identify and define medication errors, and were knowledgeable on procedures for administering all medications, specifically nitroglycerin. The staff were knowledgeable of abuse and neglect policy and procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455572 If continuation sheet Page 8 of 8