Inspection·April 30, 2024

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record reviews, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for 1 of 3 residents (Resident #1) reviewed for Care Plans. The facility failed to ensure Resident #1's Care Plan was reviewed and updated quarterly, based on record reviews made on 04/30/24. This failure could place residents at risk of their needs not being met. Findings included: Record review of Resident #1's face sheet, dated 04/30/24, revealed the resident was a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included: Cerebral infarction (stroke), age related nuclear cataract (age related condition affects the lens of the eye), Depression (mental state of low mood), anxiety (fearful, worrying). Record review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 15, indicating the resident was cognitively intact. Resident #1 had a resident mood interview severity score of 00, indicating the resident score did not identify mood concerns Review of MDS Behavior section reflected had physical and verbal toward behavior toward others 1 to 3 days. Resident #1 required supervision with ADLs of bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Record review of Resident #1's care plan, dated 12/30/23, revealed Resident #1 had impaired cognition, visual impairment, ADL self-care performance deficit. Resident requires the use of psychotropic medications antidepressant, antipsychotic for depression and anxiety. Resident #1 has behaviors toward others due to ineffective coping skills, including instigating and physical aggression toward others. Interventions were Monitor/document/report PRN any s/sx of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Arrange for psych consult, follow up as indicated, and Administer medications as ordered. Monitor/document for side effects and effectiveness. Interventions for Anti-anxiety medications include monitoring side effects of drowsiness, lack of energy, slow reflexes, slurred speech, confusion, depression, dizziness, impaired thinking and judgment, forgetfulness, gastric distress, and changes in vision. Resident #1's care plan had not been updated as of 12/30/23. In an observation and attempted interview on 04/30/24 at 9:25 AM, Resident #1 was independently propelling back and forth on the 100 hall and throughout the facility. An attempted interview revealed (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 455572 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 04/30/2024 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)