Health inspection·April 23, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records that were complete and accurate for one (Resident #1) of five residents reviewed for clinical records. The facility failed to ensure Resident #1's clinical record was complete and accurate when the resident experienced a change in condition on 02/02/25. LVN A did not accurately and completely document Resident #1's blood sugar monitoring, medication administration, and contact with the NP or EMS. These failures could place residents whose records are maintained by the facility at risk for delays and errors in their care and treatment. Findings include: Record review of Resident #1's undated admission Record reflected the resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Type 1 Diabetes, (body does not use insulin effectively or does not produce enough insulin), Major Depressive Disorder, End Stage Renal Disease, (kidneys can no longer function adequately to meet the body's needs), Dependence on Renal Dialysis, Chronic Respiratory Failure with Hypoxia (a condition where there is not enough oxygen in the tissues of your body), Congestive Heart Failure (heart can no longer pump blood well enough to meet the body's needs), dysphagia (difficulty swallowing) Record review of Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 01/30/25, reflected a Brief Interview of Mental Status (BIMS) score of 8, indicating he had moderate cognitive impairment. Record review of Resident #1's progress note, dated 02/13/25, reflected on 02/02/25 he had been transferred via EMS to the hospital after having hypoglycemia (low blood sugar). Record review of Resident #1's progress note, dated 02/13/25, reflected on 02/02/25 the resident had five blood glucose monitoring tests that indicated hypoglycemia (low blood sugar). The time was not documented for five of five of the blood glucose monitoring test. Record review of Resident #1's progress note, dated 02/13/25, reflected on 02/02/25 the resident had been administered three medications. The time was not documented for medication administration for three of three medications (Baqsimi Nasal Powder 3 MG/Dose-2 doses; Ipratropium-Albuterol Inhalation Solution 3 MG/3 ML). (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 5 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 04/23/2025 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)