Wedgemere Healthcare

In the surveyor’s words

From the most serious findings on record at Wedgemere Healthcare, in the surveyor’s own words.

• Actual harm, patternF658Dec 18, 2023

  Based on observations, interviews, and record review, the facility failed to ensure one Resident (#30), out of a total sample of 20 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed for Resident #30, to obtain a physician's order for wound care on admission, develop and implement a pressure ulcer care plan on admission, to assess and monitor a pressure ulcer, to obtain orders for wound consultant recommendations-including medications, treatments and lab work, to transcribe orders for wound care accurately, and to provide wound care per physician's orders resulting in the progression of a deep tissue injury (DTI- intact skin with localized area of persistence non-blanchable deep red, maroon, or purple discoloration due to… […]

• Actual harm, patternF686Dec 18, 2023

  Based on observation, interviews, policy review, and record review, the facility failed to ensure one Resident (#30), out of a total sample of 20 residents, received care and treatment to prevent and promote healing of pressure injuries. Specifically, the facility failed for Resident #30, to obtain a physician's order for wound care on admission, develop and implement a pressure ulcer care plan on admission, to assess and monitor a pressure ulcer, to obtain orders for wound consultant recommendations-including medications, treatments and lab work, to transcribe orders for wound care accurately, and to provide wound care per physician's orders resulting in the progression of a deep tissue injury (DTI-intact skin with localized area of persistence non-blanchable deep red, maroon, or purple… […]

• Actual harm, isolatedF624Jul 8, 2021

  Based on records reviewed and interviews, for one of three sampled resident's (Resident #2), the Facility failed to ensure he/she was provided with a safe discharge when on 5/27/21, Resident #2 was discharged home with a medication reconciliation list which included an inaccurate dosage of [MEDICATION(S)] (antidepressant medication), his/her physician;s orders were for 90 milligrams (mg) daily, but the Facility's discharge summary instruction were for Resident #2 to take 270 mg daily (three times the physician ordered dose). […]

• No harm, potential for more than minimal, widespreadF680Apr 1, 2026

  Based on interviews and review of the Activity Director's (AD) personnel file, the facility failed to ensure the activity program was directed by a qualified activities professional. Findings include:Review of the employee file for the Activity Director (AD) indicated the following: - she was offered and accepted the role of AD in January 2026;- she did not possess the completed training and qualifications of an AD;- she signed a job description indicating she was the AD on 1/6/26.Further review of the AD's personnel file on 4/1/26 failed to indicate she was a qualified therapeutic recreation specialist or an activities professional, who had two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities… […]

• No harm, potential for more than minimal, widespreadF812Dec 18, 2023

  Based on observation, policy review, and staff interview, the facility failed to ensure staff served food in accordance with professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Findings include: Review of the facility's policy titled Food Temperature Measurement, revised in June 2018, indicated the following guidelines: -sanitize a clean, calibrated food thermometer before use and between foods (or use a different clean, sanitized, calibrated food thermometer for each food). Use either of the following methods: a. Immerse the thermometer stem into clean sanitizing solution at the proper concentration and contact time recommended by the sanitizer manufacturer. Air drying before using. b. […]