Wallace Gardens

The facility failed to ensure the implementation of physician orders for one resident regarding weekly weight checks. Specifically, weight checks were not performed or documented as ordered for several weeks in February, March, and April 2025. Staff also failed to record the actual weight results in the Vital Signs Book or the MAR/eMAR.

The facility failed to ensure the implementation of physician orders for weekly weight checks for one resident. Specifically, weight checks were not documented for several scheduled dates in February, March, and April 2025, and when entries were made, the actual weight results were not recorded.

The facility failed to maintain hot water temperatures between 100 and 116 degrees Fahrenheit. Specifically, 14 resident room fixtures and 3 spa room fixtures were found to have temperatures below the required 100-degree minimum.

The facility failed to maintain hot water temperatures at a minimum of 100 degrees F and a maximum of 116 degrees F for 14 resident room fixtures and 3 spa rooms. Observations and resident interviews revealed multiple instances where water temperatures in sinks, tubs, and showers were significantly below the required 100-degree minimum.

The facility failed to maintain hot water temperatures at all fixtures between 100°F and 116°F, with 9 of 9 tested fixtures exceeding the maximum limit. Observations revealed temperatures as high as 131.5°F, posing a scalding risk to residents. Additionally, some residents reported water temperatures dropping below the required minimum of 100°F following adjustments to the water heater.

The facility failed to maintain hot water temperatures between 100°F and 116°F at 9 of 9 inspected fixtures. Observations revealed temperatures as high as 131.5°F in resident bathrooms, posing a scalding risk, and some temperatures dropping below the required minimum.

The facility failed to ensure that 7 of 7 exit doors accessible to residents were equipped with a sounding device that activates when opened. This failure allowed residents known to be disoriented or prone to wandering to leave the facility without staff knowledge.

The facility failed to ensure medications were administered as ordered by a prescribing practitioner, resulting in a 9% medication error rate. Specifically, during medication passes on August 9 and 10, 2016, a resident did not receive prescribed Restasis eye drops because the medication was not on the medication cart.