A list of the most recent deficiencies for Edgemoor Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2022-10-10 | 2022-10-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-22 | 2021-12-02 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-10-22 | 2021-12-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-22 | 2021-12-02 | N |
| Keep all essential equipment working safely. | Health | 2021-10-22 | 2021-12-02 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-10-26 | 2021-11-15 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2021-10-26 | 2021-11-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-26 | 2021-11-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-10-26 | 2021-11-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-26 | 2021-11-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-10-26 | 2021-11-15 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-10-26 | 2021-11-15 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2021-10-26 | 2021-11-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-26 | 2021-11-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-27 | 2021-08-31 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-01-17 | 2020-02-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-20 | 2020-02-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-20 | 2020-02-25 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2020-01-20 | 2020-02-25 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2020-01-20 | 2020-02-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-20 | 2020-02-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-01-17 | 2019-03-04 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-01-17 | 2019-03-04 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-01-17 | 2019-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-01-17 | 2019-03-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-17 | 2019-03-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2018-12-13 | 2019-01-13 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-12-13 | 2019-01-13 | N |
