A list of the most recent deficiencies for Sedgewood Commons. 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? |
|---|---|---|---|---|
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-04-05 | 2022-06-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-05 | 2022-06-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-05 | 2022-06-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-07 | 2022-05-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-07 | 2022-05-22 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-04-07 | 2022-05-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-04-07 | 2022-05-22 | 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 | 2022-04-07 | 2022-05-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-07 | 2022-05-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-07 | 2022-05-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-07 | 2022-05-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-05 | 2022-05-13 | N |
| Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. | Health | 2021-04-20 | 2021-04-19 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-08-15 | 2019-10-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-08-15 | 2019-10-28 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-08-15 | 2019-10-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-15 | 2019-10-28 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-15 | 2019-10-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-15 | 2019-10-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-14 | 2019-10-01 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2018-07-25 | 2018-10-01 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2018-07-25 | 2018-10-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-07-25 | 2018-10-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-07-25 | 2018-10-01 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2018-07-25 | 2018-10-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-07-25 | 2018-10-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-07-25 | 2018-10-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-25 | 2018-10-01 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-07-25 | 2018-10-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-25 | 2018-10-01 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-07-26 | 2018-08-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-07-26 | 2018-08-22 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-07-26 | 2018-08-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-07-26 | 2018-08-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-26 | 2018-08-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-26 | 2018-08-22 | N |
