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Deficiency Records for Sedgewood Commons
View the most recent health deficiencies and inspection results for Sedgewood Commons. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Sedgewood Commons. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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 | 2025-06-04 | 2025-10-03 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2025-06-04 | 2025-10-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-06-04 | 2025-10-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2025-06-04 | 2025-07-16 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2025-06-04 | 2025-07-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2025-06-04 | 2025-07-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-06-04 | 2025-07-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-06-04 | 2025-07-16 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2025-06-04 | 2025-07-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2025-06-04 | 2025-07-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2025-06-04 | 2025-07-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-06-04 | 2025-07-16 | 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 | 2025-06-04 | 2025-07-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-06-04 | 2025-07-16 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2025-06-04 | 2025-07-16 | 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 | 2025-06-04 | 2025-07-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-06-04 | 2025-07-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2025-06-04 | 2025-07-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-24 | 2024-08-21 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-03-29 | 2024-06-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-03-29 | 2024-06-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-03-29 | 2024-05-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-29 | 2024-05-20 | 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 | 2024-03-29 | 2024-05-20 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-03-29 | 2024-05-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-29 | 2024-05-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-29 | 2024-05-20 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-03-29 | 2024-05-20 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-03-29 | 2024-05-20 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-03-29 | 2024-05-20 | 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 | 2024-03-29 | 2024-05-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-29 | 2024-04-22 | N |
| Use approved construction type or materials. | Fire Safety | 2024-03-29 | 2024-04-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-29 | 2024-04-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-29 | 2024-04-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-29 | 2024-04-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-29 | 2024-04-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-07 | 2022-06-03 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-04-07 | 2022-06-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-04-07 | 2022-06-03 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-07 | 2022-05-13 | N |