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Deficiency Records for Edgemoor Hospital
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.
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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2024-09-06 | 2024-10-18 | Y |
| Use approved construction type or materials. | Fire Safety | 2024-07-30 | 2024-09-16 | 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 | 2024-07-30 | 2024-09-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-07-30 | 2024-09-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-30 | 2024-09-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-07-30 | 2024-09-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-30 | 2024-09-16 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-07-30 | 2024-09-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-07-30 | 2024-09-16 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2024-07-30 | 2024-09-16 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-07-30 | 2024-09-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-07-25 | 2024-08-25 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-07-25 | 2024-08-25 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-07-25 | 2024-08-25 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-07-25 | 2024-08-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-07-25 | 2024-08-25 | N |
| Provide activities to meet all resident's needs. | Health | 2024-07-25 | 2024-08-25 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-07-25 | 2024-08-25 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-07-25 | 2024-08-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-07-25 | 2024-08-25 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-07-25 | 2024-08-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-07-25 | 2024-08-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-07-25 | 2024-08-25 | N |
| Keep all essential equipment working safely. | Health | 2024-07-25 | 2024-08-25 | N |
| 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 |
| 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 |
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