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Deficiency Records for Sedgewood Commons
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.
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? |
|---|---|---|---|---|
| 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 |
| 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 |
| 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | 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 |
| Observe each nurse aide's job performance and give regular training. | 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 |
| 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 |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | 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 |
| Use approved construction type or materials. | Fire Safety | 2024-03-26 | 2024-04-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-03-26 | 2024-04-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-26 | 2024-04-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-26 | 2024-04-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-26 | 2024-04-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-26 | 2024-04-22 | N |
| 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 |
| 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 |
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