Sedgewood Commons

Inspectors wroteBased on observations and interviews, the facility failed to maintain adequate housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior in 36 of 56 resident rooms and on 3 of 3 units ([NAME], [NAME], and [NAME]).

Inspectors wroteBased on observations and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of chemicals being properly secured on 1 of 3 units ([NAME]) for 1 of 3 days of survey (6/2/25).

Inspectors wroteBased on observations, record review and interview, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification, dated 6/4/25, were effective. The Federal citations F761 and F880 were cited again during the re-visit for the Annual Long Term Care Recertification Survey, completed 9/10/25.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to have an effective infection prevention and control program (IPCP) for the surveillance and transmission prevention of Gastrointestinal disease for 1 out of 6 residents reviewed for infection control.

Inspectors wroteBased on record reviews and interviews, the facility failed to issue a written transfer/discharge notice to a resident or their legal representative for a facility-initiated transfer/discharge for 2 of 3 sampled residents transferred/discharged to an acute care facility. ( Resident #13 and #66)

Inspectors wroteBased on record reviews and interviews, the facility failed to issue a written bed hold notice to a resident, known family member or legal representative for 2 of 3 sampled residents who had been transferred to an acute care facility (Resident #13 and #66).

Inspectors wroteBased on record review and interviews, the facility failed to monitor temperature controls for 2 of 3 refrigerators observed and 3 of 3 months of medication refrigerator logs reviewed.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to have a working system in place to communicate, separate and carry out the disposition of controlled substances. In addition, the facility failed to ensure that all scheduled medications were being received from the pharmacy by 2 licensed staff.

Inspectors wroteBased on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 2 of 3 units ([NAME] and [NAME]) for 1 of 1 environmental tour (3/29/24).

Inspectors wroteBased on performance evaluations and interview, the facility failed to complete annual performance evaluations at least every 12 months for 3 of 5 sampled Certified Nursing Assistants (CNA #3, CNA #4, and CNA #5).

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to properly store medications and biologicals in 2 out of 3 medication rooms refrigerators surveyed. ([NAME] House and [NAME] House)

Inspectors wroteBased on observations and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for 1 of 1 initial kitchen tour completed on 3/26/24. Additionally, the facility failed to ensure that food temperatures were recorded at the time of cooking breakfast on the morning of 3/26/24.

Inspectors wroteBased on review of the facility's Pneumococcal Vaccination policy and procedure, interviews, and record review the facility failed to provide the Resident and/or the Resident's Representatives with the Vaccine Information Statement (VIS) prior to immunizing a resident with the pneumococcal vaccine (Prevnar) for all residents receiving the Prevnar vaccine.

Inspectors wroteBased on review of the facility's COVID-19 Vaccination policy and procedures, interviews and record review the facility failed to ensure each resident, or the resident representative received education regarding the benefits, risks and potential side effects associated with the COVID-19 vaccine prior to immunizing a resident with the COVID-19 vaccine for all residents who received the COVID-19 vaccine. In addition, the facility failed ensure staff were provided education regarding the benefits and potential risks associated with COVID-19 vaccine.

Inspectors wroteBased on employee record review and interview, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on Resident Rights for 2 of 5 Certified Nursing Assistant (CNA) staff reviewed (CNA #1, CNA #2).

Inspectors wroteBased on record review and interview, the facility failed to coordinate assessments for Pre-admission Screening and Resident Review (PASRR) Level I and Level II programs for 1 of 1 residents reviewed for PASRR (#46).

Inspectors wroteBased on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each assessment (Resident #32).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to meet the personal hygiene preferences for 1 of 6 residents who are dependent on staff to complete Activities of Daily Living needs. (Resident #49)

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that a resident received treatment and services in accordance with the standards of practice for 1 of 2 residents reviewed for skin conditions (#343).

Inspectors wroteBased on record review, observations and interviews, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction (POC) for an identified deficiency from the annual Long Term Care Recertification Survey, dated 3/29/24, was effective. The Federal citation F584 was cited again during the re-visit to the annual Long Term Care Recertification Survey, dated 5/20/24.

Inspectors wroteBased on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT) meeting, which included the participation of the resident and resident's representative, after each Minimum Data Set (MDS) 3.0 assessments, for 7 of 33 residents whose care plans were reviewed (#10, #24, #25, #33, #37, #39, #49).

Inspectors wroteBased on interview, review of the daily staffing postings, and the nursing working schedule, the facility failed to have a Registered Nurse on duty for at least 8 consecutive hours for 1 of 128 days reviewed for Sufficient and Competent Nurse Staffing.

Inspectors wroteBased on record review and interview, the facility failed to ensure an as needed (PRN) psychotropic medication met the required 14-day limit for 1 of 5 residents reviewed for unnecessary medications (#80).

Inspectors wroteBased on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications in 1 of 3 units, [NAME] House.

Inspectors wroteBased on observations and interviews the facility failed to ensure a sanitary environment during 1of 2 dining observations of meal service on 1 of 3 units ([NAME]).

Inspectors wroteBased on record review, observation and interview the facility failed to ensure the Medication Administration Record (MAR) was accurately documented for removing a Lidoderm patch for 1 of 7 residents observed during medication administration review (#71).

Inspectors wroteBased on record review, review of the facility's immunization policy, and interview, the facility failed to implement their Pneumococcal Vaccine policy for 1 of 5 residents whose immunization records were reviewed (#26).

Inspectors wroteBased on record review and interview, the facility failed to issue a written transfer/discharge notice, which included information regarding appeal rights, and the name and address of the Office of the State Long-Term Care Ombudsman, to a resident or their representative for 1 of 2 sampled residents transferred/discharged by the facility to an acute care hospital (#80).