Sedgewood Manor Health Care Center

Inspectors wroteBased on review of facility policy, record review, and interviews, the facility failed to ensure call lights were within reach for Resident (R)1, R2, R3, R8 and R9, 5 of 5 rooms reviewed for call light placement.

Inspectors wroteBased on review of facility policy, observations and staff interviews, the facility failed to properly label and discard expired food items in 1 of 1 main kitchen and 1 of 1 resident nourishment refrigerator. This failure to follow proper food storage protocols presents a potential risk to the health and safety of the 33 residents who consume food prepared in the facility's kitchen. Review of an undated facility policy titled Labeling, Dating, Rotating Foods revealed the following: Food must be rotated while in storage to maintain quality and limit the growth of pathogens. Food items must be rotated so the items with the earliest use-by or expiration dates are used before those listed with later dates. The first in, first out method (FIFO) is used to rotate foods refrigerated, frozen, and/or dry goods so that items dated earlier are used first. Identify food's use-by or expiration date. [...]

Inspectors wroteBased on review of facility policy, record review and interviews, the facility failed to ensure that an allegation of abuse was immediately reported to the abuse coordinator for 1 of 3 residents, Resident (R) 31 reviewed for abuse. This failure had the potential to expose the victim to ongoing harm and allow harmful behavior to continue without intervention. Review of the undated facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revealed, It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations withing prescribed timeframes. [...]

Inspectors wroteBased on review of facility policy, record review, observations, and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs) for Resident (R4), 1 of 3 residents reviewed for ADL care. Specifically, staff failed to provide showers and nail care for R4, who was dependent on staff for assistance with ADLs. Review of the facility's undated policy titled Activities of Daily Living (ADLs) revealed, The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. [...]

Inspectors wroteBased on a review of the facility policy, record reviews, observations, and interviews, the facility failed to provide an ongoing resident-centered program designed to meet the resident's interests, hobbies, and cultural preferences in order to promote physical, mental, and psychosocial well-being for 1 of 2 residents reviewed for activities, Resident (R)35. Review of an undated facility policy titled, Activities states, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. [...]

Inspectors wroteBased on observations, interviews, record review, and review of facility policy, the facility failed to follow physician orders for changing oxygen tubing and nasal cannulas for 3 of 3 residents (R) R7, R32 and R42 reviewed for respiratory care. This failure has the potential for harm due to increased risk of infection. Review of the undated facility policy titled Oxygen Administration revealed, 5b. Change Oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Review of R7's face sheet showed she was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: chronic obstructive respiratory disease (COPD; a lung disease causing shortness of breath), chronic respiratory failure, generalized anxiety disorder, and muscle weakness. [...]

Inspectors wroteBased on interviews, and employee record reviews, the facility failed to provide yearly performance evaluations for Certified Nursing Assistants (CNAs), for 3 of 5 CNAs reviewed for yearly performance evaluations; CNA3, CNA4,and CNA5. Review of CNA3's employee record revealed she has a hire date of 04/20/23. She received her last performance review on 05/10/24. She received a rating of Excellent in all areas except one. Her 2025 performance review had not yet been completed as of 07/28/25. Review of CNA4's employee record revealed she has a hire date of 02/24/16. She received her last performance review on 02/28/24. She was rated Excellent and Good in all areas. When Surveyor initially asked for her file on 07/28/25, Human Resources (HR) revealed CNA4's 2025 review was not yet completed. Later in the day on 07/28/25, HR informed Surveyor CNA4's 2025 was completed. [...]

Inspectors wroteBased on observations, interviews, and Daily Nursing Hours sheet reviews, the facility failed to visibly post the Daily Nursing Hours sheets on a daily basis where residents, staff, and visitors could visibly access them. During an observation on 07/27/25 at 9:59 AM, the Daily Nursing Hours sheets were posted in one of two resident hallways outside the Director of Nursing (DON) office. The office was located within the facility and was not readily accessible to visitors as they entered the facility. The date on the sheet that was visible was 07/24/25. Under the Daily Nursing Hours sheet dated 07/24/25 was a Daily Nursing Hours sheet dated 07/21/25. During an interview with Regional Consultant on 07/27/25 at 4:30 PM, he revealed, We do not post the Daily Nursing Hours sheets in the front of the building. We have always posted these at the nurses' station. [...]

Inspectors wroteBased on review of facility policy, record reviews, observations and staff interviews, the facility failed to ensure a medication error rate below 5% during medication administration for 2 of 25 opportunities for error; the error rate was 8 percent. Specifically, Resident (R) 30 did not receive two medications for which there were active physician orders, resulting in a medication omission error. Review of the undated facility policy titled, Medication Administration, states, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician. Observation of medication pass on 06/28/25 at 8:34 AM, Licensed Practical Nurse (LPN)1 was observed preparing to administer medications to R30. R30 had active physician orders for the following medications: [...]

Inspectors wroteBased on review of facility policy, record review, observations and interviews, the facility failed to failed to provide appropriate assistive devices for 1 of 2 Residents (R) reviewed for food. Specifically, R22 did not receive an ordered cup with two handles and lid during meals. This failure has the potential for harm due the potential loss of independence with feeding self. Review of the undated policy titled, Use of Assistive Devices revealed, Assistive devices are tools, products, types of equipment, or technology that help individuals perform tasks and activities . Assistive devices include . g. Eating utensils. The policy also stated, The facility will provide assistive devices for residents who need them. Review of R22's face sheet showed she was admitted to the facility on [DATE]. Her diagnoses included, but were not limited to: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the services of a Registered Nurse (RN) were used for at least eight consecutive hours a day, seven days a week. A review of the nursing schedule provided by the facility revealed an RN was not on site for eight consecutive hours a day on the weekends for seven (7) consecutive months, from January 2024 through July 2024. This failure had the potential to affect the provision of registered nursing assessments and services to all 32 residents in the facility.

Inspectors wroteBased on observation, interviews and review of the facility policy, the facility failed to discard expired food items for 1 of 1 kitchen area. Findings Include: Review of the facility policy titled, Food Storage without a revision date, revealed, All stock must be rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of all foods. Place new items behind supply in stock of the same item; in this way oldest stock is always used first. Supervision is necessary to make sure that the person designated to put stock away is rotating it properly. Review of Storage policy from Optima Solutions titled, Guidelines for Storage revealed, Bread must be stored in pantry area at room temperature for five to seven days. [...]

Inspectors wroteBased on the review of facility policy, interviews, and record review, the facility failed to develop, implement, and monitor the Antibiotic Stewardship Program. This failure placed all residents at risk for the potential transmission of infections and communicable diseases.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure all nurse aide personnel have completed the required 12 hours of training per employment year based on the hire date for 07 out of 14 Certified Nursing Assistants (CNAs).

Inspectors wroteBased on observations, interviews, record review, and review of facility policy, the facility failed to ensure the environment remained as free from potential accident hazards as possible for 1 of 1 resident (R)23. Specifically medications were found at R23's bedside.

Inspectors wroteBased on observations, interviews, record review and facility policy the facility failed to maintain an effective pest control program. Findings Include: Review of the undated facility policy titled, Pest Control Program, revealed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Effective pest control program is defined as measures to eradicate and contain common household pests (e.g. bed bugs, lice, roaches, ants, mosquitos, flies, mice, and rats). During a review of the Service Inspection Reports for June 2024 revealed Open Conditions of unsealed cracks and crevices, doors have gaps allowing pest entry, back door has gaps, cracks and gaps in the ceiling, and there is standing water under appliance/machinery/equipment in the kitchen. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a system of records of receipt of controlled drugs, in sufficient detail, to enable an accurate reconciliation until disposition of destruction and identification of the method of destruction used for controlled medications. Specifically, the facility had the potential for drug diversion with controlled substances and failed to ensure a system of receipt and disposition of all controlled drugs in sufficient detail to ensure an accurate reconciliation and the controlled drugs destruction log did not contain the destruction method for controlled medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure hand hygiene for 1 of 1 Residents ((R) 30) prior to lunch and the laundry area was free of potential spread of infections. Specifically, the facility failed to provide hand hygiene for residents prior to meals and ensure no dust, holes, or exposed plaster was noted in the laundry area.