Inspection Reports for
Sedgewood Commons

This document is the facility's plan of correction for the survey completed on 09/10/2025 addressing deficiencies related to medication storage and infection prevention.

The facility failed to adequately date and properly dispose of open biologicals, failed to monitor medication refrigerator temperatures daily, and failed to maintain an effective Infection Control Program by not applying appropriate Enhanced Barrier Precautions for Resident #28.

This plan of correction responds to the deficiencies cited in the survey completed on 06/04/2025, including issues with housekeeping and maintenance, failure to provide proper notice before resident transfers or discharges, inadequate bed hold policy notifications, unsafe storage of accident hazards, improper labeling and storage of drugs and biologicals, and deficiencies in infection prevention and control practices.

Sedgewood Commons was found to be in compliance with 42 CFR 483, Sub-part B-Requirements for Long Term Care Facilities. No deficiencies were cited.

Sedgewood Commons was determined to be in compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, indicating substantial compliance with no deficiencies cited.

Sedgewood Commons was determined to be in compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities; no deficiencies were cited.

Sedgewood Commons was found to be in substantial compliance with 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities. No deficiencies were cited.

This plan of correction addresses the deficiency cited at F584 regarding inadequate housekeeping and maintenance services to maintain the building in good repair and sanitary condition. The facility has implemented corrective actions including labeling and storing bedpans and urinals properly and conducting audits to ensure compliance.

The facility failed to maintain sanitary conditions in resident shared bathrooms on the Longfellow unit, with unlabeled urinals and bed pans stored improperly. The Quality Assurance Committee failed to ensure the effectiveness of the Plan of Correction from the prior survey, resulting in the same deficiency being cited again.

The facility failed to maintain a safe, clean, and homelike environment, did not complete required pre-admission screenings and care plan meetings, and failed to ensure proper medication storage and staff training. Multiple deficiencies were identified related to resident care, environment, and staff education.

Sedgewood Commons was found to be in substantial compliance with 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities. No deficiencies were cited.

The facility is not in substantial compliance with emergency preparedness and life safety code requirements as evidenced by multiple deficiencies in training, fire safety, and emergency preparedness policies.

The facility did not maintain twice daily temperature readings for medication refrigerators for multiple months, confirmed by interview with the Market Clinical Advisor.

The facility failed to maintain a safe and sanitary environment, did not provide required written notices for resident transfers and bed holds, failed to secure chemicals properly, had ineffective quality assurance processes, and lacked an effective infection prevention and control program.

The facility failed to maintain a working system for controlled substances, resulting in a medication error where morphine intended for one resident was given to another. Additionally, the facility did not ensure that all scheduled medications were received and logged by two licensed staff as required.

The facility was found to have multiple deficiencies including inadequate housekeeping and maintenance, failure to coordinate PASRR assessments, incomplete care plan reviews, unmet personal hygiene preferences, untreated skin conditions, missing staff performance evaluations, improper medication storage, unsanitary kitchen conditions, ineffective quality assurance follow-up, incomplete vaccination education, and lack of required staff training on resident rights.

The facility was cited for multiple deficiencies including failure to provide timely transfer/discharge notices, incomplete interdisciplinary care plan meetings, insufficient RN staffing, improper psychotropic medication orders, inadequate medication storage and labeling, unsanitary food handling practices, inaccurate medication administration records, and failure to implement pneumococcal vaccination policy.