Inspection Reports for Diversicare of Sedgwick
712 N. MONROE AVENUE, KS, 67135
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 19, 2025 found the facility in compliance with all regulations and no deficiencies. Prior inspections showed some deficiencies related mainly to resident discharge documentation, quality of care including medication management, restorative care, infection control, and environmental safety. Complaint investigations were mostly unsubstantiated, except for a substantiated case in 2025 involving inappropriate discharge practices without proper physician documentation. Enforcement actions included a license suspension and immediate jeopardy findings in 2016 related to abuse and supervision failures, and a fine was not listed in the available reports. The facility has shown improvement over time, correcting prior deficiencies through plans of correction and follow-up surveys.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
22.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
270% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
48 residents
Based on a September 2025 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Nov 19, 2025
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-09-09.
Findings
All deficiencies previously cited have been corrected as of the compliance date 2025-09-25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 0
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 16, 2025
Visit Reason
The document is a Plan of Correction submitted by the facility in response to deficiencies cited related to inappropriate discharge practices.
Findings
The Plan of Correction addresses the deficiency of inappropriate discharge by providing physician documentation for a resident's immediate involuntary discharge, conducting audits of center-initiated discharges, and re-educating key staff on discharge documentation requirements.
Deficiencies (1)
| Description |
|---|
| Inappropriate Discharge |
Report Facts
Audit duration: 4
Audit duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Rayna Bittel | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Sep 9, 2025
Visit Reason
The inspection was conducted based on complaint investigations regarding the facility's handling of involuntary discharge of a resident.
Findings
The facility failed to ensure that Resident 1's medical record contained physician documentation justifying the involuntary immediate discharge, placing the resident at risk for impaired rights and inappropriate discharge. The resident exhibited severe behavioral symptoms and safety risks, leading to multiple hospital transfers and eventual discharge.
Complaint Details
The complaint investigations numbered 2605163, 2598557, 1596702, and 1596693 focused on the facility's inappropriate discharge of Resident 1 without proper physician documentation and justification.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure physician documentation of rationale for involuntary immediate discharge of Resident 1. | SS = D |
Report Facts
Census: 48
Complaint investigations: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff B | Provided interview details regarding Resident 1's discharge and facility's efforts | |
| Administrative Nurse D | Administrative Nurse | Entered physician order for Resident 1's transfer and was notified during behavioral incident |
| Physician Extender EE | Physician Extender | Ordered transfer/discharge of Resident 1 to Emergency Department |
| Physician DD | Physician | Documented exam of Resident 1 and noted behavioral issues |
| Social Services Designee X | Social Services Designee | Communicated with Resident 1's representative regarding emergency transfer/discharge |
| Administrative Staff A | Signed discharge letter and was unavailable for interview |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 25, 2025
Visit Reason
A revisit survey and complaint investigation was conducted on 06/25/2025 to verify correction of all previous deficiencies cited on 05/15/2025.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 06/12/2025, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
The visit included a complaint investigation identified by KS00195538 and KS00195340; all deficiencies related to the complaint were corrected.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 7
May 15, 2025
Visit Reason
The inspection was an Extended Health Recertification Survey and complaint survey regarding allegations related to medication refusal and failure to notify the physician for Resident 29, as well as other compliance areas.
Findings
The facility failed to promptly identify and respond to changes in Resident 29's medical condition, resulting in immediate jeopardy due to medication refusals and lack of physician notification. Additional deficiencies included failure to provide adequate restorative care for Resident 21, failure to monitor weight for enteral feeding resident, lack of trauma-informed care for Resident 12, incomplete annual nurse aide performance reviews, and infection control and environmental safety issues in laundry and care areas.
Complaint Details
The visit included a complaint survey regarding allegations KS00195260 and KS00195266 related to Resident 29's medication refusals and failure to notify the physician, resulting in immediate jeopardy.
Severity Breakdown
G: 1
F: 2
E: 1
D: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to identify and respond to changes in Resident 29's medical condition and notify physician of medication refusals and high blood glucose levels. | G |
| Failure to provide adequate restorative care including application of splints for Resident 21, placing resident at risk for pain and contractures. | D |
| Failure to monitor weight routinely and/or as ordered for Resident 21 receiving enteral feeding, placing resident at risk for weight loss and malnutrition. | D |
| Failure to provide trauma-informed care for Resident 12 with history of trauma and substance abuse, lacking appropriate care plan interventions. | D |
| Failure to complete annual performance reviews for two of three Certified Nurse Aides employed for a year or more. | F |
| Failure to implement infection control practices during direct care and laundry services, including improper glove use, catheter bag positioning, and contaminated laundry environment. | E |
| Failure to maintain a safe, functional, sanitary, and comfortable environment in laundry area, including exposed light fixtures, peeling paint, lint accumulation, and open drain with standing water. | F |
Report Facts
Resident census: 42
Sample size: 15
Blood glucose level: 388
Blood glucose level: 513
Weight: 145
Weight: 153.3
Weight: 144.6
Annual performance reviews: 1
Annual performance reviews missing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in medication refusal investigation and terminated for failure to perform duties on 05/04/25 |
| LN I | Licensed Nurse | Reported charting by exception and prior provider contact regarding Resident 29 |
| Administrative Nurse C | Administrative Nurse | Verified lack of progress notes and annual performance review requirements |
| Therapy Staff LL | Therapy Staff | Found splints buried in drawer and reported lack of restorative program |
| Administrative Nurse E | Administrative Nurse | Reported facility had no restorative program and was working to initiate one |
| Social Services Staff FF | Social Services Staff | Reported evaluation process for PTSD and resident R12's history |
| CMA M | Certified Medication Aide | Had annual performance evaluation without employee signature |
| CMA N | Certified Medication Aide | Had no annual performance review for over a year |
| CNA T | Certified Nurse Aide | Observed with infection control breaches during care of Resident 21 |
| CMA N | Certified Medication Aide | Observed with infection control breaches during care of Resident 21 |
| Maintenance Staff QQ | Maintenance Staff | Reported laundry area conditions and maintenance activities |
Inspection Report
Plan of Correction
Deficiencies: 7
May 15, 2025
Visit Reason
This document is a Plan of Correction submitted by Diversicare of Sedgwick RS in response to deficiencies cited during a regulatory inspection conducted on 05/15/2025.
Findings
The Plan of Correction addresses multiple deficiencies including quality of care, mobility management, tube feeding management, trauma-informed care, nurse aide performance reviews, infection prevention and control, and maintaining a safe and sanitary environment. Corrective actions include audits, staff education, and environmental improvements with ongoing monitoring and reporting to the QAPI committee.
Severity Breakdown
J: 1
D: 3
F: 2
E: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Quality of Care - Resident transported to hospital; audits and re-education on physician notification for blood glucose levels. | J |
| Increase/Prevent Decrease in ROM/Mobility - OT evaluation ordered; education on splint application; audits for appropriate splint use. | D |
| Tube Feeding Management/Restore Eating Skills - Weight monitoring orders updated; education and audits for enteral nutrition weight monitoring. | D |
| Trauma Informed Care - Care plans updated with triggers and interventions; staff education; audits for compliance. | D |
| Nurse Aide Performance Review - Annual performance reviews completed and audited; education for timely reviews. | F |
| Infection Prevention & Control - Immediate corrective actions for catheter care and environmental sanitation; staff education; audits for catheter placement, glove use, hygiene, and clean linen space. | E |
| Safe/Functional/Sanitary/Comfortable Environment - Maintenance and housekeeping improvements; education; audits for laundry area safety and sanitation. | F |
Report Facts
Audit frequency: 5
Audit duration: 3
Annual performance review hours: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rayna Bittel | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 15, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 07/19/23.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 08/25/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Census: 40
Deficiencies: 16
Jul 19, 2023
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigations #18628 and #180568 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including safe and homelike environment, care plan timing and revision, ADL care, accident hazards, bowel/bladder continence, respiratory care, pain management, staffing sufficiency, nurse aide performance reviews, drug regimen review, unnecessary drug use, food safety, infection control, and COVID-19 immunization.
Severity Breakdown
Level F: 5
Level E: 4
Level D: 6
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to ensure a safe, sanitary, and homelike environment in seven resident rooms. | Level E |
| Failed to review and revise care plans for residents related to psychotropic medications, wheelchair foot pedals, toileting, and behavioral interventions. | Level D |
| Failed to provide facial grooming and hair care for dependent residents and ensure residents wore clean clothing and were dressed and out of bed. | Level E |
| Failed to ensure wheelchair safety including use of foot pedals and safe transfers for residents. | Level E |
| Failed to provide timely toileting and individualized toileting program for a dependent resident. | Level D |
| Failed to ensure oxygen concentrator humidifier bottle was not dry for a resident on oxygen at 7 liters. | Level D |
| Failed to provide adequate pain relief for a resident complaining of pain from indwelling urinary catheter. | Level D |
| Failed to ensure sufficient qualified nursing staff available at all times to meet residents' needs safely. | Level F |
| Failed to complete annual competency performance reviews for five CNAs/CMAs. | Level F |
| Failed to follow up on pharmacy recommendations for gradual dose reduction of antipsychotic medications for residents. | Level D |
| Failed to ensure a resident was kept free from unnecessary medications by failing to notify physician of blood sugars outside ordered parameters. | Level D |
| Failed to ensure residents had Abnormal Involuntary Movement Scale (AIMS) assessments when receiving antipsychotic medications. | Level D |
| Failed to store, prepare, and serve food in a sanitary manner including failure to wear hairnets, dirty reach-in refrigerators and freezers, and unclean cooking utensil drawers. | Level F |
| Failed to store resident food items in a sanitary manner in the medication room. | Level F |
| Failed to maintain an effective infection control program including incomplete infection tracking logs, improper storage of personal protective equipment, and housekeeping staff not knowledgeable on cleaning chemical dwell times. | Level F |
| Failed to offer residents COVID-19 vaccinations per CDC guidelines. | Level E |
Report Facts
Resident census: 40
Residents sampled: 16
Staff on night shift: 3
Oxygen flow rate: 7
Pain medication dose: 50
Blood sugar level: 350
Number of days antipsychotic medication received: 7
Number of days antipsychotic medication received: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LN J | Licensed Nurse | Named in pain management deficiency related to resident penis pain and medication administration |
| CMA T | Certified Medication Aide | Named in pain management and wheelchair foot pedal deficiencies |
| CNA M | Certified Nurse Aide | Named in toileting and wheelchair positioning deficiencies |
| Administrative Nurse D | Administrative Nurse | Named in multiple deficiencies including pain management, staffing, infection control, and COVID-19 immunization |
| Consultant Nurse II | Consultant Nurse | Named in antipsychotic medication monitoring deficiency |
| Maintenance Staff U | Maintenance Staff | Named in environmental and infection control deficiencies |
| Dietary Staff BB | Dietary Staff | Named in food safety deficiencies |
Inspection Report
Plan of Correction
Deficiencies: 16
Jul 19, 2023
Visit Reason
This Plan of Correction document addresses deficiencies cited during a prior survey conducted on 2023-07-19 and outlines corrective actions the facility will implement to ensure compliance with regulations.
Findings
The facility identified multiple deficiencies related to environmental conditions, care plan reviews, resident care needs, safety equipment, toileting assistance, medication management, staffing, performance reviews, infection control, and COVID-19 vaccination offerings. Corrective actions include repairs, education, audits, and ongoing monitoring to ensure compliance and resident well-being.
Severity Breakdown
E: 5
D: 7
F: 6
Deficiencies (16)
| Description | Severity |
|---|---|
| Environmental items such as missing paint, broken floor tiles, privacy curtain replacement, and cleanliness addressed | E |
| Care plans reviewed and revised per RAI guidelines | D |
| Residents provided facial grooming, clean clothing, and ADL care needs reassessed | E |
| Wheelchair safety and foot petals assessed and provided | E |
| Toileting assistance and individualized toileting program initiated | D |
| Humidifier bottle replaced and humidification provided | D |
| Pain assessment and relief provided | D |
| Staffing schedules reviewed and adjusted | F |
| Annual performance reviews completed for nurse aides | F |
| Review and follow-up on unnecessary medications and pharmacy recommendations | D |
| Blood glucose levels evaluated and physician notified as needed | D |
| AIMS assessments completed for residents on antipsychotic medications | D |
| Deep cleaning and sanitation audits performed in dietary areas | F |
| QAPI plan developed and implemented to address environment and care issues | F |
| Infection tracking, sanitary storage, and cleaning protocols implemented | F |
| COVID-19 vaccinations offered according to CDC guidelines | E |
Report Facts
Audit frequency: 4
Audit duration: 3
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 13, 2022
Visit Reason
An offsite revisit survey was conducted on 04/13/2022 for all previous deficiencies cited on 03/15/2022.
Findings
All deficiencies have been corrected as of the compliance date of 03/16/2022, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 3
Mar 15, 2022
Visit Reason
The visit was a Non-Compliance Revisit to assess the facility's compliance with respiratory care regulations, specifically related to respiratory/tracheostomy care and suctioning.
Findings
The facility failed to provide sanitary respiratory care measures for two residents, including improper storage and failure to date oxygen nasal cannula tubing and humidifier bottles, increasing the risk of respiratory infections. The facility also failed to activate standing oxygen orders timely and lacked clear instructions for changing and storing oxygen equipment.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to properly store oxygen nasal cannula tubing, date the tubing, and date the humidifier bottle for Resident R99. | SS=D |
| Failure to properly store oxygen nasal cannula tubing connected to the concentrator and portable oxygen bottle, failure to change oxygen tubing connected to the concentrator, and failure to date the humidifier bottle and oxygen tubing connected to the portable bottle for Resident R17. | SS=D |
| Failure to activate standing oxygen orders timely for Resident R99 and lack of instructions for changing/dating tubing and humidifier bottles. | SS=D |
Report Facts
Census: 47
Residents reviewed: 9
Oxygen tubing change frequency: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided statements regarding expectations for oxygen tubing replacement and storage. | |
| Licensed Nurse G | Licensed Nurse | Provided information about previous and current oxygen tubing change processes. |
| Certified Medication Aide R | Certified Medication Aide | Confirmed oxygen tubing connected to portable bottle lacked a date and described storage practices. |
Inspection Report
Plan of Correction
Deficiencies: 8
Feb 15, 2022
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection, detailing corrective actions taken and planned to address those deficiencies.
Findings
The Plan of Correction outlines multiple areas of concern including medication administration, nail care, wound care, pressure ulcer interventions, IV fluid administration, oxygen equipment maintenance, medical record documentation, and environmental maintenance. The facility describes re-education of staff, audits, and ongoing monitoring to ensure compliance and correction of deficiencies.
Deficiencies (8)
| Description |
|---|
| Resident R7’s antibiotics were administered as ordered; Resident R10’s IV fluids were administered as ordered; re-education on Abuse/Neglect/Misappropriation policy and audits planned. |
| Resident R23 received nail care; nursing department re-educated on nail care; audits planned. |
| Residents with wounds assessed; nursing re-educated on antibiotic orders, wound care, and treatments; audits planned. |
| Residents with pressure ulcers reassessed; interventions in place; nursing re-educated on skin care and wound documentation; audits planned. |
| Resident R10’s IV fluids administered as ordered; nursing re-educated on IV fluids and stat orders; audits planned. |
| Oxygen humidifier bottles, tubing, and cannulas changed and stored properly; nursing re-educated; audits planned. |
| Resident R29’s medical record updated for mammogram request; nursing re-educated on documentation; audits planned. |
| Environmental repairs completed or planned; maintenance director educated on environmental rounds; audits planned. |
Report Facts
Audit frequency: 5
Audit duration: 3
Audit duration: 4
Date: Feb 15, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Justin Harland | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 8
Jan 11, 2022
Visit Reason
The inspection was conducted as a Health Resurvey, Extended Health Resurvey, and Complaint Investigation involving multiple complaint numbers related to abuse, neglect, exploitation, and medication errors.
Findings
The facility failed to investigate and report medication errors involving missed IV antibiotics and delayed IV fluids, failed to provide necessary personal hygiene and wound care services, failed to administer IV fluids as ordered, failed to maintain respiratory equipment properly, and failed to maintain accurate and complete medical records. Additionally, the facility failed to maintain a safe and sanitary environment in the laundry area.
Complaint Details
The visit was complaint-related involving allegations of abuse, neglect, exploitation, and medication errors. The facility failed to investigate and report these allegations as required.
Severity Breakdown
SS=D: 6
SS=G: 1
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to complete an investigation and report medication errors involving missed IV antibiotics for Resident 7 and delayed IV fluids for Resident 10. | SS=D |
| Failed to provide necessary personal hygiene services related to nail care for Resident 23. | SS=D |
| Failed to provide necessary treatment and care to promote healing of wounds for Resident 7 and multiple wounds for Resident 4. | SS=G |
| Failed to provide necessary treatment and services to promote healing of pressure ulcers for Residents 4 and 17. | SS=D |
| Failed to administer IV fluids as ordered for Resident 10, resulting in delayed treatment for dehydration. | SS=D |
| Failed to provide appropriate respiratory care related to maintaining respiratory equipment to prevent infection for Residents 29 and 11. | SS=D |
| Failed to maintain medical records that were complete and accurately documented for Residents 10 and 29, including failure to update records after hospitalization and failure to document a resident's request for a mammogram. | SS=D |
| Failed to maintain a safe and sanitary environment in the facility laundry area, including ceiling stains, damaged flooring, and damaged folding tables. | SS=E |
Report Facts
Census: 39
Residents sampled: 21
Days of missed IV antibiotic doses: 4
Hours delayed IV fluid administration: 24
Date of survey completion: Jan 11, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in medication error findings, failure to report incidents, and failure to maintain medical records. |
| Nurse Practitioner GG | Nurse Practitioner | Documented medication errors and follow-up related to Resident 7. |
| Nurse Practitioner KK | Nurse Practitioner | Ordered IV antibiotics for Resident 7 and involved in telemed visits. |
| Licensed Nurse J | Licensed Nurse | Observed dressing changes and confirmed findings related to wound care and respiratory equipment. |
| Consultant Pharmacist LL | Consultant Pharmacist | Provided expert opinion on antibiotic administration. |
| Certified Medication Aide R | Certified Medication Aide | Responsible for appointments and transportation; unaware of resident's mammogram request. |
| Licensed Nurse H | Licensed Nurse | Discussed medication order placement responsibilities. |
| Licensed Nurse I | Licensed Nurse | Reported on wound condition and medication order issues. |
| Licensed Nurse G | Licensed Nurse | Performed weekly wound assessments and discussed antibiotic orders. |
| Licensed Nurse J | Licensed Nurse | Reported on respiratory equipment maintenance and infection control. |
| Certified Nurse Aide O | Certified Nurse Aide | Confirmed respiratory equipment storage practices. |
| Certified Nurse Aide M | Certified Nurse Aide | Confirmed respiratory equipment storage practices. |
| Administrative Staff A | Administrative Staff | Verified documentation and environmental concerns. |
| Licensed Nurse K | Licensed Nurse | Discussed appointment scheduling responsibilities. |
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 11, 2022
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection report dated 1/11/22 for Diversicare Sedgwick.
Findings
The plan addresses deficiencies related to the storage, dating, and changing of oxygen humidifier bottles, tubing, and cannulas for residents receiving oxygen and/or nebulizer treatments. The nursing staff was re-educated, audits were scheduled, and results will be reviewed by the Quality Assurance/Assessment Committee.
Deficiencies (1)
| Description |
|---|
| Improper storage, dating, and changing of oxygen nebulizer tubing, humidifier bottles, and cannulas affecting residents receiving oxygen and/or nebulizer treatments. |
Report Facts
Deficiency completion date: Mar 16, 2022
Audit frequency: 4
Audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Evelyn Lacey | KDADS submitter of Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 29, 2021
Visit Reason
An offsite revisit survey was conducted on 10/29/2021 to verify correction of all previous deficiencies cited on 09/29/2021.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 10/13/2021, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies corrected: 0
Inspection Report
Plan of Correction
Deficiencies: 1
Sep 29, 2021
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated 09/29/2021.
Findings
The plan addresses deficiencies related to accident hazards and supervision, specifically interventions to prevent burns from hot liquids, including providing residents with safer drinking cups, updating care plans, educating staff, and auditing implementation and coffee temperatures.
Deficiencies (1)
| Description |
|---|
| Free of Accident Hazards/Supervision/Devices - Resident #1 was provided with a new cup with lid and a clothing protector; Resident #2 no longer resides in the center; all residents assessed for ability to handle hot liquids; care plans updated; staff educated on risk assessments and interventions to prevent burns. |
Report Facts
Audit frequency: 5
Audit duration: 4
Audit duration: 3
Coffee temperature log audit frequency: 1
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 1
Sep 29, 2021
Visit Reason
The inspection was conducted as a result of complaint investigations #KS 165808 and #KS 165930 regarding resident safety and accident hazards.
Findings
The facility failed to ensure two residents remained free from accidents when they sustained burns from hot coffee spills. Observations, interviews, and record reviews confirmed that coffee temperatures ranged from 160 to 165 degrees, causing third degree burns to one resident and burns to another.
Complaint Details
The visit was triggered by complaint investigations #KS 165808 and #KS 165930. The complaints were substantiated as the facility failed to prevent accidents resulting in burns to two residents from hot coffee spills.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents remained free from accident hazards related to hot coffee spills causing burns. | SS=D |
Report Facts
Census: 107
Coffee temperature range: 160
Coffee temperature range: 165
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Interviewed regarding the burn injury of Resident 1 and observed injuries |
| Consultant Staff GG | Consultant Staff | Conducted admission assessment and noted burn injury of Resident 2 |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 20, 2021
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 12/09/20.
Findings
All the deficiencies cited previously have been corrected as of the compliance date of 12/15/20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Follow-Up
Deficiencies: 0
Jan 20, 2021
Visit Reason
Health Licensure revisit was conducted on 01/20/21 for all previous deficiencies cited on 11/03/20.
Findings
All deficiencies have been corrected as of the compliance date of 12/11/20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 20, 2021
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 11/03/20.
Findings
All deficiencies have been corrected as of the compliance date of 12/11/20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 7
Dec 9, 2020
Visit Reason
The inspection was conducted as a complaint investigation involving allegations of abuse and neglect, as well as a partial extended survey.
Findings
The facility failed to provide adequate supervision to prevent physical abuse by a resident with a history of aggressive behavior, failed to timely notify the physician and state agency of an incident, failed to monitor neurological status after a resident was struck in the head, and failed to ensure hospice education and end-of-life decisions were honored.
Complaint Details
The complaint investigation involved allegations that resident R4 physically abused resident R3 by striking her in the head on 11/27/20. The facility failed to provide adequate supervision, failed to notify the physician and state agency timely, and failed to monitor neurological status after the incident.
Severity Breakdown
SS=D: 5
SS=L: 1
SS=J: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to notify the physician of a resident receiving a blow to her head within 24 hours. | SS=D |
| Failed to provide adequate supervision and one-to-one care to prevent physical abuse by a resident with aggressive behaviors, placing another resident in immediate jeopardy. | SS=L |
| Failed to report an allegation of abuse to the state agency in a timely manner. | SS=D |
| Failed to thoroughly investigate an allegation of abuse, prevent further abuse during investigation, and report investigation results timely. | SS=J |
| Failed to provide hospice education and information to a resident to make informed decisions regarding quality of care. | SS=D |
| Failed to monitor a confused resident for neurological changes after being struck in the head by another resident. | SS=D |
| Failed to ensure a resident's end-of-life decisions were available and honored by staff. | SS=D |
Report Facts
Resident census: 49
Incident notification delay: 5
BIMS score: 0
BIMS score: 3
Duration unconscious: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Reported the incident of resident R4 striking R3 and failed to notify the physician. |
| Administrative Nurse D | Administrative Nurse | Began investigation of the incident, confirmed failure to maintain one-to-one supervision, and failed to notify the state agency. |
| Certified Nurse Aide M | Certified Nurse Aide | Witnessed the altercation between R4 and R3 and reported the incident to Licensed Nurse H. |
| Consulting Staff GG | Consulting Staff | Notified late about the incident and expected immediate notification and neurological monitoring. |
| Physician Extender GG | Physician Extender | Expected immediate notification of the incident and neurological monitoring. |
| Licensed Nurse L | Licensed Nurse | Reported resident R10 found unresponsive and initiated CPR. |
| Administrative Nurse E | Administrative Nurse | Reported resident R1's condition and hospice referral status. |
| Social Service Staff X | Social Service Staff | Unaware of hospice referral for resident R1. |
| Administrative Staff A | Administrative Staff | Notified state agency of abuse incident five days after occurrence. |
Inspection Report
Plan of Correction
Deficiencies: 5
Dec 9, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during the inspection of Diversicare Sedgwick on December 9, 2020.
Findings
The plan addresses multiple deficiencies related to resident care, notification of changes to physicians, abuse/neglect prevention, timely reporting, hospice services, neurological monitoring, CPR policy, and code status verification. Corrective actions include re-education of staff, audits, interviews, and ongoing monitoring with results submitted to the Quality Assurance/Assessment Committee.
Severity Breakdown
D: 3
L: 1
J: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Notification of change to physician provider regarding aggressive behaviors not properly done | D |
| Failure to prevent abuse, neglect, and exploitation | L |
| Failure in timely reporting of abuse/neglect/misappropriation | D |
| Failure to report alleged violations timely | J |
| Failure to assist residents in obtaining hospice information, neurological monitoring, CPR policy, and code status verification | D |
Report Facts
Residents no longer residing in the center: 4
Number of residents/nurses interviewed weekly: 5
Audit frequency: 4
Plan of Correction completion date: 2020
Inspection Report
Re-Inspection
Census: 50
Deficiencies: 1
Nov 3, 2020
Visit Reason
The inspection was conducted as a Licensure Resurvey and Complaint Investigation involving multiple complaint numbers.
Findings
The facility failed to ensure that all nursing staff completed required mandatory in-service education, including disaster training, dementia training, resident rights, and fire prevention and safety training, as evidenced by incomplete training records for five nursing staff.
Complaint Details
The visit included a complaint investigation as indicated by multiple complaint numbers (#157114, #157063, #156988, #157051, #157052, and #150380).
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide regular, planned in-service education for all staff, including disaster training, dementia training, resident rights, and fire prevention and safety. | SS=F |
Report Facts
Census: 50
Nursing staff reviewed: 5
Nursing staff lacking fire prevention and safety training: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided interview statements regarding staff training and monitoring. |
Inspection Report
Plan of Correction
Deficiencies: 16
Nov 3, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during the Diversicare Sedgwick State Resurvey and Federal Resurvey conducted on 11/03/2020, including COVID and complaint-related issues.
Findings
The Plan of Correction addresses multiple deficiencies related to resident care, notification to responsible parties, abuse/neglect prevention, care planning, bathing, fall interventions, medication reviews, staff training, and policy reviews. Corrective actions include re-education of staff, audits, and ongoing monitoring with results submitted to the Quality Assurance/Assessment Committee over the next three months.
Severity Breakdown
D: 8
K: 1
E: 2
G: 1
F: 4
Deficiencies (16)
| Description | Severity |
|---|---|
| Failure to notify responsible parties of changes including weight loss and behaviors | D |
| Failure to prevent abuse, neglect, and exploitation including supervision | K |
| Failure to timely report abuse/neglect/misappropriation | D |
| Failure to provide bed-hold policy upon hospital transfer | E |
| Incomplete or untimely comprehensive assessments (CAA) | D |
| Care plans not individualized to include bathing preferences | D |
| Care plans not updated to include fall interventions | D |
| Failure to provide baths per resident preferences and document refusals | D |
| Failure to assess and implement fall interventions and prevent cognitively impaired residents from leaving unattended | D |
| Failure to assess and update dietician orders for residents with tube feedings | G |
| Incomplete annual performance reviews for CNA team members | E |
| Failure to post nurse staffing information and maintain postings | F |
| Failure to address consultant pharmacist recommendations timely | D |
| Failure to review and approve policies annually by governing body | F |
| Failure to obtain and maintain transfer agreements with hospital | F |
| Failure to complete required 12 hour in-service training for nurse aides | F |
Report Facts
Audit frequency: 5
Audit duration: 3
In-service training hours: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Justin Harland | Administrator | Administrator submitting the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Lanae Workman | Person who added the Plan of Correction | |
| Lori Mouak | Person who modified the Plan of Correction |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Apr 28, 2020
Visit Reason
A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess the facility's compliance with recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 28, 2020
Visit Reason
The document is a Plan of Correction submitted in response to a COVID-19 related survey conducted on April 28, 2020.
Findings
The facility was found to be deficiency free in the COVID-19 survey conducted on April 28, 2020.
Deficiencies (1)
| Description |
|---|
| Deficiency free covid survey |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 15, 2020
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2019-11-27.
Findings
All previously cited deficiencies have been corrected as of the compliance date 2019-12-18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 8
Nov 27, 2019
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #144660 to assess compliance with regulatory requirements related to resident care and facility policies.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity by dressing a resident in damaged clothing, failure to provide written bed hold policy notices upon hospitalization transfers, failure to document discharge summaries, inadequate assistance with activities of daily living such as bathing and shaving, unsafe resident transfers without proper foot pedals, improper catheter care, and failure to monitor and act on unnecessary medication use.
Complaint Details
The inspection included a complaint investigation identified as #144660.
Severity Breakdown
SS=D: 7
SS=E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Resident was dressed in pants with holes exposing skin, failing to maintain dignity. | SS=D |
| Facility failed to provide written notice of bed hold policy to residents upon hospitalization transfers. | SS=E |
| Facility failed to document a discharge summary for a discharged resident. | SS=D |
| Inadequate assistance with activities of daily living including failure to provide scheduled bathing and shaving assistance. | SS=D |
| Unsafe resident transfers and failure to provide proper foot pedal for wheelchair to prevent accidents. | SS=D |
| Failure to provide appropriate catheter care including securing catheter to prevent urethral trauma and maintaining sanitary drainage tubing. | SS=D |
| Pharmacist failed to identify unnecessary use of as needed Ativan cream beyond 14 days without physician reevaluation. | SS=D |
| Facility failed to ensure residents did not receive unnecessary psychotropic medications beyond 14 days without physician documentation of continued need. | SS=D |
Report Facts
Residents reviewed: 18
Residents reviewed for hospitalization: 7
Residents with bed hold policy failure: 5
Scheduled baths missed: 4
Days of Ativan cream use without reevaluation: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in findings related to resident dressing, transfers, and catheter care. |
| Certified Nurse Aide M | Certified Nurse Aide | Named in findings related to dressing resident in damaged clothing and bathing. |
| Certified Medication Aide T | Certified Medication Aide | Named in findings related to dressing resident and catheter care. |
| Administrative Nurse D | Administrative Nurse | Named in findings related to discharge summary, catheter care, and medication monitoring. |
| Consulting Pharmacist HH | Consulting Pharmacist | Named in findings related to failure to identify unnecessary medication use. |
Inspection Report
Plan of Correction
Deficiencies: 8
Nov 27, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the inspection conducted on 2019-11-27.
Findings
The Plan of Correction addresses multiple deficiencies including respect and dignity regarding personal property, bed-hold policy notification, discharge summaries, ADL care for dependent residents, accident hazards and supervision, catheter care, and medication regimen reviews. The facility outlines corrective actions, staff education, audits, and ongoing monitoring to ensure compliance.
Severity Breakdown
D: 7
E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Respect, Dignity/Right to have personal Property | D |
| NOTICE OF BED-HOLD POLICY BEFORE/UPON TRANSFER | E |
| Discharge Summary | D |
| ADL Care provided for dependent residents | D |
| Free of Accident Hazards/Supervision/Devices | D |
| Bowel/Bladder Incontinence, Catheter, UTI | D |
| Drug Regimen is Free from Unnecessary Drugs | D |
| Free From Unnecessary Drugs | D |
Report Facts
Resident interviews for dignified dressing: 5
Resident discharges reviewed weekly: 5
Resident interviews regarding ADL care: 5
Audit frequency for safe foot rest positioning: 4
Audit frequency for catheter care: 4
Audit frequency for AIMS assessment: 5
Audit frequency for medication review for Ativan: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Markus Meyer | Administrator | Administrator or designee responsible for re-education and audits |
| Lanae Workman | Added Plan of Correction | |
| Janice VanGotten | Modified Plan of Correction |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Nov 1, 2019
Visit Reason
The inspection was conducted as a complaint investigation (#KS 147202) by the Kansas Department for Aging and Disability Services on behalf of CMS, triggered by concerns regarding failure to provide CPR to a resident with a full code status.
Findings
The facility failed to provide CPR to a resident (R1) with a full code status who was found unresponsive and without vital signs. Staff incorrectly assumed the resident had a DNR order due to hospice status and did not verify code status before withholding CPR, placing the resident in immediate jeopardy. The facility subsequently suspended the nurse involved and implemented corrective actions including staff re-education and code status verification.
Complaint Details
The complaint investigation found the facility was not in substantial compliance with 42 CFR 483 subpart B due to failure to provide CPR to a resident with a full code status. The nurse assumed a DNR order due to hospice care without verification. The facility suspended the nurse, reported the incident to the State complaint hotline, and initiated corrective actions.
Severity Breakdown
SS=J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide CPR to a resident with a full code status when found without pulse or respirations. | SS=J |
Report Facts
Resident census: 56
Hospice residents: 5
Residents with full code status: 40
Residents with DNR status: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Licensed Nurse | Failed to provide CPR to resident with full code status; suspended following incident |
| Administrative Staff A | Reported suspension of Licensed Nurse C and investigation of incident | |
| Social Service Designee D | Social Service Designee | Verified meeting with resident and family regarding hospice and code status |
| Administrative Licensed Staff B | Verified CPR certification on duty and informed of immediate jeopardy status |
Inspection Report
Re-Inspection
Deficiencies: 1
May 15, 2019
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency related to regulation 26-40-303 (b)(c) was corrected as of 04/15/2019. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 26-40-303 (b)(c) corrected |
Inspection Report
Follow-Up
Deficiencies: 4
May 15, 2019
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit report indicates that all previously cited deficiencies identified by regulation numbers 483.10(i)(1)-(7), 483.21(b)(2)(i)-(iii), 483.24(a)(2), and 483.60(i)(1)(2) were corrected as of 04/15/2019.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 483.10(i)(1)-(7) |
| Deficiency related to regulation 483.21(b)(2)(i)-(iii) |
| Deficiency related to regulation 483.24(a)(2) |
| Deficiency related to regulation 483.60(i)(1)(2) |
Report Facts
Date corrections completed: Apr 15, 2019
Inspection Report
Abbreviated Survey
Deficiencies: 1
Mar 22, 2019
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be an "E" level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective April 15, 2019.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| "E" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | E |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Mar 22, 2019
Visit Reason
The inspection was conducted as a complaint investigation #KS00139020 to assess compliance with nursing workroom visibility requirements.
Findings
The facility failed to ensure visual monitoring of two of four hallways where residents resided from the nursing work area, as the nursing desk was removed and relocated to an office without line of sight and no electronic monitoring was in place.
Complaint Details
The findings represent the results of complaint investigation #KS00139020. The complaint was substantiated as the facility lacked visual monitoring of two hallways from the nursing work area.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Nurses' workroom or area lacked direct visual access to two hallways where residents resided. | SS=E |
Report Facts
Census: 58
Hallways lacking visualization: 2
Inspection Report
Plan of Correction
Deficiencies: 5
Mar 22, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint survey conducted at the facility.
Findings
The Plan of Correction addresses multiple deficiencies including safe/clean environment, care plan timing and revision, ADL care for dependent residents, food procurement and sanitation, and nurses' workroom visibility. The facility has implemented corrective actions, re-education, and auditing processes to ensure compliance and ongoing monitoring.
Complaint Details
This Plan of Correction is in response to deficiencies cited during a complaint survey. The facility shared findings with the QAPI team on 3/29/2019 and will update the team monthly on implementation and audits.
Deficiencies (5)
| Description |
|---|
| Safe/Clean/Comfortable/Homelike Environment |
| Care plan timing and revision |
| ADL Care provided for dependent residents |
| Food Procurement, Store/Prepare/Serve-Sanitary |
| Nurses' workroom or area |
Report Facts
Audit frequency: 4
Audit frequency: 3
Residents reviewed: 5
Meal services audited: 4
Inspection Report
Re-Inspection
Deficiencies: 0
Feb 8, 2019
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-11-29.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 2018-12-19, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 8
Dec 19, 2018
Visit Reason
This Plan of Correction document is submitted as required under state and federal law in response to deficiencies cited during a prior survey to assure correction and continued compliance with regulations.
Findings
The facility identified multiple deficiencies related to care plan development, timing and revision, discharge summaries, ADL care, quality of care, accident hazards and supervision, bowel/bladder care, and infection prevention and control. The facility has implemented corrective actions including re-education of staff, audits, and ongoing monitoring through the QAPI committee.
Severity Breakdown
D: 6
E: 1
F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Develop Comprehensive Care Plan for Resident #46 | D |
| Care plan timing and revision for Residents #16, 44, and 33 | D |
| Discharge Summary for Resident #55 | D |
| ADL Care provided for dependent Resident #4 | D |
| Quality of Care related to skin impairment for Resident #26 | D |
| Free of Accident Hazards/Supervision/Devices for Residents #26, 14, 16, and 44 | E |
| Bowel/Bladder Incontinence, Catheter, UTI for Residents #33 and #4 | D |
| Infection Prevention & Control for Residents #40, #49, #13, #2, and #26 | F |
Report Facts
Audit frequency: 5
Audit frequency: 3
Audit frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Markus Meyer | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Plan of Correction
Deficiencies: 1
Nov 29, 2018
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be a widespread 'F' level deficiency that constitutes no actual harm but has potential for more than minimal harm and is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, and the facility was found to be in substantial compliance effective 2018-12-19.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be a 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Named as contact and signatory related to enforcement and plan of correction acceptance. |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 8
Nov 29, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint investigations #s131241 and #119930.
Findings
The facility was found deficient in multiple areas including failure to develop and revise comprehensive care plans, failure to provide adequate oral hygiene care, failure to provide appropriate skin care to prevent irritation, failure to provide adequate supervision and assistive devices to prevent accidents, failure to maintain sanitary catheter care, and failure to maintain infection control practices including proper hand hygiene and equipment sanitation.
Complaint Details
The inspection was triggered by complaints #s131241 and #119930.
Severity Breakdown
SS=D: 5
SS=E: 1
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan for resident #46 related to activities. | SS=D |
| Failed to review and revise care plans for residents #16, #44, and #33 regarding falls and catheter care. | SS=D |
| Failed to complete discharge summary including recapitulation of stay and medication reconciliation for resident #55. | SS=D |
| Failed to provide necessary oral hygiene services to resident #4, resulting in poor oral hygiene. | SS=D |
| Failed to provide appropriate skin care to resident #26 to prevent irritation and worsening of skin condition related to urinary incontinence and shearing. | SS=D |
| Failed to provide adequate supervision and assistive devices to prevent accidents for residents #16, #26, #44, and failed to ensure safe drinking supplies for resident #14. | SS=E |
| Failed to maintain catheter tubing and urine collection bag off the floor for resident #33 and failed to provide proper perineal care for resident #4, increasing risk of urinary tract infection. | SS=D |
| Failed to maintain infection prevention and control including sanitary storage of respiratory and wound care equipment, and proper hand hygiene and glove use for residents #2, #13, #26, #40, and #49. | SS=F |
Report Facts
Residents sampled: 17
Residents census: 54
Falls: 2
BIMS score: 15
BIMS score: 6
BIMS score: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Transferred resident #26 alone with hoyer lift despite care plan requiring 2 staff; failed to perform proper hand hygiene after pericare. | |
| Staff T | Licensed Nursing Staff | Used improper incontinence care technique wiping resident #4 back-to-front. |
| Staff D | Licensed Nursing Staff | Used improper incontinence care technique wiping resident #4 back-to-front and failed to offer oral care to resident #4. |
| Staff P | Direct Care Staff | Failed to offer oral care to resident #4 until prompted. |
| Staff Q | Direct Care Staff | Attempted to involve resident #46 in activities; assisted resident #4 with oral care. |
| Staff R | Direct Care Staff | Provided oral care to resident #4; reported resident's resistive behaviors. |
| Staff S | Direct Care Staff | Toileted resident #16 and transferred resident during inspection. |
| Staff L | Direct Care Staff | Described fall interventions for resident #44. |
| Staff N | Licensed Staff | Described fall interventions and proper CPAP facemask care. |
| Staff M | Direct Care Staff | Reported wound vac kept on floor for resident #49. |
| Administrative Staff A | Administrative Nursing Staff | Confirmed failures in care plan revisions, fall interventions, discharge summary completion, and infection control. |
| Administrative Staff B | Examined skin irritations on resident #26. | |
| Administrative Staff C | Administrative Nursing Staff | Confirmed resident #26 required 2 staff for transfer; examined skin irritations. |
Inspection Report
Plan of Correction
Deficiencies: 2
Sep 6, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation for Diversicare Sedgwick.
Findings
The plan of correction addresses past noncompliance issues identified under tags F0000 and F689-J, with no new corrective actions required.
Complaint Details
This plan of correction is linked to a complaint investigation as indicated by the reference to Complaint Diversicare Sedgwick 2567.
Deficiencies (2)
| Description |
|---|
| Past noncompliance: no plan of correction required. |
| Past noncompliance: no plan of correction required. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Sep 5, 2018
Visit Reason
The inspection was conducted as a complaint investigation (#133018) following an incident where a resident eloped from the facility and was found injured outside.
Findings
The facility failed to provide adequate supervision and assistive devices to prevent accidents, resulting in a resident leaving the facility unnoticed, falling from a wheelchair, and sustaining a minor injury. The wanderguard alarm system was temporarily disabled due to an electrical disturbance caused by a storm.
Complaint Details
Complaint investigation #133018. The resident exited the facility without staff knowledge, was missing for approximately one hour, and was found four blocks away with a minor knee abrasion. The wanderguard alarm failed due to an electrical disturbance.
Severity Breakdown
SS=J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision and/or assistive devices to prevent accidents, leading to resident elopement and injury. | SS=J |
Report Facts
Resident census: 56
Staff in-service attendance: 48
Staff in-service non-attendance: 13
Resident elopement duration: 60
Distance resident found from facility: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided information about the resident's elopement and wanderguard alarm status | |
| Administrative Nursing Staff B | Explained the incident and participated in interviews | |
| Licensed Nursing Staff C | Assisted resident outside, failed to notice resident missing during bed check, completed physical assessment after resident was found |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 12, 2018
Visit Reason
A complaint survey was conducted on 3/12/18 for complaint # KS 00127366.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaint # KS 00127366 was investigated and found to be unsubstantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 12, 2018
Visit Reason
A complaint survey was conducted on 3/12/18 for complaint # KS 00127366.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found. The facility is in compliance with all regulations surveyed.
Complaint Details
Complaint # KS 00127366 was investigated and found unsubstantiated with no noncompliance.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 18, 2017
Visit Reason
An offsite visit was completed on 10/18/2017 to verify correction of previous deficiencies cited on 08/24/2017.
Findings
The deficiencies have been corrected and no new non-compliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 9
Sep 19, 2017
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey, outlining corrective actions to address and maintain compliance with federal and state regulations.
Findings
The plan addresses multiple deficiencies including updating residents' bathing preferences and care plans, environmental concerns, medication administration errors, restorative services, timely delivery and temperature of food trays, proper labeling and cleaning of kitchen and medication storage areas, and appropriate storage of urinals and other resident care items.
Severity Breakdown
D: 3
E: 3
F: 3
Deficiencies (9)
| Description | Severity |
|---|---|
| Residents' bathing preferences were not properly documented or reflected in care plans. | D |
| Environmental items needed correction including labeling of personal hygiene items. | E |
| Care plans for several residents were not individualized or up to date. | E |
| Medication administration errors occurred; staff required re-education on medication pass policy. | F |
| Residents with contractures required updated care plans and restorative services. | D |
| Timely delivery and temperature of food and drink items for room trays were inadequate. | D |
| Refrigerators and freezers lacked proper thermometers; expired or unlabeled food items were present. | F |
| Expired and undated medications were found and discarded; medication storage policies needed reinforcement. | F |
| Urinals and other resident care items were improperly stored. | E |
Report Facts
Resident interviews for bathing preferences: 5
Audit frequency for care plans and restorative services: 5
Dietary Manager kitchen audits: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Markus Meyer | Administrator | Administrator who submitted the Plan of Correction |
Inspection Report
Health Resurvey And Complaint Investigation
Census: 54
Deficiencies: 9
Aug 24, 2017
Visit Reason
The inspection was conducted as a Health Resurvey and complaint investigation #120101 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to provide residents with preferred bathing choices, inadequate housekeeping and maintenance services, failure to develop individualized care plans especially related to bathing preferences and restorative services, improper medication administration practices, failure to maintain food at proper temperatures and palatability, unsanitary food storage and preparation areas, expired and improperly stored medications, and inadequate infection control practices.
Complaint Details
The inspection included a complaint investigation identified as #120101.
Severity Breakdown
SS=D: 4
SS=E: 3
SS=F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure residents received preferred bathing choices. | SS=D |
| Failure to provide and maintain a sanitary, orderly, and comfortable interior in resident rooms and facility areas. | SS=E |
| Failure to develop and implement individualized comprehensive care plans related to bathing preferences and restorative services. | SS=E |
| Failure to ensure medication administration competency to prevent medication errors. | SS=F |
| Failure to ensure residents did not experience reduction in range of motion unless unavoidable. | SS=D |
| Failure to serve food that was palatable and at an appetizing temperature. | SS=D |
| Failure to maintain a clean and sanitary dietary department for food storage, preparation, and service. | SS=F |
| Failure to monitor expiration dates of medications and ensure safe storage of drugs and biologicals. | SS=F |
| Failure to provide proper infection control practices to prevent possible contamination. | SS=D |
Report Facts
Residents reviewed for bathing choices: 3
Residents reviewed for restorative services: 3
Expired Bisacodyl suppositories: 31
Residents census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff G | Reported bathing schedules and food delivery issues | |
| Licensed nursing staff C | Verified care plan deficiencies and medication administration practices | |
| Administrative nursing staff B | Verified scheduling practices, medication storage, and expired medications | |
| Dietary staff M | Reported food temperature and sanitation issues | |
| Direct care staff J | Observed medication administration errors and IV kit storage | |
| Consultant staff F | Reported care plan policy and procedures | |
| Direct care staff N | Reported restorative services and range of motion exercises |
Inspection Report
Re-Inspection
Deficiencies: 1
Aug 24, 2017
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a most serious deficiency at an "F" level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2017-09-19.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency at an "F" level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure and Certification Enforcement Manager | Named as contact for questions concerning the information in the letter. |
Inspection Report
Follow-Up
Deficiencies: 3
Dec 18, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.12(b)(1)&(2), 483.25, and 483.25(f)(1) were corrected as of the revisit date.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.12(b)(1)&(2) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(f)(1) |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Nov 18, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiency to be F205, an 'E' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiency F205, 'E' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. | E |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named in relation to the survey findings and contact for questions concerning the information in the letter. |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 3
Nov 18, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#107903) focusing on allegations related to failure to notify residents and families about bed-hold policies upon hospital discharge and concerns about resident care.
Findings
The facility failed to provide written notification of bed-hold policies to residents and families upon hospital discharge. Additionally, the facility did not ensure timely treatment for an oral lesion for one resident and failed to provide appropriate mental health treatment and services for another resident with documented mental health issues.
Complaint Details
The complaint investigation (#107903) found deficiencies related to failure to notify residents and families about bed-hold policies upon hospital discharge and inadequate care for residents including oral lesion treatment and mental health services.
Severity Breakdown
SS=E: 1
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide residents and family members written notification of bed-hold policy upon hospital discharge. | SS=E |
| Failed to ensure timely treatment of an oral lesion for a resident, including lack of biopsy/removal and dentures provision. | SS=D |
| Failed to provide appropriate treatment and services for mental or psychosocial adjustment difficulties for a resident with mental health diagnoses. | SS=D |
Report Facts
Residents reviewed for bed holds: 4
Residents sampled for oral lesion review: 3
Residents sampled for mental health review: 1
Census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff B | Provided list of residents discharged to hospital and reported on bed hold policy and oral lesion treatment efforts | |
| Social services staff L | Discussed oral lesion and denture issues with resident | |
| Administrative staff A | Reported on licensed social worker availability and counseling services | |
| Direct care staff D | Reported resident behavior and mental health observations | |
| Licensed nursing staff C | Reported on resident behavior and mental health treatment awareness | |
| Direct care staff E | Reported resident boredom and behavioral issues |
Inspection Report
Plan of Correction
Deficiencies: 3
Nov 18, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during the DVC Sedgwick complaint investigation dated 11/18/2016.
Findings
The plan outlines corrective actions for deficiencies related to bed-hold policy delivery, dental assessments and care, and PASRR II mental health referrals and care planning. The facility describes steps to ensure compliance, including audits, staff education, and tracking systems.
Complaint Details
This Plan of Correction is in response to deficiencies cited during the DVC Sedgwick complaint investigation dated 11/18/2016.
Severity Breakdown
E: 1
D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to properly deliver and document the Center Bed-Hold Policy to residents and their DPOA/next of kin upon discharge/transfer/leave. | E |
| Failure to assess and address residents' dental needs, including proper nursing assessments and offering on-site dental services. | D |
| Failure to identify residents with PASRR II and complete referrals for mental health counseling and medication management as needed. | D |
Report Facts
Deficiency completion dates: Dec 18, 2016
Audit periods: 90
Inspection Report
Abbreviated Survey
Deficiencies: 1
Jun 9, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found that the facility was not in substantial compliance with participation requirements and that conditions constituted Immediate Jeopardy and Past Non-compliance to resident health or safety for specific regulatory citations.
Severity Breakdown
Immediate Jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Non-compliance with participation requirements constituting Immediate Jeopardy and Past Non-compliance for F223, CFR 483.13(b) and F225, CFR 483.13(c)(1)(ii). | Immediate Jeopardy |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Markus Meyer | Administrator | Named as facility administrator in the report. |
| Caryl Gill | Complaint Coordinator | Signed the letter as Complaint Coordinator. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Jun 9, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#100847) regarding allegations of sexual abuse by a resident towards other residents in the facility.
Findings
The facility failed to protect residents from sexual abuse by a mobile resident who sexually abused two cognitively impaired residents. The facility also failed to provide adequate supervision and timely reporting of the incidents, placing all residents in immediate jeopardy. The facility abated the immediate jeopardy by implementing one-to-one supervision and staff training.
Complaint Details
The complaint investigation found that resident #1 sexually abused residents #2 and #3, both cognitively impaired. The facility failed to provide adequate supervision and failed to report the incidents to the administrator or director of nursing for approximately 41 hours. The facility policy required separation of residents involved in alleged abuse until circumstances were determined. The facility abated immediate jeopardy on 5/17/16 by implementing one-to-one supervision, staff training, and seeking behavioral health services for resident #1.
Severity Breakdown
Level L: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to protect residents from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. | Level L |
| Failure to investigate and report allegations of abuse in a timely manner and failure to prevent further potential abuse during the investigation. | Level L |
Report Facts
Census: 56
Sample size: 3
Time delay in reporting: 41
Medication dosage: 10
Medication dosage: 20
Inspection Report
Plan of Correction
Deficiencies: 18
Feb 7, 2016
Visit Reason
This document is a Plan of Correction submitted by Diversicare of Sedgwick to address and correct deficiencies identified in a prior inspection or survey.
Findings
The plan outlines corrective actions taken or to be taken for multiple deficiencies including resident assessments, notification procedures, abuse/neglect policies, care plan updates, environmental and kitchen sanitation, and staff education. Audits and reviews are scheduled to ensure ongoing compliance and improvement.
Severity Breakdown
D: 11
E: 5
F: 4
C: 1
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to complete assessments and notify physicians on change in condition | D |
| Issues with mail delivery process and resident notification | C |
| Abuse/Neglect/Misappropriation policy violations and investigations | D |
| Incomplete reference and background checks for staff | D |
| Resident bathing preferences not properly documented or followed | D |
| Activity preferences and care plans not updated | D |
| Environmental deficiencies addressed | E |
| Care plans not updated with appropriate interventions | D |
| MDS assessments not properly completed | D |
| Comprehensive care plans not developed or reviewed | E |
| Care plan revisions not properly audited | D |
| Failure to properly document and notify physicians regarding bowel movements and medication adjustments | D |
| Kitchen sanitation issues including opened, unsecured, undated items | F |
| Medication regimen reviews not thoroughly conducted | D |
| Infection control practices and glucometer cleaning deficiencies | E |
| Environmental items needing repair and follow-up | E |
| QAPI process and committee oversight deficiencies | F |
| Resident funds not deposited in financial institution timely | F |
Report Facts
Residents interviewed per month: 10
Weekly audits: 5
3-day voiding patterns started: 3
Nail care date: Jan 11, 2016
Care plan update date: Jan 15, 2016
Environmental audits frequency: 3
Date of staff reference checks: Jan 12, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Janrau | Administrator | Submitted the Plan of Correction |
| Irina Strakhova | Added and modified the Plan of Correction document |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 22
Jan 8, 2016
Visit Reason
Complaint investigation and health re-survey conducted due to concerns including resident care, infection control, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to timely notify physicians of resident condition changes, inadequate mail delivery, incomplete abuse investigations, lack of reference checks for employees, failure to honor resident bathing and activity preferences, environmental maintenance issues, incomplete comprehensive assessments and care plans, inadequate monitoring of medications and vital signs, poor infection control practices, and failure to prevent pressure ulcers and falls.
Complaint Details
Complaint investigation #95791 triggered the health re-survey due to multiple resident care and facility concerns.
Severity Breakdown
SS=F: 1
SS=E: 2
SS=D: 15
: 1
Deficiencies (22)
| Description | Severity |
|---|---|
| Failure to timely notify physician and family of resident's change in condition resulting in hospitalization. | SS=D |
| Failure to ensure residents promptly received mail 6 days per week. | SS=C |
| Failure to thoroughly investigate and report allegations of abuse, neglect, and injuries of unknown origin. | SS=D |
| Failure to obtain reference checks prior to employment for certain staff. | — |
| Failure to provide bathing preferences and frequency for residents. | SS=D |
| Failure to provide individualized ongoing activity programs for residents. | SS=D |
| Environmental maintenance issues including damaged walls, floors, doors, and furniture creating unsanitary and unsafe conditions. | SS=D |
| Failure to complete comprehensive assessments including care area assessments for residents. | SS=D |
| Failure to accurately complete Minimum Data Set (MDS) assessments for care planning. | SS=D |
| Failure to develop comprehensive care plans addressing hydration, side rails, constipation, range of motion, activities, and urinary incontinence. | SS=D |
| Failure to provide necessary care and services to maintain highest practicable well-being including nursing assessment, monitoring, and treatment. | SS=D |
| Failure to provide necessary services to maintain good grooming and personal hygiene. | SS=D |
| Failure to provide treatment and services to promote healing and prevent pressure ulcers. | SS=D |
| Failure to provide appropriate treatment and services to prevent urinary tract infections and restore bladder function. | SS=D |
| Failure to provide restorative services to increase or maintain range of motion for residents with contractures. | SS=D |
| Failure to provide adequate supervision to prevent accidents for a resident with poor safety awareness and history of falls. | SS=D |
| Failure to provide sufficient fluid intake to maintain proper hydration for a dependent resident. | SS=D |
| Failure to monitor drug regimen for irregularities including failure to notify physician of low pulse readings related to cardiac medication. | SS=D |
| Failure to maintain sanitary conditions in food storage, preparation, and serving areas. | SS=E |
| Failure to follow infection control practices including proper cleaning of glucometer, resident care equipment, and hand hygiene. | SS=E |
| Failure to maintain a safe, functional, sanitary, and comfortable environment in laundry and clean utility rooms. | SS=D |
| Failure to maintain an effective quality assessment and assurance committee to identify and correct quality deficiencies. | SS=F |
Report Facts
Residents reviewed: 16
Residents with pressure ulcers reviewed: 5
Days resident went without bowel movement: 6
Days resident went without bowel movement: 8
Days resident went without bowel movement: 6
Days resident went without bowel movement: 6
Pressure ulcer size: 6.8
Pressure ulcer size: 5.9
Pressure ulcer size: 3.4
Pressure ulcer size: 3
Pressure ulcer size: 2
Pressure ulcer size: 1.5
Pressure ulcer size: 1.8
Pressure ulcer size: 0.1
Pressure ulcer size: 1.2
Pressure ulcer size: 1
Pressure ulcer size: 0.2
Pressure ulcer size: 0.4
Pressure ulcer size: 0.2
Pressure ulcer size: 0.1
Pressure ulcer size: 0.9
Pressure ulcer size: 0.5
Pressure ulcer size: 0.2
Pressure ulcer size: 0.6
Pressure ulcer size: 0.3
Pressure ulcer size: 0.1
Braden scale score: 16
Braden scale score: 15
Braden scale score: 14
Braden scale score: 13
Braden scale score: 12
Repositioning interval: 299
Repositioning interval: 160
Repositioning interval: 299
Pulse readings: 39
Pulse readings: 57
Pulse readings: 49
Pulse readings: 57
Pulse readings: 59
Pulse readings: 59
Pulse readings: 44
Pulse readings: 52
Pulse readings: 32
Pulse readings: 56
Pulse readings: 59
Pulse readings: 47
Pulse readings: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Direct Care Staff | Reported cleaning glucometer without proper 2 minute wet time; failed to push resident's overbed table next to bed. |
| Staff N | Licensed Nurse | Reported resident had pressure ulcers; failed to document low pulse notifications; reported resident's nails needed trimming. |
| Staff P | Direct Care Staff | Reported resident needed repositioning and incontinent care every 2 hours; failed to offer fluids and reposition timely. |
| Staff T | Direct Care Staff | Reported resident needed repositioning every 2 hours; failed to offer fluids timely. |
| Staff L | Direct Care Staff | Failed to offer fluids timely; failed to reposition resident timely. |
| Staff F | Activity Staff | Reported resident did not have individualized activity program; failed to plan 1:1 activities. |
| Staff E | Social Services Staff | Reported family concerns about resident's condition and feeding. |
| Staff AA | Licensed Nurse | Reported resident did not receive ordered nausea medication; verified lack of activity instructions. |
| Staff C | Administrative Nursing Staff | Reported failure to timely notify physician; verified lack of care plan revisions; acknowledged infection control failures. |
| Staff O | Administrative Nursing Staff | Reported failure to complete care area assessments; verified lack of restorative program; reported failure to monitor voiding diary. |
| Staff M | Licensed Nurse | Reported resident needed toileting and repositioning every 2 hours; reported failure to monitor bowel movements. |
| Staff B | Administrative Staff | Reported facility failed to identify quality concerns and develop corrective plans. |
| Staff G | Dietary Staff | Reported food items in freezer lacked dates; acknowledged unsanitary kitchen conditions. |
| Staff X | Housekeeping Staff | Failed to change gloves after cleaning toilet before touching keys. |
Inspection Report
Follow-Up
Deficiencies: 3
Sep 17, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously identified deficiencies were corrected by the revisit date of 09/17/2015, with corrections documented for specific regulatory citations.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) |
| Deficiency related to regulation 483.25 |
| Deficiency related to regulation 483.25(h) |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Aug 18, 2015
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective September 17, 2015.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at 'D' level constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary Jane Kennedy | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Plan of Correction
Deficiencies: 4
Aug 18, 2015
Visit Reason
This Plan of Correction document addresses deficiencies cited during a prior complaint-related survey at Diversicare Sedgwick and outlines corrective actions to ensure compliance with state and federal regulations.
Findings
The facility identified deficiencies related to elopement risk management, skin and wound assessments, and reporting suspected abuse or neglect. Corrective actions include staff training, audits of residents at risk for elopement, and modifications to care plans and monitoring procedures.
Complaint Details
This Plan of Correction is related to deficiencies cited during a complaint investigation at Diversicare Sedgwick.
Severity Breakdown
D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Staff members were trained on elopement procedures and reporting suspected abuse, neglect, or exploitation. | D |
| A focus audit was conducted to identify residents at risk for elopement and ensure care plans and sensors were updated accordingly. | D |
| A focus audit was conducted on residents with wounds to assure wound care protocol and assessments were followed. | D |
| The resident found outside without supervision was assessed for elopement risk and appropriate measures were implemented. | D |
Report Facts
Complete Date: Sep 17, 2015
Audit Period: 20
Training Dates: 4
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 4
Aug 18, 2015
Visit Reason
The inspection was conducted based on complaint investigations regarding potential neglect and safety concerns involving residents at the facility.
Findings
The facility failed to thoroughly investigate and report potential neglect related to a diabetic foot ulcer in one resident and an elopement incident involving another resident. The facility also failed to complete weekly skin assessments and provide adequate supervision to prevent a cognitively impaired resident from leaving the building unattended.
Complaint Details
The complaint investigations 89601 and 84516 involved allegations of neglect including a diabetic foot ulcer in resident #1 and an elopement incident involving resident #2 who was found outside the facility unattended.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to thoroughly investigate and report potential neglect related to a diabetic foot ulcer in resident #1. | SS=D |
| Failure to thoroughly investigate and report potential neglect related to elopement of resident #2. | SS=D |
| Failure to provide necessary care and services to maintain highest practicable well-being for residents #1 and #2 related to wound care and elopement. | SS=D |
| Failure to ensure resident environment free of accident hazards and provide adequate supervision to prevent resident #2 from exiting the building unattended. | SS=D |
Report Facts
Resident census: 57
Sample size: 3
Wound measurements: 5
Wound measurements: 1.5
Wound measurements: 2
BIMS score: 15
BIMS score: 8
Inspection Report
Follow-Up
Deficiencies: 10
Oct 17, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers and prefix codes were corrected as of the revisit date, 10/17/2014.
Deficiencies (10)
| Description |
|---|
| Deficiency related to regulation 483.13(a) |
| Deficiency related to regulation 483.15(b) |
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(m)(1) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.70(h) |
| Deficiency related to regulation 483.75(l)(1) |
Report Facts
Deficiencies corrected: 10
Inspection Report
Plan of Correction
Deficiencies: 10
Oct 17, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The Plan of Correction details corrective actions taken or planned for multiple deficiencies including restraint use, bathing schedules, environmental maintenance, medication administration, food safety, and documentation of care. The facility aims to achieve substantial compliance by 10/17/2014.
Severity Breakdown
D: 7
E: 2
F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Resident #31 monitored to ensure restraint use does not exceed 2 hours; physician's order obtained; care plans updated. | D |
| Residents interviewed for bathing schedule preferences; care plans updated accordingly. | D |
| Environmental maintenance including cleaning, repainting, tile replacement, and repairs in resident areas. | E |
| Care plans updated for restraint devices; interdisciplinary team reviews care plans quarterly. | D |
| Residents repositioned every two hours; staff educated on pressure reduction techniques. | D |
| Fall prevention measures including mattress replacement and staff education on fall documentation. | D |
| Staff involved in medication errors re-educated; competencies conducted quarterly. | D |
| Food safety improvements including covering, dating, labeling food items and cleaning schedules. | F |
| Dish room cove base and tiles replaced; ceiling light covers replaced; janitor closet mop sink cleaned. | E |
| Staff educated on documentation of care and use of ROM and splints; documentation monitored weekly. | D |
Report Facts
Date for substantial compliance: Oct 17, 2014
Inspection Report
Enforcement
Deficiencies: 1
Sep 17, 2014
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a most serious deficiency at an 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective October 17, 2014.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency at an 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date of substantial compliance: Oct 17, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Author of the enforcement letter |
| Robin Saffle | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 10
Sep 17, 2014
Visit Reason
The inspection was conducted as a health resurvey and complaint investigations #73169, 73741, 76600, and 76821.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints without physician orders and failure to release restraints timely, failure to ensure residents' right to choose bathing frequency, unsanitary housekeeping and maintenance conditions, incomplete care plans especially regarding physical restraint schedules, failure to prevent and properly treat pressure ulcers, unsafe resident environment with fall hazards, medication errors exceeding 5%, unsanitary food storage and preparation areas, and incomplete documentation of range of motion services.
Complaint Details
The inspection included complaint investigations #73169, 73741, 76600, and 76821.
Severity Breakdown
SS=D: 7
SS=E: 2
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to ensure physical restraint was used only as medically necessary with physician's order and released every 2 hours. | SS=D |
| Failure to ensure residents received the right to choose the frequency of bathing. | SS=D |
| Failure to provide housekeeping and maintenance services to maintain a sanitary and comfortable interior on multiple hallways. | SS=E |
| Failure to develop a comprehensive care plan including instructions for physical restraint release schedule. | SS=D |
| Failure to prevent development and promote healing of a facility acquired pressure ulcer and failure to provide timely position changes. | SS=D |
| Failure to ensure resident environment remained free from accident hazards related to floor/fall mat and bed height. | SS=D |
| Failure to ensure freedom from medication errors; medication error rate was 12% involving 3 residents. | SS=F |
| Failure to maintain a clean and sanitary food storage, preparation, and service environment. | SS=E |
| Failure to maintain a sanitary and comfortable environment including broken tiles, stains, peeling wallpaper, and unclean sinks. | SS=D |
| Failure to maintain complete and accurate clinical records related to range of motion services provided. | SS=D |
Report Facts
Census: 55
Residents reviewed: 16
Medication error rate: 12
Medication errors: 3
Physical restraint duration: 162
Physical restraint duration: 135
Pressure ulcer size: 2.5
Braden score: 16
ROM exercise frequency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Reported restraint use and assisted resident #31 with restraint application and transfer | |
| Staff I | Reported restraint use and assisted resident #31 with restraint application and transfer | |
| Staff M | Licensed nursing staff | Confirmed use of lap devices for positioning and restraint removal schedule |
| Staff B | Administrative nursing staff | Confirmed lack of physician order for restraint and care plan instructions |
| Staff D | Administrative nursing staff | Reported restraint release schedule and care plan deficiencies |
| Staff H | Direct care staff | Reported bathing schedule and restraint application |
| Staff J | Direct care staff | Reported bathing schedule and restraint application |
| Staff K | Direct care staff | Reported bathing schedule and restraint application |
| Staff G | Social service staff | Reported bathing schedule and restraint application |
| Staff U | Licensed staff | Administered incorrect insulin doses and medication |
| Staff T | Direct care staff | Administered wrong medication to resident #60 |
| Staff E | Dietary staff | Reported food storage and sanitation issues |
| Staff F | Maintenance staff | Reported sanitation issues and maintenance concerns |
| Staff N | Housekeeping staff | Reported sanitation issues and maintenance concerns |
| Staff O | Dietary staff | Reported kitchen sanitation issues |
| Staff Z | Direct care staff | Reported restorative exercise practices |
Inspection Report
Life Safety
Deficiencies: 1
Feb 11, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an 'E' level deficiency, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency found was an 'E' level deficiency, pattern, with no harm but potential for more than minimal harm that is not immediate jeopardy. | E |
Report Facts
Denial of payments effective date: May 11, 2014
Provider agreement termination date: Aug 11, 2014
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Robin Saffle | Administrator | Named as facility administrator in the report. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
| Irina Strakhova | Enforcement Coordinator | Signed the report as Enforcement Coordinator. |
Inspection Report
Follow-Up
Deficiencies: 3
Jan 3, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report shows that all previously identified deficiencies with ID prefixes F0309, F0329, and F0425 were corrected as of 01/03/2014.
Deficiencies (3)
| Description |
|---|
| Deficiency with ID prefix F0309 related to regulation 483.25 |
| Deficiency with ID prefix F0329 related to regulation 483.25(l) |
| Deficiency with ID prefix F0425 related to regulation 483.60(a),(b) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 3
Jan 3, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint investigation at Diversicare of Sedgwick.
Findings
The plan addresses deficiencies related to physician orders, behavior/intervention documentation, and medication ordering and delivery processes, with corrective actions including staff in-service training, audits, and interdisciplinary team reviews.
Complaint Details
This Plan of Correction is related to a complaint investigation identified by Event ID 3F3611 and Complaint ID 120413.
Severity Breakdown
D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Physician orders of all new admissions were not correctly entered into the electronic medical record and implemented by staff. | D |
| Inadequate review and documentation of behaviors for residents receiving psychoactive medications. | D |
| Medications were not always ordered correctly or present in the facility. | D |
Report Facts
Correction completion date: Dec 14, 2013
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 3
Dec 4, 2013
Visit Reason
Investigation into complaint #70407 regarding failure to provide necessary care and services to maintain residents' highest practicable well-being, including medication and treatment issues.
Findings
The facility failed to follow physician orders for two sampled residents, did not identify targeted behaviors for psychoactive medications or monitor them effectively for three residents, and failed to ensure timely acquisition and administration of medications for two residents.
Complaint Details
Investigation into complaint #70407 revealed multiple deficiencies related to care and medication management.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to follow physician orders for daily weights and treatment of feeding tube insertion site for residents #1 and #2. | SS=D |
| Failure to identify targeted behaviors for psychoactive medications and lack of routine behavior monitoring for residents #2, #5, and #8. | SS=D |
| Failure to ensure timely acquisition and administration of medications for residents #2 and #8. | SS=D |
Report Facts
Facility census: 56
Sample size: 8
Residents with psychoactive medications reviewed: 3
Days medication not administered: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Interviewed regarding failure to follow physician orders and medication acquisition issues |
| APRN A | Advanced Practice Registered Nurse | Gave new orders for resident #1 including daily weights |
Inspection Report
Follow-Up
Deficiencies: 0
Jun 20, 2013
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit report shows that all previously cited deficiencies identified by regulation numbers 483.20(b)(1), 483.25, 483.25(l), and 483.60(c) were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 4
Inspection Report
Plan of Correction
Deficiencies: 4
Jun 20, 2013
Visit Reason
This Plan of Correction document addresses deficiencies cited during a prior survey of Diversicare of Sedgwick and outlines the facility's corrective actions to ensure compliance with state and federal regulations.
Findings
The facility submitted plans to correct deficiencies related to comprehensive assessments of residents' functional capacity, monitoring of dialysis shunts, and evaluation of psychotropic medication effectiveness. The facility committed to staff training, audits, and Quality Assurance Committee oversight to ensure sustained compliance.
Severity Breakdown
D: 2
E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to conduct initial and periodic comprehensive assessments for each resident's functional capacity and update care plans accordingly. | D |
| Failure to assess and monitor residents' dialysis shunts following dialysis treatment for complications. | D |
| Failure to identify and monitor specific targeted behaviors/indications for residents on psychotropic medications and evaluate medication effectiveness and necessity. | E |
| Failure to ensure pharmacist identification and review of targeted behaviors/indications for residents on psychotropic medications and evaluate medication effectiveness and necessity. | E |
Report Facts
Deficiency completion date: Jun 20, 2013
Mandatory in-service date: Jun 13, 2013
Residents referenced: 11
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 4
May 29, 2013
Visit Reason
Annual health resurvey of Diversicare of Sedgwick to assess compliance with comprehensive assessments, care and services, drug regimen review, and psychotropic medication monitoring.
Findings
The facility failed to conduct comprehensive assessments for cognition, urinary incontinence, and ADLs for some residents, and failed to monitor a resident post-dialysis for complications. Additionally, the facility did not adequately identify or monitor specific behaviors related to psychotropic medications for multiple residents, and the pharmacist failed to report irregularities related to medication indications and monitoring.
Severity Breakdown
SS=D: 2
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to conduct comprehensive assessments of cognition, urinary incontinence, and ADLs for some residents, including inadequate Care Area Assessments (CAAs). | SS=D |
| Failure to assess and monitor a resident for complications upon return from dialysis treatment. | SS=D |
| Failure to identify and monitor specific behaviors related to psychotropic medications for 9 of 10 sampled residents. | SS=E |
| Pharmacist failed to report irregularities related to lack of indications for use or targeted behaviors for psychoactive medications for multiple residents. | SS=E |
Report Facts
Residents sampled for comprehensive assessments: 19
Residents receiving dialysis: 1
Residents sampled for medication regimen review: 10
Resident census: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Consultant M | Pharmacist Consultant | Reported being new to the facility and reviewed psychoactive medications and lab results, but had limited discussion on monitoring behaviors or care planning. |
| Consultant N | Previous Pharmacist Consultant | Reported facility had a good process for monitoring psychoactive medications and worked on reducing psychotropic medication use. |
| Administrative nurse staff A | Reported expectations for behavior monitoring forms and documentation in nurse, social service, and activity notes. | |
| Administrative Nurse I | Reported expectations for care plans to include typical behaviors monitored, side effects, and non-pharmacological interventions. | |
| Licensed nurse D | Reported expectations that direct care staff report behaviors and documented that direct care staff should document behaviors in ADL charting. | |
| Direct care staff O | Reported lack of knowledge of medications and behaviors to monitor, would report changes to nurse. | |
| Direct care staff C | Reported not monitoring residents for side effects or behaviors, stating it was the nurses and CMA's job. | |
| Direct care staff L | Lacked knowledge of specific behaviors to monitor for a resident. | |
| Direct care staff J | Reported monitoring for drowsiness and alertness but not documenting behaviors when residents became combative. | |
| Direct care staff Q | Reported monitoring behaviors in old computer system and reporting to nurse or MDS coordinator. | |
| Licensed nurse R | Reported resident had no recent behaviors but used to steal cigarettes. |
Inspection Report
Follow-Up
Deficiencies: 2
Oct 26, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report shows that deficiencies identified under regulations 483.20(d), 483.20(k)(1), and 483.25(h) were corrected as of 08/20/2012.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.20(d), 483.20(k)(1) |
| Deficiency related to regulation 483.25(h) |
Report Facts
Correction completion date: Aug 20, 2012
Inspection Report
Plan of Correction
Deficiencies: 2
Aug 20, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint-related survey at the facility.
Findings
The facility addressed deficiencies related to developing comprehensive care plans for personal alarm use and providing an environment free of accident hazards with adequate supervision and assistive devices to prevent accidents. The facility implemented training, updated policies, and established audit and monitoring procedures to ensure compliance.
Complaint Details
This Plan of Correction is related to a complaint investigation identified by Event ID X9HR11 and Sedgwick Health 080112 Complaint. The facility responded to credible allegations of noncompliance.
Severity Breakdown
D: 1
G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop comprehensive care plans including goals and timetables for personal alarm use. | D |
| Failure to provide an environment free of accident hazards with adequate supervision and assistive devices to prevent accidents. | G |
Report Facts
In-service training dates: 2
Audit reporting period: 3
Weekly checklist duration: 4
Elopement drill frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Crowley | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 2
Aug 1, 2012
Visit Reason
The inspection was conducted as a result of complaint investigations #58134, 58175, and 58726 focusing on resident care and safety issues.
Findings
The facility failed to develop a comprehensive care plan with goals and timetables for a resident's personal alarm use and failed to provide adequate supervision and assistive devices to prevent accidents, resulting in a resident sustaining a fractured hip from a fall and another resident eloping unattended on three occasions.
Complaint Details
The visit was complaint-related, investigating allegations of inadequate care planning and supervision leading to resident falls and elopements.
Severity Breakdown
SS=D: 1
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to develop a comprehensive care plan including goals and timetables for a resident's personal alarm use. | SS=D |
| Failed to ensure adequate supervision and assistive devices to prevent accidents for two residents, resulting in a fractured hip and multiple elopements. | SS=G |
Report Facts
Residents reviewed: 3
Fall risk assessment score: 9
Fall risk assessment score: 11
Skin tear size: 7
Skin tear size: 3
Elopement incidents: 3
Temperature: 100
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed administrative staff B | Provided statements regarding resident falls and elopement incidents | |
| Direct care staff D | Reported resident fall incident and alarm use | |
| Licensed staff C | Reported on alarm use and supervision during resident fall | |
| Licensed staff E | Verified alarm use and resident supervision details | |
| Direct care staff F | Described resident transfer and alarm use | |
| Direct care staff G | Described alarm use on resident | |
| Administrative staff A | Reported on facility policies and elopement risk interventions |
Inspection Report
Plan of Correction
Deficiencies: 3
N040007 POC 7RP411
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Diversicare Sedgwick.
Findings
The Plan of Correction addresses deficiencies identified by KDADS, with corrective actions cross-referenced to specific deficiency tags F0000, F223-L, and F225-L.
Complaint Details
This Plan of Correction is related to a complaint investigation as indicated by the reference to the Diversicare Sedgwick complaint revised 06092016.
Deficiencies (3)
| Description |
|---|
| Deficiency referenced by tag F0000 |
| Deficiency referenced by tag F223-L |
| Deficiency referenced by tag F225-L |
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