Inspection Reports for
Diversicare of Sedgwick
712 N. MONROE AVENUE, SEDGWICK, KS, 67135
Back to Facility ProfileDeficiencies (last 13 years)
Deficiencies (over 13 years)
24.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
313% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
80% occupied
Based on a September 2025 inspection.
Occupancy rate over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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 from the prior inspection have been corrected as of 2025-09-25, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 16, 2025
Visit Reason
The document is a Plan of Correction submitted by the facility in response to deficiencies cited during an inspection.
Findings
The Plan of Correction addresses an inappropriate discharge deficiency, including documentation provided by a physician and corrective actions such as audits and staff re-education.
Deficiencies (1)
F627: Documentation was provided by Resident 1's physician for the immediate involuntary discharge. The facility conducted audits and provided re-education on discharge documentation requirements.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Sep 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure proper physician documentation for an involuntary immediate discharge of a resident with complex behavioral and mental health issues.
Complaint Details
The complaint investigation focused on Resident 1's involuntary discharge due to behavioral and safety concerns. The discharge was unplanned and lacked physician documentation supporting the transfer, raising concerns about resident rights and safety. The complaint was substantiated with findings of minimal harm.
Findings
The facility failed to ensure that Resident 1's electronic health record contained physician documentation justifying the involuntary discharge. The resident exhibited severe behavioral symptoms and safety risks, leading to an unplanned discharge to a hospital, but the facility lacked adequate physician documentation supporting the transfer.
Deficiencies (1)
F 0627: Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. The facility failed to provide physician documentation of the rationale for Resident 1's involuntary immediate discharge, placing the resident at risk for impaired rights and inappropriate discharge.
Report Facts
Residents present: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Entered physician order for Resident 1's transfer/discharge |
| Administrative Staff A | Administrative Staff | Signed discharge letter for Resident 1 |
| Administrative Staff B | Administrative Staff | Interviewed regarding Resident 1's discharge and facility expectations |
| Physician DD | Physician | Documented exam and observations of Resident 1's behaviors |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Sep 9, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations of inappropriate discharge of a resident from the facility.
Complaint Details
The complaint investigations 2605163, 2598557, 1596702, and 1596693 were the basis for this survey. The complaint involved concerns about the involuntary discharge of Resident 1 without proper physician documentation and failure to meet discharge requirements.
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, but physician documentation supporting the discharge rationale was absent.
Deficiencies (1)
F0627 Inappropriate Discharge: The facility failed to ensure physician documentation of the rationale for Resident 1's involuntary immediate discharge, risking impaired rights and inappropriate discharge.
Report Facts
Census: 48
Resident sample size: 6
Dates: 06/26/25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff B | Interviewed regarding Resident 1's discharge and facility's efforts. | |
| Administrative Nurse D | Entered physician order for Resident 1's transfer/discharge and was notified during behavioral incident. | |
| Physician Extender EE | Physician Extender | Documented order to transfer/discharge Resident 1 to Emergency Department. |
| Physician DD | Physician | Documented exam of Resident 1 and noted behavioral concerns. |
| Social Services Designee X | Social Services Designee | Notified Resident 1's representative of emergency transfer/discharge. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
A revisit survey and complaint investigation was conducted to verify correction of all previous deficiencies cited on 2025-05-15.
Complaint Details
The visit was complaint-related under investigation numbers KS00195538 and KS00195340. All deficiencies from the complaint investigation were corrected.
Findings
All previously cited deficiencies have been corrected as of 2025-06-12, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 7
Date: May 15, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide appropriate care and services to residents, including failure to manage symptoms, provide restorative care, monitor feeding tubes, implement trauma-informed care, conduct annual staff evaluations, maintain infection control, and ensure a safe environment.
Complaint Details
The investigation was complaint-driven, focusing on failures in care for multiple residents including medication management, restorative care, nutrition monitoring, trauma-informed care, staff evaluations, infection control, and environmental safety. Immediate jeopardy was identified related to Resident 29's diabetes care.
Findings
The facility failed to promptly identify and respond to changes in a diabetic resident's condition, provide adequate restorative care to a resident in a vegetative state, monitor weight for a resident with a feeding tube, implement trauma-informed care for a resident with PTSD, complete annual performance evaluations for nursing aides, maintain infection control practices, and ensure a safe and clean environment in the laundry area.
Deficiencies (7)
F684: The facility failed to provide necessary care for Resident 29 with diabetes by not notifying the physician of medication refusals and dangerously high blood glucose levels, resulting in immediate jeopardy.
F688: The facility failed to provide adequate restorative care including application of splints for Resident 21 in a persistent vegetative state, risking increased pain and contractures.
F693: The facility failed to ensure Resident 21, fed by enteral means, received appropriate treatment by not routinely monitoring weight as ordered, risking continued weight loss and malnutrition.
F699: The facility failed to develop and implement trauma-informed care approaches for Resident 12 with PTSD and substance abuse history, risking decreased quality of life and re-traumatization.
F730: The facility failed to complete annual performance evaluations for two Certified Nurse Aides employed for over a year, risking inadequate resident care.
F880: The facility failed to implement infection control standards during direct care and laundry services, including improper glove use and catheter care, risking resident infections.
F921: The facility failed to maintain a safe, clean, and comfortable environment in the laundry area, including exposed light fixtures, cracked ceilings, standing water, lint accumulation, and lack of maintenance policies, risking contaminated laundry and fires.
Report Facts
Resident census: 42
Sample size: 15
Blood glucose level: 388
Blood glucose level: 513
Medication refusal count: 2
Weight: 153.3
Weight: 144.6
Certified Medication Aide hire date: Feb 12, 2021
Certified Medication Aide hire date: May 8, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in medication and charting issues related to Resident 29 |
| LN I | Licensed Nurse | Reported charting practices and provider notification for Resident 29 |
| Administrative Nurse C | Administrative Nurse | Verified charting practices, facility protocols, and infection control expectations |
| LN F | Licensed Nurse | Reported standing orders and notification instructions for Resident 29 |
| Therapy Staff LL | Therapy Staff | Reported restorative program status and located splints for Resident 21 |
| Administrative Nurse E | Administrative Nurse | Discussed restorative program initiation and training |
| Social Services Staff FF | Social Services Staff | Reported on trauma-informed care and PTSD diagnosis for Resident 12 |
| CMA M | Certified Medication Aide | Employee with incomplete annual performance evaluation |
| CMA N | Certified Medication Aide | Employee with overdue annual performance evaluation and infection control observation |
| CNA T | Certified Nurse Aide | Observed in infection control deficiencies and restorative care |
| CNA U | Certified Nurse Aide | Observed in catheter bag handling during transfer |
| Maintenance Staff QQ | Maintenance Staff | Reported on laundry area conditions and maintenance |
| Administrative Staff A | Administrative Staff | Received Immediate Jeopardy notification and reported on PTSD diagnosis coordination |
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 7
Date: May 15, 2025
Visit Reason
The inspection was conducted as an annual survey of the nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate care for residents with diabetes, inadequate restorative care, failure to monitor feeding tube residents' weights, lack of trauma-informed care, incomplete annual staff evaluations, infection control lapses, and unsafe environmental conditions in the laundry area.
Deficiencies (7)
F 0684: The facility failed to promptly identify and respond to a change in condition for Resident 29 with diabetes mellitus, resulting in immediate jeopardy due to failure to notify the physician of medication refusals and dangerously high blood glucose levels.
F 0688: The facility failed to provide adequate restorative care for Resident 21 in a persistent vegetative state, including failure to apply wrist splints and conduct range of motion exercises, placing the resident at risk for pain and contractures.
F 0693: The facility failed to monitor Resident 21's weight as ordered, resulting in risk for continued weight loss and malnutrition related to enteral feeding.
F 0699: The facility failed to develop and implement trauma-informed care approaches for Resident 12 with a history of trauma and substance abuse, placing the resident at risk for decreased quality of life and re-traumatization.
F 0730: The facility failed to complete annual performance evaluations for two Certified Nurse Aides employed for over a year, risking inadequate resident care.
F 0880: The facility failed to implement proper infection control practices during direct care and laundry services, including improper glove use, contaminated linens, and improper catheter bag handling, placing residents at risk for infections.
F 0921: The facility failed to maintain a safe and clean environment in the laundry area, including exposed light fixtures, cracked ceilings, standing water drains, lint accumulation, and lack of maintenance policies, creating risks for contaminated laundry and fires.
Report Facts
Resident census: 42
Sample size: 15
Blood glucose levels: 388
Blood glucose levels: 513
Weight: 145
Weight: 153.3
Weight: 144.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in medication refusal and charting issues related to Resident 29 |
| LN I | Licensed Nurse | Reported charting practices and provider notification for Resident 29 |
| Administrative Nurse C | Administrative Nurse | Verified charting and notification policies, infection control expectations |
| Therapy Staff LL | Therapy Staff | Reported restorative program status and splint location for Resident 21 |
| Administrative Nurse E | Administrative Nurse | Reported restorative program initiation and training status |
| Social Services Staff FF | Social Services Staff | Reported on trauma-informed care and PTSD diagnosis for Resident 12 |
| CMA M | Certified Medication Aide | Named in incomplete annual performance evaluation |
| CMA N | Certified Medication Aide | Named in incomplete annual performance evaluation and infection control observations |
| CNA T | Certified Nurse Aide | Named in infection control observations |
| Licensed Nurse KK | Licensed Nurse | Provided information on infection control and weight monitoring |
| Maintenance Staff QQ | Maintenance Staff | Reported on laundry area maintenance and environmental conditions |
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 7
Date: May 15, 2025
Visit Reason
The inspection was conducted as an Extended Health Recertification Survey and complaint survey regarding allegations involving Resident 29's care and other facility concerns.
Complaint Details
The complaint investigation was triggered by allegations related to Resident 29's care, specifically medication refusals and failure to notify the physician of dangerously high blood glucose levels, resulting in immediate jeopardy.
Findings
The facility failed to provide necessary care for Resident 29, who had diabetes mellitus, resulting in immediate jeopardy due to failure to notify the physician of medication refusals and dangerously high blood glucose levels. Additional deficiencies included failure to provide restorative care for Resident 21, inadequate monitoring of enteral feeding and weight, lack of trauma-informed care for Resident 12, incomplete annual nurse aide performance reviews, and infection control and environmental safety issues in the laundry area.
Deficiencies (7)
F684 Quality of Care: The facility failed to identify and respond to changes in Resident 29's medical condition, including medication refusals and high blood glucose levels, placing the resident in immediate jeopardy.
F688 Mobility: The facility failed to provide adequate restorative care including use of splints for Resident 21, placing the resident at risk for increased pain and contractures.
F693 Tube Feeding Management: The facility failed to monitor Resident 21's weight routinely as ordered, risking continued weight loss and malnutrition.
F699 Trauma Informed Care: The facility failed to develop and implement trauma-informed care approaches for Resident 12, risking decreased quality of life and re-traumatization.
F730 Nurse Aide Performance Review: The facility failed to complete annual performance reviews for two of three certified nurse aides employed for a year or more.
F880 Infection Prevention and Control: The facility failed to implement infection control practices during direct care and laundry services, placing residents at risk for infections.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to ensure a safe environment in the laundry area, including exposed light fixtures, peeling paint, lint accumulation, and open drains, creating risks for contaminated laundry and fires.
Report Facts
Resident census: 42
Resident sample size: 15
Blood glucose level: 388
Blood glucose level: 513
Weight: 145
Weight: 153.3
Weight: 144.6
Certified Nurse Aides reviewed: 5
Certified Nurse Aides with annual evaluations reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN G | Licensed Nurse | Named in medication error finding and terminated after investigation |
| LN I | Licensed Nurse | Reported charting practices and provider notifications |
| LN F | Licensed Nurse | Reported standing orders and medication refusal notification |
| CNA T | Certified Nurse Aide | Observed during infection control deficiencies and restorative care |
| CMA N | Certified Medication Aide | Observed during infection control deficiencies |
| Therapy Staff LL | Therapy Staff | Reported restorative program issues and splint management |
| Administrative Nurse C | Administrative Nurse | Verified findings and provided interviews on multiple deficiencies |
| Administrative Nurse E | Administrative Nurse | Reported restorative program status and plans |
| Social Services Staff FF | Social Services Staff | Reported on trauma-informed care and PTSD evaluation |
| Maintenance Staff QQ | Maintenance Staff | Reported on laundry area maintenance and environmental issues |
Inspection Report
Plan of Correction
Deficiencies: 7
Date: May 15, 2025
Visit Reason
This document is a Plan of Correction submitted by Diversicare of Sedgwick RS following an inspection conducted on 05/15/2025. It outlines corrective actions to address cited deficiencies.
Findings
The plan 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.
Deficiencies (7)
F684 Quality of Care: Resident R29 was transported to the hospital for evaluation. All residents with diabetes were audited for condition changes and physician notification.
F688 Increase/Prevent Decrease in ROM/Mobility: An OT evaluation was ordered for resident R21 for contracture management. Residents at risk will be reassessed and staff educated on splint application.
F693 Tube Feeding Management/Restore Eating Skills: Resident R21's weight order was updated. All residents on enteral nutrition were audited for appropriate weight monitoring orders.
F699 Trauma Informed Care: Resident R12's care plan was updated with trauma-related triggers and interventions. Staff were educated on trauma-informed care and audits will be conducted.
F730 Nurse Aide Perform Review: Two CNA team members had annual performance reviews completed. All team members were audited for timely reviews.
F880 Infection Prevention & Control: Resident R21's catheter tubing was immediately placed below the bladder. Staff were educated on catheter care and hygiene. Environmental improvements were made to eliminate standing water and maintain clean linen areas.
F921 Safe/Functional/Sanitary/Comfortable Environment: Maintenance replaced light fixtures and repaired ceilings in laundry area. Housekeeping schedules were modified and staff educated to ensure a safe and sanitary environment.
Report Facts
Audit frequency: 5
Inspection date: May 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rayna Bittel | Administrator | Submitted the Plan of Correction |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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 prior inspection have been corrected as of 08/25/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Census: 40
Deficiencies: 16
Date: Jul 19, 2023
Visit Reason
The survey was conducted as a health resurvey and complaint investigation to assess compliance with regulatory requirements.
Findings
The facility had multiple deficiencies including failure to maintain a safe, sanitary, and homelike environment, inadequate care plan revisions, insufficient ADL care, unsafe wheelchair use, inadequate pain management, insufficient staffing, incomplete staff competency reviews, failure to follow up on pharmacy recommendations, improper medication management, unsanitary food storage and preparation, ineffective infection control, and failure to offer COVID-19 vaccinations per CDC guidelines.
Deficiencies (16)
F584 The facility failed to ensure a safe, sanitary, and homelike environment in seven resident rooms, including issues with missing paint, broken floor tiles, unclean privacy curtains, improper food storage, and a bed frame without a mattress.
F657 The facility failed to review and revise care plans for residents regarding psychotropic medication monitoring, wheelchair foot pedal use, individualized toileting, and behavioral interventions.
F677 The facility failed to provide adequate facial grooming for two residents, ensure one resident changed into clean clothing, and assist one resident to get out of bed and dressed for the entire day.
F689 The facility failed to ensure wheelchair foot pedals were used for two residents, failed to provide safe upper extremity positioning for one resident in a wheelchair, and failed to provide safe transfers for one resident.
F690 The facility failed to provide timely toileting for one dependent resident and failed to complete a 72-hour voiding diary to assist in developing an individualized toileting program.
F695 The facility failed to ensure the humidifier water bottle on one resident's oxygen concentrator was not allowed to run dry.
F697 The facility failed to provide adequate pain relief for one resident who repeatedly complained of pain related to an indwelling urinary catheter.
F725 The facility failed to ensure sufficient qualified nursing staff were available at all times to meet residents' needs safely and promote their well-being.
F730 The facility failed to complete annual competency performance reviews for five Certified Nurse Aides and Certified Medication Aides.
F756 The facility failed to follow up on pharmacy recommendations for two residents regarding unnecessary medications.
F757 The facility failed to ensure one resident was kept free from unnecessary medications by failing to notify the physician of blood sugars outside ordered parameters.
F758 The facility failed to ensure two residents had required Abnormal Involuntary Movement Scale assessments when receiving antipsychotic medications and failed to provide a gradual dose reduction for one resident.
F812 The facility failed to store, prepare, and serve food in a sanitary manner, including failure to wear hairnets, dirty reach-in refrigerators and freezers, and unclean plastic drawers containing cooking utensils.
F867 The facility failed to ensure the Quality Assurance Performance Improvement program identified and corrected resident care and environmental issues in a timely and effective manner.
F880 The facility failed to maintain an effective infection control program, including incomplete infection tracking logs, improper storage of personal protective equipment, and housekeeping staff not following cleaning product dwell times.
F887 The facility failed to offer residents COVID-19 vaccinations per CDC guidelines, with many residents lacking updated booster doses.
Report Facts
Residents sampled: 16
Residents reviewed for bowel and bladder: 3
Residents reviewed for respiratory care: 3
Residents reviewed for pain: 2
Residents reviewed for unnecessary medications: 5
Residents reviewed for immunizations: 5
Staff on night shift: 3
Blood sugars above ordered parameters: 6
Inspection Report
Plan of Correction
Deficiencies: 16
Date: Jul 19, 2023
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a survey conducted on 2023-07-19. It outlines corrective actions to address identified deficiencies and ensure ongoing compliance with regulations.
Findings
The Plan of Correction addresses multiple deficiencies including environmental issues, care plan reviews, ADL care needs, upper extremity safety, toileting assistance, medication management, staffing, infection control, and COVID-19 vaccination offerings. The facility has implemented education, audits, and ongoing monitoring to correct and prevent recurrence of these issues.
Deficiencies (16)
F584-E Environmental items on the statement of deficiencies have been addressed with maintenance and housekeeping, including repairs to resident rooms and replacement of privacy curtains and mattresses.
F657-D Resident #13 care plans have been reviewed and revised, with ongoing audits planned to ensure compliance with RAI guidelines.
F677-E Residents #10, #7, #4, and #34 received facial grooming, clean clothing, and assistance with ADL care needs, with education provided to staff and audits planned.
F689-E Residents #24, #7, and #34 were provided foot petals and wheelchair assessments, with education on upper extremity safety and audits planned.
F690-D Residents #8 and #30 received toileting assistance and individualized toileting programs, with staff education and audits planned.
F695-D Resident #R10 humidifier bottle was replaced and all residents requiring humidification were provided appropriate care, with staff education and audits planned.
F697-D Resident #R10 was assessed and provided pain relief, with education on pain assessment and audits planned.
F725-F Staffing schedules have been reviewed and adjusted to meet resident needs, with re-education of interdisciplinary team and ongoing audits.
F730-F All nurse aides have had performance reviews, with education provided and audits planned.
F756-D Resident #R34 was reviewed for unnecessary medications and pharmacy recommendations were followed up, with staff education and audits planned.
F757-D Resident #R4 was evaluated for blood glucose levels outside ordered parameters, with physician notification and staff education completed.
F758-D Residents #34 and #36 had AIMS assessments completed for antipsychotic medications, with education and audits planned.
F812-F The dietary manager performed deep cleaning of kitchen equipment and educated staff on sanitary food handling, with sanitation audits planned.
F867-F QAPI was completed to include effective action plans to timely identify and correct infractions related to residents' environment and care.
F880-F Accurate tracking and trending of infections has been completed, with education on sanitary storage and cleaning protocols and audits planned.
F887-E Residents were offered COVID-19 vaccinations according to CDC guidelines, with staff education and audits planned to ensure compliance.
Report Facts
Audit frequency: 4
Audit duration: 3
Inspection Report
Annual Inspection
Census: 40
Deficiencies: 6
Date: Jul 19, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements and quality of care at Diversicare of Sedgwick nursing home.
Findings
The facility failed to provide adequate assistance with activities of daily living including grooming, dressing, toileting, and positioning for several residents. Staffing levels were insufficient to meet resident needs safely. The facility also failed to complete required staff competency evaluations, maintain an effective infection control program, and implement an effective Quality Assurance Performance Improvement (QAPI) program.
Deficiencies (6)
F 0677: The facility failed to provide facial grooming for two residents, ensure one resident changed into clean clothing, and get one resident out of bed and dressed for the entire day.
F 0690: The facility failed to provide timely toileting for one dependent incontinent resident and failed to complete a 72-hour voiding diary to assist in developing an individualized toileting program.
F 0725: The facility failed to ensure sufficient qualified nursing staff were available at all times to meet residents' needs safely and promote their well-being.
F 0730: The facility failed to complete annual competency performance reviews for five Certified Nurse Aides and Certified Medication Aides to ensure adequate care.
F 0867: The facility failed to ensure the Quality Assurance Performance Improvement program identified and corrected resident care and environmental issues effectively.
F 0880: The facility failed to maintain an effective infection control program, including missing infection tracking logs, improper storage of supplies, and housekeeping staff not following cleaning product dwell times.
Report Facts
Census: 40
Residents sampled: 16
Certified Nurse Aides and Certified Medication Aides lacking annual review: 5
Facility staff postings: 1
Facility staff postings: 4
Inspection Report
Routine
Census: 40
Deficiencies: 16
Date: Jul 19, 2023
Visit Reason
Routine inspection of Diversicare of Sedgwick nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility had multiple deficiencies including unsafe and unsanitary resident environments, incomplete care plans, inadequate assistance with activities of daily living, unsafe wheelchair use, insufficient staffing, incomplete staff competency evaluations, failure to follow pharmacy recommendations, inadequate infection control, and failure to offer COVID-19 vaccinations per CDC guidelines.
Deficiencies (16)
F584: The facility failed to ensure a safe, sanitary, and homelike environment for residents in seven rooms, including issues with missing paint, broken floor tiles, unclean privacy curtains, and improper food storage.
F657: The facility failed to review and revise care plans for residents related to psychotropic medication monitoring, wheelchair foot pedal use, and behavioral interventions.
F677: The facility failed to provide adequate facial grooming, clean clothing, and assistance with dressing and positioning for several residents.
F689: The facility failed to ensure safe wheelchair use by not providing foot pedals, improper upper extremity positioning, and unsafe transfer techniques for residents.
F690: The facility failed to provide timely toileting and lacked an individualized toileting program for a dependent incontinent resident.
F695: The facility failed to ensure the humidifier bottle on a resident's oxygen concentrator was maintained with water and did not run dry.
F697: The facility failed to provide adequate pain relief for a resident complaining of pain related to an indwelling urinary catheter.
F725: The facility failed to ensure sufficient qualified nursing staff were available at all times to meet residents' needs safely.
F730: The facility failed to complete annual competency performance reviews for five CNAs and CMAs to ensure adequate care.
F756: The facility failed to follow up on pharmacy recommendations for gradual dose reduction of antipsychotic medications for two residents.
F757: The facility failed to notify a resident's physician of blood sugars outside ordered parameters to allow medication adjustment.
F758: The facility failed to perform Abnormal Involuntary Movement Scale (AIMS) assessments for two residents on antipsychotic medications.
F812: The facility failed to store, prepare, and serve food in a sanitary manner, including failure to wear hairnets and clean kitchen equipment.
F867: The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program to identify and correct resident care and environmental issues.
F880: The facility failed to maintain an effective infection control program, including incomplete infection tracking logs, improper storage of supplies, and inadequate housekeeping knowledge of cleaning protocols.
F887: The facility failed to offer COVID-19 vaccinations to residents per CDC guidelines, with no vaccinations offered since January 2022.
Report Facts
Resident census: 40
Residents sampled: 16
Staff daily postings: 1
Staff daily postings: 4
Missing infection control logs: 3
Blood sugar readings above 350: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Provided multiple statements regarding expectations for care plans, staffing, infection control, and medication management |
| Licensed Nurse G | Licensed Nurse | Interviewed regarding care plan expectations, pain management, and wheelchair safety |
| Certified Nurse Aide M | Certified Nurse Aide | Observed providing care and interviewed regarding resident positioning and toileting |
| Certified Medication Aide T | Certified Medication Aide | Mentioned in pain management and resident care observations |
| Consultant Nurse II | Consultant Nurse | Interviewed regarding antipsychotic medication monitoring and COVID-19 vaccination |
| Dietary Staff BB | Dietary Staff | Interviewed regarding kitchen sanitation and hairnet policy |
| Maintenance Staff U | Maintenance Staff | Interviewed regarding environmental sanitation and supply storage |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 13, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-03-15.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date 2022-03-16, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 16, 2022
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
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 facility outlines corrective actions including re-education of nursing staff and ongoing audits.
Deficiencies (1)
F695-D: Resident R99’s and R17’s oxygen humidifier bottles, tubing, and cannulas were changed on 3/16/2022 by nursing staff. The nursing department was re-educated on proper storage, dating, and changing of oxygen nebulizer supplies, with audits planned for compliance.
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 1
Date: Mar 15, 2022
Visit Reason
This inspection was a Non-Compliance Revisit to verify correction of previous deficiencies related to respiratory/tracheostomy care and suctioning.
Findings
The facility failed to provide sanitary measures to prevent respiratory infections for two residents by not properly storing oxygen nasal cannula tubing, failing to date tubing and humidifier bottles, and failing to change oxygen tubing as required. These failures increased the residents' risk of respiratory infection.
Deficiencies (1)
Respiratory care regulation 483.25(i): The facility failed to properly store oxygen nasal cannula tubing, date tubing and humidifier bottles, and change oxygen tubing for two residents, increasing risk of respiratory infections.
Report Facts
Resident census: 47
Residents reviewed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Staff A | Provided statements regarding oxygen tubing replacement expectations and storage | |
| Licensed Nurse G | Licensed Nurse | Provided information about oxygen tubing change procedures and lack of current process knowledge |
| Certified Medication Aide R | Certified Medication Aide | Confirmed oxygen tubing storage practices and dated tubing |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Feb 15, 2022
Visit Reason
This document is a Plan of Correction submitted by the facility to address deficiencies identified in a prior inspection report.
Findings
The plan outlines corrective actions for multiple deficiencies related to medication administration, nail care, wound care, pressure ulcer interventions, IV fluid administration, oxygen equipment storage, medical record documentation, and environmental maintenance. The facility has re-educated staff, implemented audits, and scheduled ongoing monitoring to ensure compliance.
Deficiencies (8)
F609-D Resident R7’s antibiotics and Resident R10’s IV fluids were administered as ordered. Staff were re-educated on abuse/neglect policies and medication administration audits will be conducted.
F677-D Resident R23 received nail care and all residents’ nail care was assessed and provided. Staff were re-educated and audits of nail care completion and documentation will be conducted.
F684-G Resident R7’s antibiotics were administered as ordered. Wound care was assessed and treatments completed. Staff were re-educated and audits of antibiotic orders and wound care will be conducted.
F686-D Residents with pressure ulcers were reassessed and interventions implemented. Staff were re-educated on skin care and wound documentation. Audits of wound documentation and skin assessments will be conducted.
F694-D Resident R10’s IV fluids were administered as ordered. Staff were re-educated on IV fluid administration and audits will be conducted to ensure compliance.
F695-D Oxygen humidifier bottles, tubing, and cannulas were changed and stored properly. Staff were re-educated and audits of oxygen equipment storage and changing will be conducted.
F842-D Resident R29’s medical record was updated for a mammogram request. Staff were re-educated on accurate medical record documentation and audits will be conducted.
F921-E Environmental repairs were completed or scheduled. Maintenance staff were educated on environmental rounds and audits will be conducted to monitor conditions.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 8
Date: Jan 11, 2022
Visit Reason
The inspection was conducted as a Health Resurvey, Extended Health Resurvey, and Complaint Investigation related to concerns of abuse, neglect, exploitation, medication errors, and quality of care.
Complaint Details
The complaint investigation involved allegations of abuse, neglect, and exploitation related to medication errors, failure to provide ordered treatments, and failure to maintain a safe environment.
Findings
The facility failed to complete investigations and report incidents of neglect related to medication errors, failed to provide necessary personal hygiene and wound care services, failed to administer IV fluids as ordered, failed to maintain respiratory equipment properly, failed to maintain accurate and complete medical records, and failed to maintain a safe and sanitary environment in the laundry area.
Deficiencies (8)
F 609: The facility failed to investigate and report incidents of neglect involving missed IV antibiotic doses for Resident 7 and delayed administration of IV fluids for Resident 10 within required timeframes.
F 677: The facility failed to provide necessary personal hygiene services related to nail care for Resident 23, resulting in long fingernails despite care plan instructions.
F 684: The facility failed to provide ordered IV antibiotic treatment for four days for Resident 7, resulting in worsening of a surgical wound and infection, and failed to provide consistent wound care and monitoring for Resident 4 with multiple wounds.
F 686: The facility failed to provide necessary treatment and services to promote healing of pressure ulcers for Residents 4 and 17, including failure to provide ordered wound care treatments and weekly wound evaluations.
F 694: The facility failed to administer IV fluids as ordered for Resident 10, delaying stat fluids for over 24 hours and failing to notify the provider and pharmacy of the delay.
F 695: The facility failed to maintain respiratory equipment properly for Residents 29 and 11, including improper storage of oxygen/nebulizer tubing and cannulas and failure to change humidifier bottles and tubing weekly, increasing risk of infection.
F 842: The facility failed to maintain complete and accurate medical records for Residents 10 and 29, including failure to document hospitalization and resident requests for diagnostic studies.
F 921: The facility failed to maintain a safe and sanitary environment in the laundry area, including ceiling stains, peeling spackling, damaged flooring, and damaged folding tables.
Report Facts
Resident 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 findings related to failure to investigate medication errors, failure to place orders, and failure to notify providers |
| Nurse Practitioner GG | Nurse Practitioner | Named in findings related to medication order and wound care oversight |
| Nurse Practitioner KK | Nurse Practitioner | Named as ordering provider for IV antibiotics for Resident 7 |
| Licensed Nurse J | Licensed Nurse | Observed dressing changes and confirmed wound care observations |
| Consultant Pharmacist LL | Consultant Pharmacist | Provided expert opinion on antibiotic administration |
| Licensed Nurse G | Licensed Nurse | Provided wound assessments and observations |
| Licensed Nurse H | Licensed Nurse | Discussed medication order placement responsibilities |
| Licensed Nurse I | Licensed Nurse | Observed wound condition and medication order issues |
| Licensed Nurse J | Licensed Nurse | Reported on oxygen equipment maintenance and storage |
| Certified Nurse Aide O | Certified Nurse Aide | Confirmed oxygen equipment storage practices |
| Certified Nurse Aide M | Certified Nurse Aide | Confirmed oxygen equipment storage practices |
| Certified Medication Aide R | Certified Medication Aide | Named in documentation and appointment scheduling issues |
| Licensed Nurse K | Licensed Nurse | Named in appointment scheduling and communication issues |
| Administrative Staff A | Administrative Staff | Verified documentation and environmental maintenance issues |
| Housekeeping Staff U | Housekeeping Staff | Reported laundry area maintenance issues |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 8
Date: Jan 11, 2022
Visit Reason
The inspection was conducted due to concerns of abuse, neglect, exploitation, and complaints related to medication administration, wound care, respiratory care, and facility environment.
Complaint Details
The investigation was complaint-driven based on concerns of abuse, neglect, exploitation, medication errors, wound care deficiencies, respiratory care issues, and environmental safety.
Findings
The facility failed to administer ordered IV antibiotics and fluids timely, failed to report incidents of neglect, failed to provide adequate wound care and personal hygiene, failed to maintain respiratory equipment properly, and failed to maintain accurate and complete medical records. Additionally, the facility environment in the laundry area was not maintained safely and sanitary.
Deficiencies (8)
F0609: The facility failed to timely report suspected abuse, neglect, or theft and failed to investigate medication errors involving IV antibiotics and fluids for residents R7 and R10.
F0677: The facility failed to provide necessary personal hygiene services related to nail care for Resident R23.
F0684: The facility failed to provide appropriate wound care and monitoring for Residents R4 and R7, resulting in worsening wounds and lack of documentation of treatments.
F0686: The facility failed to provide necessary treatment and services to promote healing of pressure ulcers for Residents R4 and R17, including lack of wound care documentation and monitoring.
F0694: The facility failed to administer IV fluids as ordered for Resident R10, resulting in delayed treatment for dehydration.
F0695: The facility failed to maintain respiratory equipment properly for Residents R29 and R11, including improper storage and failure to change tubing and humidifier bottles weekly, risking infection.
F0842: The facility failed to maintain complete and accurate medical records for Resident R10 regarding hospitalization and failed to document Resident R29's request for a mammogram.
F0921: The facility failed to maintain a safe and sanitary environment in the laundry area, including ceiling stains, damaged flooring, and damaged folding tables.
Report Facts
Resident census: 39
Days of missed IV antibiotic administration: 4
Days delayed IV fluid administration: 1
Dates of missing wound care documentation: 5
Dates of missing wound care documentation: 3
Dates of missing wound care documentation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in findings related to failure to report neglect, failure to place medication orders, and failure to document resident concerns |
| Licensed Nurse J | Licensed Nurse | Named in wound care observation and respiratory equipment maintenance findings |
| Nurse Practitioner GG | Nurse Practitioner | Documented medication errors and telemed visits related to Resident R7 |
| Nurse Practitioner KK | Nurse Practitioner | Ordered IV antibiotics for Resident R7 and documented medication errors |
| Consultant Pharmacist LL | Consultant Pharmacist | Provided expert opinion on antibiotic administration for Resident R7 |
| Certified Medication Aide R | Certified Medication Aide | Responsible for appointments and transportation; involved in documentation findings |
| Administrative Staff A | Administrative Staff | Verified documentation and environmental maintenance findings |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 29, 2021
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 09/29/2021.
Findings
All deficiencies cited in the prior inspection have been corrected as of 10/13/2021, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 1
Date: 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.
Complaint Details
The citations represent findings from complaint investigations #KS 165808 and #KS 165930. The facility was found noncompliant due to burns sustained by two residents from hot coffee spills.
Findings
The facility failed to ensure two residents remained free from accidents when hot coffee spilled on them, causing burns. Observations, interviews, and record reviews confirmed injuries including third degree burns due to coffee served at temperatures between 160 to 165 degrees.
Deficiencies (1)
CFR 483.25(d) Accidents. The facility failed to ensure two residents remained free from accident hazards when hot coffee spilled on them, causing burns including third degree burns on one resident's right leg.
Report Facts
Resident census: 107
Coffee temperature range: 160
Coffee temperature range: 165
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Interviewed regarding the incident of Resident 1's coffee burn and observed injuries. |
| Consultant Staff GG | Consultant Staff | Conducted admission assessment and noted burn on Resident 2's left thigh. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 29, 2021
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 addresses a deficiency related to accident hazards and supervision, specifically regarding residents' ability to handle hot liquids and prevention of burns.
Deficiencies (1)
F689 Free of Accident Hazards/Supervision/Devices: Resident #1 was provided with a new cup with lid and a clothing protector. Residents were assessed for ability to handle hot liquids and care plans updated with interventions to prevent burns.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 20, 2021
Visit Reason
A revisit survey was conducted to verify correction of all previous deficiencies cited on 2020-12-09.
Findings
All previously cited deficiencies were corrected as of the compliance date 2020-12-15, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: 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 cited in the prior inspection have been corrected as of 12/11/20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 5
Date: Dec 9, 2020
Visit Reason
Complaint investigation triggered by allegations of abuse and neglect involving resident-to-resident physical aggression and failure to notify physicians and state agency timely.
Complaint Details
The complaint investigation involved allegations of neglect and abuse including failure to notify physicians and state agency timely, inadequate supervision leading to resident-to-resident physical abuse, and failure to honor end-of-life care decisions.
Findings
The facility failed to provide adequate supervision and one-to-one monitoring for a resident with aggressive behaviors, resulting in physical abuse of another resident. The facility also failed to notify the physician and state agency timely, did not monitor neurological status after injury, and failed to provide hospice information and honor end-of-life decisions for other residents.
Deficiencies (5)
F580: Facility failed to notify the physician immediately of a resident receiving a blow to the head and did not perform neurological checks after the incident.
F600: Facility failed to provide adequate supervision and one-to-one care to prevent physical abuse by an aggressive resident, placing others in immediate jeopardy.
F609: Facility failed to report an allegation of abuse to the state agency within required timeframes.
F610: Facility failed to thoroughly investigate resident-to-resident abuse, prevent further abuse during investigation, and provide adequate supervision to prevent physical abuse.
F684: Facility failed to provide hospice education to a resident, failed to monitor neurological status after a head injury, and failed to ensure end-of-life decisions were available and honored.
Report Facts
Resident census: 49
Days delay in physician notification: 5
Days delay in state agency notification: 5
Duration resident was 'out' after being struck: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Named in failure to notify physician and inadequate supervision findings |
| Licensed Nurse H | Licensed Nurse | Named in failure to notify physician and inadequate documentation findings |
| Certified Nurse Aide M | Certified Nurse Aide | Witnessed resident altercation and reported incident |
| Physician Extender GG | Physician Extender | Consulting staff not notified timely of resident behavior and injury |
| Administrative Staff A | Administrative Staff | Notified state agency late about abuse incident |
| Licensed Nurse L | Licensed Nurse | Reported resident found unresponsive and initiated CPR |
| Administrative Nurse E | Administrative Nurse | Discussed hospice referral and resident care |
| Social Service Staff X | Social Service Staff | Unaware of hospice referral for resident |
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Dec 9, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection at Diversicare Sedgwick CP.
Findings
The plan addresses multiple deficiencies related to resident notifications, abuse prevention, timely reporting, hospice services, neurological monitoring, CPR policy, and code status verification. Corrective actions include staff re-education, audits, and ongoing monitoring through interviews and reviews.
Deficiencies (5)
F580-D Resident #4 no longer resides in the center. Nurses have been re-educated on notification of changes to physician providers regarding aggressive behaviors. Nurse notes will be reviewed regularly for required notifications.
F600-L Resident #4 no longer resides in the center and Resident #3 is no longer at risk. Staff have been re-educated on abuse, neglect, and exploitation prevention. Social Services will interview residents to identify any abuse or neglect.
F609-D Resident #4 no longer resides in the center. Leadership and staff have been re-educated on timely reporting of abuse, neglect, and misappropriation. Social Services will conduct resident interviews to monitor for abuse or neglect.
F610-J Resident #4 no longer resides in the center. Leadership has been re-educated on reporting alleged violations. Social Services will interview team members to identify investigations or alleged violations.
F684-D Residents #1, #3, and #10 no longer reside in the center. Leadership and nursing staff have been educated on hospice services, neurological monitoring, CPR policy, and code status verification. Ongoing audits and interviews will monitor compliance.
Inspection Report
Plan of Correction
Deficiencies: 19
Date: 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 November 3, 2020, related to COVID and complaint investigations.
Findings
The Plan of Correction addresses multiple deficiencies including notification of responsible parties, abuse/neglect prevention, care plan updates, bathing preferences, fall interventions, medication reviews, staff training, policy reviews, and documentation improvements. The facility has implemented re-education, audits, and monitoring to ensure compliance and quality assurance.
Deficiencies (19)
F580-D Resident #19 no longer resides in the center. Responsible parties have been notified of weight loss and changes. Nurses have been re-educated on notification procedures and audits will be conducted.
F600-K Resident #19 no longer resides in the center. Staff re-educated on abuse, neglect, and exploitation prevention. Social Services will interview residents to identify issues and audits will be submitted to QAPI.
F609-D Investigation regarding residents #45 and #250 completed. Staff re-educated on timely reporting of abuse/neglect/misappropriation. Social Services will conduct resident interviews and audits will be submitted to QAPI.
F625-E Residents discharged to hospital reviewed and bed-hold policy provided. Nurses and business office re-educated on policy delivery and documentation. Audits will monitor compliance.
F641-D Resident #26 assessment modified and completed. Interdisciplinary team re-educated on completion of comprehensive assessments. Audits will be conducted.
F656-D Care plans for residents #26 and #30 updated to include bathing preferences. Staff re-educated on individualized care planning. Audits will monitor care plans.
F657-D Resident #9's care plan updated to include fall interventions. Care plans will be updated as needed. Staff re-educated on care plan timing and revision. Audits will be conducted.
F677-D Residents #7, #44, and #26 received baths per preferences. Nursing staff re-educated on bathing documentation. Audits will monitor bathing completion and refusals.
F689-D Residents #9 and #30 reviewed for fall interventions; resident #26 on one-on-one supervision. Staff re-educated on fall prevention and supervision. Audits will monitor implementation.
F692-G Resident #30 assessed by dietician and orders updated. Staff re-educated on dietician recommendations. Audits will monitor adherence.
F730-E All CNA team members employed over one year have completed evaluations. DNS educated on annual performance reviews. Audits will monitor completion.
F732-F Nurse staffing information posted and maintained for 18 months. DNS re-educated on posting requirements. Audits will monitor postings.
F756-D Residents #43, #47, and #12 reviewed by consultant pharmacist; recommendations addressed. Staff re-educated on timely addressing of pharmacy reports. Audits will monitor completion.
F757-D Residents #43 and #47 had medications reviewed and addressed by pharmacy consultant. Staff re-educated on unnecessary drugs and physician orders. Audits will monitor compliance.
F758-D Resident #12 reviewed by pharmacy consultant and acted upon. Staff re-educated on unnecessary drugs and physician orders. Audits will monitor compliance.
F837-F All policies reviewed and approved by governing body. Administrator re-educated on annual review process. Audits will monitor policy approval.
F843-F Transfer agreement with hospital obtained. Administrator educated on agreements. Audits will monitor signatures annually.
F947-F Full-time nurse aides completed required 12-hour in-service training. Staff educated on required in-services. Audits will monitor training completion.
S1420-F Nurse aides completed required 12-hour in-service training. Staff educated on required in-services. Audits will monitor training completion.
Inspection Report
Re-Inspection
Census: 50
Deficiencies: 1
Date: Nov 3, 2020
Visit Reason
The inspection was a Licensure Resurvey combined with a Complaint Investigation involving multiple complaint numbers.
Complaint Details
The visit included a complaint investigation with multiple complaint numbers (#157114, #157063, #156988, #157051, #157052, and #150380).
Findings
The facility failed to ensure all nursing staff completed required mandatory in-service education for disaster training, dementia training, resident rights, and fire prevention and safety training as required by regulations.
Deficiencies (1)
28-39-163 Staff Development: The facility failed to ensure all nursing staff completed mandatory in-service education for disaster training, dementia training, resident rights, and fire prevention and safety training as required.
Report Facts
Census: 50
Nursing staff reviewed: 5
Nursing staff lacking fire prevention training: 4
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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 compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 28, 2020
Visit Reason
This document is a Plan of Correction submitted in response to a deficiency-free COVID-19 survey conducted on 04/28/2020.
Findings
The facility was found to be deficiency-free during the COVID-19 survey conducted on 04/28/2020.
Deficiencies (1)
F0000 Deficiency free COVID survey conducted on 04/28/2020.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 15, 2020
Visit Reason
An offsite revisit was conducted to verify correction of all previous deficiencies cited on 2019-11-27.
Findings
All deficiencies have been corrected as of the compliance date of 2019-12-18, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: Dec 18, 2019
Visit Reason
This document is a Plan of Correction submitted by the facility to address and correct previously identified deficiencies from an inspection.
Findings
The plan outlines corrective actions for multiple deficiencies including respect and dignity in resident care, bed-hold policy notification, discharge summaries, ADL care, accident hazards, catheter care, and medication management. The facility describes education, audits, and monitoring activities to ensure compliance.
Deficiencies (8)
F557 – Respect, Dignity/Right to have personal Property: Resident clothing concerns were investigated and corrected. Staff were re-educated on proper clothing and dignity standards.
F625 - NOTICE OF BED-HOLD POLICY BEFORE/UPON TRANSFR: Written notice of bed-hold policy was provided to specified residents and procedures for ongoing notification were established.
F661 – Discharge Summary: Resident #58 was discharged and audits were conducted to ensure timely completion of discharge summaries and medication reconciliation.
F677 – ADL Care provided for dependent residents: Residents #28 and #35 had care plans updated based on preferences and staff were educated on ADL care needs.
F689 - Free of Accident Hazards/Supervision/Devices: Resident #28 was assessed for safe wheelchair transfers and staff were educated on proper positioning.
F690 – Bowel/Bladder Incontinence, Catheter, UTI: Residents #36 and #45 were assessed for catheter care and staff were educated on proper catheter management.
F756 - Drug Regimen is Free from Unnecessary Drugs: Resident #40 had AIMS completed and staff were reeducated on antipsychotic medication assessments.
F758 - Free From Unnecessary Drugs: Residents #18 and #28 had medication reviews completed for Ativan and staff were reeducated on documentation requirements.
Report Facts
Resident interviews for dignified dressing: 5
Resident discharges reviewed weekly: 5
Resident audits for ADL care: 5
Audit frequency for safe foot rest positioning: 4
Audit frequency for catheter care: 4
Resident audits for antipsychotic medication: 5
Resident audits for Ativan medication: 5
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 8
Date: Nov 27, 2019
Visit Reason
Health Resurvey and Complaint Investigation #144660 conducted to assess compliance with resident care and facility policies.
Complaint Details
The inspection was triggered by a complaint investigation #144660.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, failure to provide written bed hold notices upon hospitalization, lack of discharge summaries, inadequate ADL care, unsafe resident transfers, improper catheter care, and failure to monitor and act on unnecessary psychotropic medication use.
Deficiencies (8)
CFR 483.10(e)(2): The facility failed to ensure one resident wore clothing in a dignified manner, dressing him in pants with torn fraying holes approximately 12 inches long.
CFR 483.15(d)(1)(2): The facility failed to provide written notice of the bed hold policy to five residents upon hospitalization to ensure resident/representative understanding.
CFR 483.21(c)(2): The facility failed to document a discharge summary including a recapitulation of the resident's stay upon discharge for one resident.
CFR 483.24(a)(2): The facility failed to provide adequate hygiene care including shaving and scheduled bathing for two residents, resulting in poor grooming and foul body odor.
CFR 483.25(d)(1)(2): The facility failed to ensure safe transfers and provide a foot pedal for one resident with severe cognitive impairment and below knee amputation to prevent accidents.
CFR 483.25(e)(1)-(3): The facility failed to provide appropriate catheter care including securing the catheter to prevent urethral trauma and maintaining sanitary drainage tubing for two residents with indwelling catheters.
CFR 483.45(c)(1)(2)(4)(5): The facility pharmacist failed to identify that one resident received as needed Ativan cream beyond the 14 day limit without physician reevaluation, risking unnecessary medication use.
CFR 483.45(c)(3)(e)(1)-(5): The facility failed to ensure two residents did not receive unnecessary as needed Ativan beyond the 14 day limit without physician documentation of continued need, risking adverse effects.
Report Facts
Resident census: 55
Residents selected for review: 18
Residents reviewed for hospitalization: 7
Residents failed to receive bed hold notice: 5
Scheduled baths missed: 4
Days Ativan cream exceeded limit: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in findings related to resident clothing, safe transfers, 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
Complaint Investigation
Census: 56
Deficiencies: 1
Date: 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 regarding failure to provide CPR to a resident with full code status.
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 full code resident. The facility was placed in immediate jeopardy status. Licensed nurse C was suspended and the incident reported to the State complaint hotline.
Findings
The facility failed to provide CPR to a resident (R1) with a full code status who was found unresponsive without pulse or respirations. 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.
Deficiencies (1)
42 CFR 483.24(a)(3) Personnel failed to provide basic life support including CPR to a resident with full code status when found without pulse or respirations. Staff assumed a DNR order due to hospice status without verification.
Report Facts
Resident census: 56
Hospice residents: 5
Residents with full code status: 40
Residents with DNR code status: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse C | Licensed Nurse | Failed to provide CPR to resident with full code status and was suspended |
| 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 staff and informed of immediate jeopardy status |
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 15, 2019
Visit Reason
This visit was conducted as a follow-up to verify correction of previously reported deficiencies at Diversicare of Sedgwick.
Findings
The report documents that previously identified deficiencies have been corrected as of the revisit date. Specific corrections are noted with regulation references and completion dates.
Deficiencies (1)
26-40-303 (b)(c) deficiency was corrected and completed by 04/15/2019.
Inspection Report
Follow-Up
Deficiencies: 4
Date: May 15, 2019
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported 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)
Regulation 483.10(i)(1)-(7) deficiency was corrected by 04/15/2019.
Regulation 483.21(b)(2)(i)-(iii) deficiency was corrected by 04/15/2019.
Regulation 483.24(a)(2) deficiency was corrected by 04/15/2019.
Regulation 483.60(i)(1)(2) deficiency was corrected by 04/15/2019.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Mar 22, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a complaint survey conducted on 3/22/2019 at Diversicare Sedgwick.
Complaint Details
This Plan of Correction addresses deficiencies cited during a complaint survey conducted on 3/22/2019.
Findings
The facility identified multiple deficiencies including issues with environment cleanliness, care plan timing and revision, ADL care for dependent residents, and food procurement and sanitation. The Plan of Correction outlines corrective actions, staff re-education, and ongoing audits to ensure compliance.
Deficiencies (5)
F584 - Safe/Clean/Comfortable/Homelike Environment: An immediate intervention was triggered resulting in extensive cleaning and staff training. Housekeeping outcomes will be audited weekly then monthly.
F657 - Care plan timing and revision: Care plans for multiple residents were reviewed and updated. Staff were re-educated on care plan review requirements and audits will be conducted regularly.
F677 - ADL Care provided for dependent residents: Residents were re-evaluated for bathing needs and preferences. Care plans and schedules were updated and staff educated. Audits will ensure proper bathing care.
F812 - Food Procurement, Store/Prepare/Serve-Sanitary: Dietary duties were updated and staff educated on proper food handling and sanitation. Meal services will be audited regularly.
S1080 - Nurses' workroom or area: Mirrors will be installed to allow staff visualization of halls from nursing work areas. The facility participates in a program eliminating traditional nurses’ stations in favor of neighborhood work areas.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: Mar 22, 2019
Visit Reason
The inspection was conducted as a complaint investigation identified by complaint number KS00139020.
Complaint Details
This visit was triggered by complaint investigation #KS00139020. The complaint was substantiated as the facility failed to provide visual monitoring of residents in two hallways from the nursing work area.
Findings
The facility failed to ensure visual monitoring of two of four hallways where residents resided from the nursing work area. The nursing work area was relocated to an office without line of sight to these hallways, and no electronic monitoring was in place.
Deficiencies (1)
26-40-303 (b)(c) Nurses' workroom or area must allow visual access to corridors outside resident rooms. Two of four hallways lacked staff visualization from the nursing work area, and no electronic monitoring was present.
Report Facts
Census: 58
Hallways lacking visualization: 2
Total hallways with residents: 4
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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.
Deficiencies (1)
The facility had an "E" level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Follow-Up
Deficiencies: 0
Date: 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 have been corrected as of the compliance date of 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
Date: Dec 19, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey to assure correction and continued compliance with regulations.
Findings
The plan addresses multiple deficiencies including comprehensive care plan development, care plan timing and revision, discharge summaries, ADL care, quality of care related to skin impairment, accident hazards and supervision, bowel/bladder incontinence and catheter care, and infection prevention and control. The facility has re-educated staff and implemented audits to monitor compliance.
Deficiencies (8)
F656 – Develop Comprehensive Care Plan: Resident #46 care plan has been reviewed and updated. The interdisciplinary team has been re-educated on care plan development and audits will be conducted weekly then monthly.
F657 – Care plan timing and revision: Care plans for residents #16, 44, and 33 have been reviewed and updated. Staff re-education and audits will ensure timely revision and review of care plans.
F661 – Discharge Summary: Resident #55's discharge summary and medication reconciliation were reviewed. Staff education and audits will monitor timely completion of discharge documentation.
F677 – ADL Care provided for dependent residents: Resident #4 was re-evaluated for oral care. Care plans updated and staff educated to ensure proper oral hygiene.
F684 – Quality of Care: Resident #26 care plan reviewed with interventions to reduce skin impairment risk. Nursing staff re-educated on wound and skin care per guidelines.
F689 – Free of Accident Hazards/Supervision/Devices: Residents #26, 14, 16, and 44 assessed with updated care plans. Staff educated on fall assessments, safe lifts, and dietary restrictions with audits planned.
F690 – Bowel/Bladder Incontinence, Catheter, UTI: Resident #33 catheter adjusted and privacy bag provided; Resident #4 assessed for UTI signs. Staff re-educated on catheter and peri-care with audits scheduled.
F880 – Infection Prevention & Control: Respiratory and wound care equipment properly stored for residents #40 and #49. Staff re-educated on hand hygiene, gloving, and device storage with audits planned.
Report Facts
Audit frequency: 5
Audit duration: 4
Audit duration: 3
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 8
Date: Nov 29, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint investigation for complaint numbers #s131241 and #119930.
Complaint Details
The inspection was triggered by complaints #s131241 and #119930. The facility was found noncompliant in multiple areas related to care planning, discharge procedures, ADL care, skin care, accident prevention, catheter care, and infection control.
Findings
The facility was found deficient in multiple areas including failure to develop and revise comprehensive care plans, inadequate discharge summaries, failure to provide necessary ADL care including oral hygiene, inadequate skin care leading to irritation, failure to prevent accidents and falls, improper catheter care, and infection control deficiencies including improper hand hygiene and unsanitary equipment storage.
Deficiencies (8)
F 656: The facility failed to develop a comprehensive care plan for resident #46 related to activities, lacking documentation of activity preferences and care plan interventions.
F 657: The facility failed to review and revise care plans for residents #16, #44, and #33 following falls and catheter insertion, missing appropriate interventions and updates.
F 661: The facility failed to complete a discharge summary including recapitulation of stay and medication reconciliation for resident #55.
F 677: The facility failed to provide necessary oral hygiene services to resident #4, resulting in significant debris buildup and bleeding gums.
F 684: The facility failed to provide timely and appropriate skin care for resident #26, resulting in untreated skin redness and abrasions from incontinence and shearing.
F 689: The facility failed to provide adequate supervision and assistive devices to prevent accidents and falls for residents #16, #26, and #44, and failed to provide safe drinking supplies for resident #14.
F 690: The facility 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, risking urinary tract infections.
F 880: The facility failed to ensure sanitary storage of respiratory and wound care equipment and failed to follow proper hand hygiene and glove use for residents #2, #13, #26, #40, and #49.
Report Facts
Resident census: 54
Sampled residents: 17
Resident falls: 2
Resident BIMS scores: 15
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 29, 2018
Visit Reason
The visit was conducted to determine if the facility was 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 accepted, and the facility was found to be in substantial compliance effective 2018-12-19.
Deficiencies (1)
The facility had a widespread 'F' level deficiency that constitutes no actual harm but has potential for more than minimal harm and is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Sep 6, 2018
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior complaint investigation at the facility.
Findings
The plan states that past noncompliance issues identified under tags F0000 and F689-J required no plan of correction.
Deficiencies (2)
F0000 past noncompliance: no plan of correction required.
F689-J past noncompliance: no plan of correction required.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 1
Date: 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.
Complaint Details
The complaint investigation #133018 was substantiated by findings that the facility failed to prevent a resident from eloping and sustaining injury. The resident was missing for approximately one hour before being found by police four blocks from the facility.
Findings
The facility failed to provide adequate supervision and assistive devices to prevent accidents, resulting in a resident leaving the facility unnoticed and sustaining a minor injury. The wanderguard alarm system was temporarily disabled due to an electrical disturbance caused by a storm.
Deficiencies (1)
CFR 483.25(d) Accidents. The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision or assistive devices to prevent a resident from eloping and falling from a wheelchair outside the facility.
Report Facts
Resident census: 56
Residents sampled for elopement review: 3
Staff in-service attendance: 48
Staff required to complete training: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff C | Named in relation to assisting the resident outside and conducting physical assessment after the fall. | |
| Administrative staff A | Provided information about the incident and wanderguard alarm functionality. | |
| Administrative nursing staff B | Explained the incident during interview. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 12, 2018
Visit Reason
A complaint survey was conducted on 3/12/18 for complaint # KS 00127366.
Complaint Details
Complaint # KS 00127366 was investigated and found to be not substantiated.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 12, 2018
Visit Reason
A complaint survey was conducted on 2018-03-12 for complaint # KS 00127366.
Complaint Details
Complaint # KS 00127366 was investigated and found to be unsubstantiated with no noncompliance identified.
Findings
The allegations made in the complaint were not substantiated. No noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 18, 2017
Visit Reason
The visit was an offsite follow-up conducted to verify correction of deficiencies cited on 2017-08-24.
Findings
The previously cited 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
Date: 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.
Findings
The facility identified multiple deficiencies related to resident bathing preferences, environmental cleanliness, individualized care plans, medication administration, restorative services, food service delivery, kitchen and medication storage, and proper use and storage of urinals and other resident care items. Corrective actions and ongoing monitoring plans were outlined for each deficiency.
Deficiencies (9)
F242-D: Residents #5, #28, and #74 were interviewed regarding their bathing preferences which have been updated and care planned accordingly. All residents’ bathing schedules will be updated based on preferences and reviewed quarterly or with changes.
F253-E: Environmental items discussed during exit were addressed with maintenance and housekeeping. Weekly environmental audits will be conducted to ensure proper labeling and identification of personal hygiene items.
F279-E: Care plans for residents #5, #28, #74, #26, and #53 were reviewed and updated to reflect individualized needs and preferences. Staff will be educated on care plan updates and audits conducted regularly.
F282-F: Medication administration errors involving residents #34 and #66 were addressed with immediate education of staff. Ongoing re-education and competency evaluations will be conducted to ensure compliance.
F317-D: Residents #26 and #53 were assessed for PROM needs and restorative programs initiated. Caregivers will be educated and audits conducted to ensure proper restorative services.
F364-D: Resident #74 was offered food alternatives following a complaint. Dietary and nursing staff will be trained on timely delivery of room trays and ongoing audits will be conducted.
F371-F: Refrigerators and freezers were inspected and missing thermometers replaced. Food items were labeled, dated, or discarded if expired. Ongoing audits will ensure compliance with food safety standards.
F431-F: All expired and undated medications were discarded. Staff will be educated on medication storage and destruction policies with regular audits to ensure compliance.
F441-E: Urinals have been properly stored. Nursing and housekeeping staff will be educated on appropriate use and storage with audits to maintain compliance.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 24, 2017
Visit Reason
A health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes in the Medicare and/or Medicaid program.
Findings
The survey found a widespread 'F' level deficiency indicating no actual harm but potential for more than minimal harm without 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.
Deficiencies (1)
The facility had a widespread 'F' level deficiency that constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 9
Date: Aug 24, 2017
Visit Reason
Health Resurvey and complaint investigation #120101 focusing on resident bathing choices and other care and facility concerns.
Complaint Details
Complaint investigation #120101 focused on resident bathing preferences and other care and facility concerns.
Findings
The facility failed to ensure residents received preferred bathing choices, maintain sanitary and orderly environment, develop individualized care plans including restorative services, ensure safe medication administration and storage, provide palatable and properly tempered food, and maintain proper infection control practices.
Deficiencies (9)
F242: The facility failed to ensure 3 residents received their preferred bathing choices as documented in their care plans and preference forms.
F253: The facility failed to maintain a sanitary, orderly, and comfortable interior in 20 resident rooms and other areas, including unlabeled personal items and damaged surfaces.
F279: The facility failed to develop and implement individualized comprehensive care plans for 5 residents, including bathing preferences and restorative services.
F282: The facility failed to ensure staff competency in administering medications individually to prevent errors.
F317: The facility failed to provide restorative services to maintain residents free of functional limitations in range of motion as planned.
F364: The facility failed to serve food that was palatable and at an appetizing temperature for one resident.
F371: The facility failed to maintain a clean and sanitary dietary department, including improper food storage and unclean equipment.
F431: The facility failed to monitor expiration dates and ensure safe storage of medications, including expired and discontinued drugs found in medication rooms.
F441: The facility failed to provide proper infection control practices to prevent possible contamination, including improper placement of urinals, wash basins, and urinary containers in resident rooms.
Report Facts
Resident census: 54
Number of residents reviewed for bathing choices: 3
Number of residents reviewed for restorative services: 3
Expired Bisacodyl suppositories: 31
Expired medications found: 23
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 18, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected as documented in the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation numbers 483.12(b)(1)&(2), 483.25, and 483.25(f)(1) were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Dec 5, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation related to DVC Sedgwick complaint 11182016.
Findings
The plan addresses deficiencies related to the bed-hold policy, dental assessments and care, and PASRR II mental health referrals and care planning. The facility outlines corrective actions including audits, staff education, and tracking systems to ensure compliance and resident care improvements.
Deficiencies (3)
F205-E: The bed-hold policy was not properly delivered to residents and their DPOA or next of kin upon discharge, transfer, or leave. The facility will audit delivery and documentation of the bed-hold policy.
F309-D: Nursing staff failed to properly assess and address residents' dental needs. The facility will conduct nursing education and audits, and offer an on-site dental program to residents.
F319-D: The facility did not ensure PASRR II mental health referrals and care plans were completed and updated timely. A tracking system and audits will be implemented to monitor compliance.
Report Facts
Date of identified resident discharge: Nov 4, 2016
Plan of Correction completion dates: Dec 5, 2016
Plan of Correction completion date: Dec 18, 2016
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 3
Date: Nov 18, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#107903) regarding the facility's failure to provide proper notification of bed-hold policies and to ensure appropriate care and treatment for residents.
Complaint Details
The complaint investigation (#107903) was triggered by concerns about failure to notify residents of bed-hold policies and inadequate care for residents, including treatment delays and lack of mental health services.
Findings
The facility failed to notify residents and their families about bed-hold policies upon hospital discharge, failed to provide timely treatment for an oral lesion for one resident, and did not ensure appropriate mental health treatment for a resident with ongoing psychosocial difficulties.
Deficiencies (3)
483.12(b)(1)&(2) The facility failed to provide residents and family members written notice of the bed-hold policy at the time of hospital discharge for 4 residents.
483.25 The facility failed to provide timely treatment for an oral lesion for one resident, lacking evidence of biopsy or removal and dentures provision.
483.25(f)(1) The facility failed to ensure one resident received appropriate treatment and services for mental or psychosocial adjustment difficulties.
Report Facts
Census: 55
Residents reviewed for bed holds: 4
Residents selected for sample review: 3
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 18, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be F205, an 'E' level deficiency indicating no actual harm but 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.
Deficiencies (1)
Deficiency F205 was cited as an 'E' level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Named as contact and signatory related to the survey findings and plan of correction. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Date: Jun 9, 2016
Visit Reason
Complaint investigation #100847 regarding allegations of sexual abuse by a resident towards other residents.
Complaint Details
Complaint investigation #100847 involved sexual abuse by resident #1 of residents #2 and #3. The facility failed to protect residents and delayed reporting the incidents to administration for approximately 41 hours.
Findings
The facility failed to provide adequate supervision to a mobile resident who sexually abused two cognitively impaired residents, placing all residents in immediate jeopardy. The facility also failed to timely report and thoroughly investigate the incidents of sexual abuse.
Deficiencies (2)
483.13(b), 483.13(c)(1)(i) The facility failed to protect residents from verbal, sexual, physical, and mental abuse by not providing adequate supervision to a resident who sexually abused two other residents.
483.13(c)(1)(ii)-(iii), (c)(2)-(4) The facility failed to report and investigate allegations of sexual abuse in a timely manner, with licensed nursing staff failing to notify the administrator or director of nursing for approximately 41 hours.
Report Facts
Resident census: 56
Sample size: 3
Reporting delay: 41
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jun 9, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation at Diversicare Sedgwick.
Findings
The Plan of Correction addresses deficiencies identified under tags F0000, F223-L, and F225-L, all marked as KDADS overrides.
Deficiencies (3)
Deficiency tag F0000 was addressed with a KDADS override on 06/09/2016.
Deficiency tag F223-L was addressed with a KDADS override on 06/09/2016.
Deficiency tag F225-L was addressed with a KDADS override on 06/09/2016.
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: 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 the facility was not in substantial compliance with participation requirements and conditions constituted Immediate Jeopardy and Past Non-compliance to resident health or safety for F223 and F225.
Deficiencies (2)
F223, CFR 483.13(b) deficiency related to resident health or safety constituted Immediate Jeopardy and Past Non-compliance.
F225, CFR 483.13(c)(1)(ii) deficiency related to resident health or safety constituted Immediate Jeopardy and Past Non-compliance.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | Complaint Coordinator | Signed letter regarding enforcement and dispute resolution |
Inspection Report
Plan of Correction
Deficiencies: 24
Date: Feb 7, 2016
Visit Reason
This document is a Plan of Correction submitted by Diversicare of Sedgwick to address and correct alleged deficiencies identified in a prior inspection.
Findings
The plan outlines corrective actions for multiple deficiencies including resident assessments, notification procedures, abuse/neglect policies, care plan updates, environmental issues, infection control, and dietary sanitation. The facility commits to ongoing audits, staff education, and quality assurance monitoring over several months.
Deficiencies (24)
F157-D: A new assessment was completed on Resident #13 upon readmission. Nurses will be educated on assessments and notification of change in condition.
F170-C: Residents #54, 15, and 19 were educated on mail delivery process. Manager on Duty will ensure mail delivery to residents.
F225-D: Resident #40 investigation completed and sent to KDADS. Staff educated on Abuse/Neglect/Misappropriation policy including injuries of unknown origin.
F226-D: Reference checks for staff members F and Y completed. Education on hiring practices and background checks provided to department managers.
F242-D: Residents #35, 55, and 56 re-interviewed regarding bathing preferences. Care plans updated to reflect preferences.
F248-D: Residents #9 and 51 activity preferences reviewed and care plans updated. Activity Director educated on 1:1 activities and documentation.
F253-E: Environmental items discussed during exit addressed with maintenance. Weekly environmental audits to be completed.
F272-D: Residents #21, 18, and 9 care plans updated with appropriate interventions. Interdisciplinary team re-educated on CAA completion.
F278-D: Residents #35 and 64 MDS reviewed and updated. Interdisciplinary team re-educated on MDS assessment and completion.
F279-E: Residents #55, 35, 37, 18, and 68 care plans reviewed and updated. Staff re-educated on comprehensive care plans development.
F280-D: Residents #18, 51, and 40 care plans reviewed and updated. Staff re-educated on care plan revisions.
F309-D: Resident #40 investigation completed and sent to KDADS. Resident #35 had abdominal binders ordered. Nurses educated on assessments and physician notification.
F312-D: Residents #35, 68, and 9 received nail care. Care plans updated to reflect bathing preferences. Staff educated on bathing schedule and documentation.
F314-E: Residents #55, 9, 12, 18, and 58 re-assessed by DNS with interventions in place. Staff re-educated on skin care guidelines and wound documentation.
F315-D: Residents #12, 35, and 40 had 3-day voiding patterns started. Staff educated on voiding pattern completion and toileting schedule.
F318-D: Residents #18 and 68 assessments for restorative therapy updated. Staff educated on restorative program and documentation.
F323-D: Resident #40 care plan reviewed to ensure appropriate interventions. Facility to complete group reviews after falls.
F327-D: Resident #35 care plan updated with appropriate interventions. Staff re-educated on importance of hydration.
F329-D: Residents #37 and 23 evaluated by nurse practitioner with medication adjustments. Staff educated on documentation and physician notifications.
F371-F: All opened, unsecured, and undated refrigerator items disposed. Kitchen cleaned and staff educated on sanitation.
F428-D: Resident #37 care plan updated. Consultant pharmacist to provide monthly medication and vital signs review.
F441-E: Staff members K, N, and X re-educated on glucometer cleaning and infection control practices. Audits to be conducted.
F465-E: All items identified during survey to be repaired by 2/8/16. Environmental rounds and audits ongoing.
F520-F: QAPI committee reviewed and approved plans of action. Interdisciplinary team re-educated on QAPI process.
Report Facts
Residents interviewed per month: 10
Weekly audits: 5
Audit frequency: 3
Date: Feb 7, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact for Plan of Correction assistance | |
| JANRAU | Administrator | Submitted the Plan of Correction |
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 21
Date: Jan 8, 2016
Visit Reason
Annual inspection with complaint investigation to assess compliance with health and safety regulations.
Complaint Details
Complaint investigation included allegations of failure to notify physician of resident condition changes, failure to investigate abuse, and failure to provide adequate care and supervision.
Findings
The facility was found deficient in multiple areas including failure to timely notify physicians of resident condition changes, inadequate mail delivery, failure to investigate abuse allegations, incomplete reference checks for employees, lack of resident bathing and activity preferences documentation, environmental maintenance issues, incomplete comprehensive assessments and care plans, inadequate monitoring of medication and bowel management, infection control lapses, and failure to maintain a quality assessment and assurance committee.
Deficiencies (21)
F157 - Facility failed to timely notify physician and family of resident's change in condition resulting in hospitalization.
F170 - Facility failed to ensure residents promptly received mail 6 days per week as postal service operates.
F225 - Facility failed to thoroughly investigate and report allegations of abuse and neglect for multiple residents.
F226 - Facility failed to obtain reference checks prior to employment for 2 employees.
F242 - Facility failed to provide resident bathing preferences and individualized bathing schedules for multiple residents.
F248 - Facility failed to develop and provide individualized ongoing activity programs for multiple residents.
F253 - Facility failed to maintain sanitary, orderly, and comfortable environment in multiple resident rooms and common areas.
F272 - Facility failed to complete comprehensive assessments and care area assessments for multiple residents, including dental and restorative needs.
F278 - Facility failed to accurately complete resident assessments and coordinate with health professionals, including inaccurate MDS for activities and toileting.
F279 - Facility failed to develop comprehensive care plans addressing hydration, side rails, constipation, range of motion, and activities for multiple residents.
F309 - Facility failed to provide necessary care and services to maintain highest practicable well-being for residents, including failure to assess condition changes, monitor wounds, provide ordered devices, and maintain hygiene.
F312 - Facility failed to provide necessary services to maintain good grooming and personal hygiene for dependent residents.
F314 - Facility failed to provide treatment and services to promote healing and prevent pressure ulcers, including failure to reposition timely and monitor wounds.
F315 - Facility failed to provide appropriate treatment and services to prevent urinary tract infections and promote bladder function, including failure to monitor bowel movements and pulse rate.
F318 - Facility failed to provide appropriate range of motion services to residents with contractures and failed to instruct staff on restorative programs.
F323 - Facility failed to provide adequate supervision to prevent accidents for a resident with poor safety awareness and history of falls.
F327 - Facility failed to provide sufficient fluid intake to maintain proper hydration for a dependent resident.
F329 - Facility failed to ensure drug regimen was free from unnecessary drugs by failing to monitor bowel elimination and low pulse rate for residents on medications.
F441 - Facility failed to maintain infection control practices including proper cleaning of glucometer, resident care equipment, and hand hygiene.
F465 - Facility failed to maintain a safe, functional, sanitary, and comfortable environment in laundry and clean utility rooms.
F520 - Facility failed to maintain a quality assessment and assurance committee that developed and implemented plans to correct quality deficiencies.
Report Facts
Resident census: 54
Deficiency counts: 18
Pressure ulcer measurements: 14
Pressure ulcer measurements: 3.4
Braden scale scores: 12
Time without repositioning: 299
Time without repositioning: 280
Pulse readings: 39
Pulse readings: 32
Days without bowel movement: 8
Days without bowel movement: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Direct Care Staff | Named in glucometer cleaning and hydration deficiency |
| Staff L | Direct Care Staff | Named in hydration and repositioning deficiencies |
| Staff T | Direct Care Staff | Named in hydration, repositioning, and toileting deficiencies |
| Staff P | Direct Care Staff | Named in hydration and toileting deficiencies |
| Staff M | Licensed Nurse | Named in bowel management and repositioning deficiencies |
| Staff N | Licensed Nurse | Named in bowel management, pulse monitoring, and repositioning deficiencies |
| Staff C | Administrative Nursing Staff | Named in failure to assess and report resident condition changes |
| Staff F | Activity Staff | Named in activity program deficiencies |
| Staff AA | Licensed Nurse | Named in resident assessment and care deficiencies |
| Staff E | Social Services Staff | Named in family communication and resident condition concerns |
| Staff W | Direct Care Staff | Named in resident condition and pain reporting |
| Staff GG | Direct Care Staff | Named in hydration and personal care deficiencies |
| Staff DD | Direct Care Staff | Named in personal care deficiencies |
| Staff HH | Direct Care Staff | Named in repositioning deficiencies |
| Staff J | Direct Care Staff | Named in repositioning and toileting deficiencies |
| Staff B | Administrative Staff | Named in quality assurance deficiencies |
| Staff O | Administrative Nursing Staff | Named in assessment and restorative care deficiencies |
| Staff V | Administrative Staff | Named in employee reference check deficiencies |
| Staff I | Dietary Staff | Named in kitchen sanitation deficiencies |
| Staff G | Dietary Staff | Named in kitchen sanitation deficiencies |
| Staff X | Housekeeping Staff | Named in infection control deficiencies |
Inspection Report
Follow-Up
Deficiencies: 3
Date: Sep 17, 2015
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
The revisit confirmed that all cited deficiencies identified by regulation numbers 483.13(c)(1)(ii)-(iii), (c)(2)-(4), 483.25, and 483.25(h) were corrected as of the revisit date.
Deficiencies (3)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) deficiency was corrected by the revisit date.
Regulation 483.25 deficiency was corrected by the revisit date.
Regulation 483.25(h) deficiency was corrected by the revisit date.
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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, 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 the credible allegation of compliance and the plan.
Deficiencies (1)
The facility had 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy.
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
Complaint Investigation
Census: 57
Deficiencies: 3
Date: Aug 18, 2015
Visit Reason
The inspection was conducted as a result of complaint investigations regarding potential neglect and safety concerns at the facility.
Complaint Details
The complaint investigations numbered 89601 and 84516 involved allegations of neglect related to wound care and an elopement incident where a resident was found outside the facility unattended.
Findings
The facility failed to thoroughly investigate and report potential neglect related to a diabetic foot ulcer and an elopement incident involving two residents. The facility also failed to provide adequate supervision to prevent a cognitively impaired resident from leaving the building unattended.
Deficiencies (3)
F225: The facility failed to thoroughly investigate and report potential neglect for two residents, including one with a diabetic foot ulcer and another who eloped from the facility without staff knowledge.
F309: The facility failed to provide necessary care and services to maintain the highest practicable well-being, including failure to complete weekly skin assessments and report incidents of potential neglect.
F323: The facility failed to ensure the resident environment was free of accident hazards and did not provide adequate supervision to prevent a resident from exiting the building unattended.
Report Facts
Resident census: 57
Sample size: 3
Wound measurements: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff B | Reported lack of awareness of wound development and knowledge about resident found outside. | |
| Administrative nursing staff A | Reported on elopement incident and failure to investigate thoroughly. | |
| Direct care staff E | Reported resident mostly independent but required bathing assistance. | |
| Licensed nursing staff I | Reported resident identified as elopement risk after being found outside unattended. |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Aug 18, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint survey.
Findings
The facility identified deficiencies related to elopement risk, skin and wound assessments, and reporting suspected abuse or neglect. The Plan of Correction outlines staff training, audits, and care plan modifications to address these issues.
Deficiencies (3)
F225-D: Staff were trained on elopement procedures, skin and wound assessments, and reporting suspected abuse or neglect between August 20 and September 3, 2015.
F309-D: The Director of Nursing conducted audits between August 10 and August 30, 2015, to identify residents at risk for elopement and ensure wound care protocols were followed.
F323-D: A resident found outside without supervision was assessed for elopement risk and included in the elopement notebook with sensors fitted; audits and staff training on elopement procedures were conducted.
Report Facts
Complete Date: Sep 17, 2015
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 17, 2014
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected by the revisit date of 10/17/2014.
Inspection Report
Plan of Correction
Deficiencies: 10
Date: 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 addresses multiple deficiencies including restraint use monitoring, bathing schedule preferences, environmental maintenance, medication administration, food safety, and documentation of care. The facility outlines corrective actions and monitoring plans to achieve substantial compliance by 10/17/2014.
Deficiencies (10)
F221-D: Resident #31 will be monitored to ensure restraint use does not exceed 2 hours. Physician orders and care plans were updated accordingly.
F242-D: Residents #19 and #25 were interviewed about bathing preferences; all residents will be surveyed to update care plans and schedules.
F253-E: Multiple environmental repairs and cleaning tasks were completed including repainting doors, replacing tiles, and cleaning light covers.
F279-D: Care plans for residents using restraints were updated and will be reviewed quarterly by the interdisciplinary team.
F314-D: Residents at risk will be repositioned every two hours or less; staff educated and monitoring in place.
F323-D: Resident #31’s mattress replaced and fall mats assessed; staff educated on fall prevention and documentation.
F332-D: Staff involved in medication errors re-educated; medication administration competencies conducted quarterly.
F371-F: Food items covered, dated, and labeled; cleaning protocols enhanced for ice cream parlor and dietary areas.
F465-E: Cove base and tiles in dish room replaced; ceiling light covers replaced; mop sink cleaned.
F514-D: Staff educated on documenting care for resident #31 and others; restorative nurse to oversee ROM and splint programs.
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 10
Date: Sep 17, 2014
Visit Reason
The inspection was a health resurvey and complaint investigations #73169, 73741, 76600, and 76821.
Complaint Details
The inspection included 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, failure to ensure residents' rights to choose bathing frequency, inadequate housekeeping and maintenance, incomplete care plans, failure to prevent and treat pressure ulcers, unsafe resident environment, medication errors, unsanitary food storage and preparation areas, and incomplete clinical documentation.
Deficiencies (10)
F 221: The facility failed to ensure one resident (#31) was free from physical restraints used for staff convenience and lacked a physician's order for the restraint. The resident remained restrained for extended periods without scheduled release every 2 hours.
F 242: The facility failed to ensure 2 residents (#25 and #19) received the right to choose the frequency of bathing, with most residents receiving only 2 showers per week without documented preferences.
F 253: The facility failed to provide housekeeping and maintenance services to maintain a sanitary and comfortable interior, with multiple areas showing dirt, stains, broken tiles, missing paint, rust, and dead bugs across hallways, resident rooms, and common areas.
F 279: The facility failed to develop a comprehensive care plan for resident #31 that included instructions for scheduled physical restraint release to ensure least restrictive use.
F 314: The facility failed to prevent development and promote healing of a pressure ulcer for resident #32, and failed to provide timely position changes on two occasions totaling nearly 4 hours without repositioning.
F 323: The facility failed to ensure the resident environment remained free from accident hazards for resident #31 who frequently moved from bed to floor/fall mat, with inadequate documentation and a bed that did not lower to floor level.
F 332: The facility had a medication error rate of 12%, with 3 medication errors involving 3 residents, including incorrect insulin doses and administration of the wrong medication.
F 371: The facility failed to maintain a clean and sanitary food storage, preparation, and service environment, with uncovered and unlabeled food items, dirty equipment, and unsanitary conditions in kitchen and ice cream parlor areas.
F 465: The facility failed to maintain a sanitary and comfortable environment, with missing cove base molding, broken tiles, stained ceilings and floors, peeling wallpaper, and unclean sinks and utility rooms.
F 514: The facility failed to maintain complete and accurate clinical records for resident #31 related to range of motion (ROM) services, with documentation showing ROM completed only twice in a month despite care plan requirements.
Report Facts
Resident census: 55
Medication error rate: 12
Medication errors: 3
Pressure ulcer measurements: 2.5
Pressure ulcer measurements: 1
Position change interval: 2
Position change delay: 3.88
Medication dose error: 2
Medication dose error: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Reported resident #31 wore restraint for 2 hours and 42 minutes without release | |
| Staff I | Reported resident #31 wore restraint when in chair and planned to assist resident back to bed | |
| Staff M | Licensed nursing staff | Confirmed use of lap devices for positioning resident #31 and removal every 1 hour |
| Staff B | Administrative nursing staff | Confirmed lack of physician order for lap restraint and care plan instructions for resident #31 |
| Staff U | Licensed staff | Administered incorrect insulin doses to residents #35 and #5 |
| Staff T | Direct care staff | Administered wrong medication (Pepcid instead of Zantac) to resident #60 |
| Staff E | Dietary staff | Reported food items uncovered and unlabeled in kitchen and ice cream parlor |
| Staff N | Housekeeping staff | Reported janitor closet not used and cleaners improperly stored on floor |
| Staff O | Dietary staff | Reported debris in kitchen cabinet and cleaning schedule for hot cart |
| Staff D | Administrative nursing staff | Reported restorative services could be completed every shift but documentation was lacking |
| Staff Z | Direct care staff | Reported staff completed repetitious ROM exercises but documentation was lacking |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 17, 2014
Visit Reason
The 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 an 'F' level deficiency, 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 is found to be in substantial compliance based on the credible allegation of compliance and the submitted plan.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Life Safety
Deficiencies: 1
Date: Feb 11, 2014
Visit Reason
A Life Safety Code survey was conducted to determine if the facility complied 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. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was cited with an 'E' level deficiency, pattern, indicating no harm but potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter regarding the Life Safety Code survey. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 3, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 and Plan of Correction.
Findings
The revisit confirmed that all previously cited deficiencies identified by regulation numbers F0309, F0329, and F0425 were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Jan 3, 2014
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Diversicare of Sedgwick.
Complaint Details
This Plan of Correction is related to a complaint investigation identified by event ID 3F3611 and complaint ID 120413.
Findings
The plan addresses deficiencies related to physician orders, behavior/intervention documentation, and medication management. Corrective actions include staff in-service training, audits, and ongoing interdisciplinary reviews.
Deficiencies (3)
F309-D: Physician orders for new admissions were not correctly entered or implemented. The facility will review all new orders and provide staff training on proper procedures.
F329-D: Behavior/intervention monthly flow sheets were not consistently used for residents receiving psychoactive medications. The facility will implement and monitor these sheets and train staff accordingly.
F425-D: Medications were not always ordered correctly or present in the facility. The facility will audit medication orders, provide staff training, and coordinate with the pharmacy provider.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 3
Date: Dec 4, 2013
Visit Reason
Investigation into complaint #70407 regarding failure to provide necessary care and services to residents.
Complaint Details
Investigation into complaint #70407 revealed failures in care provision, medication management, and behavior monitoring.
Findings
The facility failed to follow physician orders for residents, did not identify targeted behaviors for psychoactive medications, lacked routine behavior monitoring, and failed to ensure timely acquisition and administration of medications.
Deficiencies (3)
F309: The facility failed to follow physician orders by not obtaining daily weights for a resident and not treating the insertion site of a feeding tube as ordered.
F329: The facility failed to identify targeted behaviors for psychoactive medications, lacked a system for routine behavior monitoring, and failed to ensure effectiveness of medications for multiple residents.
F425: The facility failed to ensure timely acquisition and administration of medications for residents, resulting in missed doses and lack of physician notification.
Report Facts
Facility census: 56
Sample size: 8
Residents with psychoactive medications reviewed: 3
BIMS score: 14
Depression score: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Interviewed regarding medication acquisition delays and behavior monitoring system. | |
| APRN A | Provided physician orders for resident #1. |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Jun 20, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey. It outlines corrective actions to address identified regulatory compliance issues.
Findings
The facility identified deficiencies related to comprehensive assessments of residents' functional capacity, monitoring of dialysis shunts, and management of psychotropic medications. The Plan of Correction details steps to ensure compliance through staff training, audits, and care plan updates.
Deficiencies (4)
F272: The facility failed to conduct initial and periodic comprehensive assessments for each resident's functional capacity and to complete comprehensive Care Area Assessments (CAAs) reflecting risk factors to prevent decline in ability.
F309: The facility failed to ensure staff assessed and monitored residents and their dialysis shunts following dialysis treatment for complications.
F329: The facility failed to identify and monitor specific targeted behaviors for residents on psychotropic medications and evaluate the continued effectiveness and necessity of the medication.
F428: The facility failed to ensure pharmacist identification and review of specific targeted behaviors for residents on psychotropic medications and evaluate the continued effectiveness and necessity of the medication.
Report Facts
Plan of Correction completion date: Jun 20, 2013
Mandatory in-service date: Jun 13, 2013
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 20, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as per the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously reported deficiencies identified by regulation numbers 483.20(b)(1), 483.25, 483.25(l), and 483.60(c) were corrected by the revisit date of 06/20/2013.
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 4
Date: May 29, 2013
Visit Reason
Annual health resurvey of Diversicare of Sedgwick nursing facility to assess compliance with federal regulations including comprehensive assessments, care and services, drug regimen review, and medication monitoring.
Findings
The facility failed to conduct comprehensive assessments for some residents, including cognition, urinary incontinence, and feeding tube care. It also failed to monitor a resident post-dialysis for complications and did not adequately identify or monitor behaviors related to psychotropic medications for multiple residents. The pharmacist failed to report irregularities related to psychotropic medication monitoring and indications for use.
Deficiencies (4)
F272: Facility failed to comprehensively assess cognition, urinary incontinence, and ADLs for 2 of 19 residents and failed to assess a resident with a feeding tube comprehensively.
F309: Facility failed to assess and monitor a resident for complications after dialysis treatments, including lack of documented assessment of dialysis access site.
F329: Facility failed to identify and monitor specific behaviors related to psychotropic medications for 9 of 10 sampled residents, lacking targeted behavior monitoring and indications for medication use.
F428: Pharmacist failed to report irregularities related to lack of indications for use and targeted behavior monitoring for psychotropic medications for multiple residents.
Report Facts
Residents sampled for comprehensive assessments: 19
Resident census: 55
Residents receiving dialysis: 1
Residents reviewed for medication regimen: 10
Residents with medication monitoring failures: 9
Residents with pharmacist reporting failures: 6
Inspection Report
Follow-Up
Deficiencies: 2
Date: Oct 26, 2012
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.
Findings
The report confirms that deficiencies previously reported under regulations 483.20(d), 483.20(k)(1), and 483.25(h) were corrected by 08/20/2012.
Deficiencies (2)
Regulation 483.20(d), 483.20(k)(1): Previously cited deficiencies were corrected by 08/20/2012.
Regulation 483.25(h): Previously cited deficiency was corrected by 08/20/2012.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Aug 20, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior survey. It outlines corrective actions to address issues related to care plans, accident hazards, fall prevention, and elopement procedures.
Findings
The facility acknowledged deficiencies related to the development of comprehensive care plans for personal alarm use and the provision of an environment free of accident hazards with adequate supervision and assistive devices. The facility has updated policies, trained staff, and implemented monitoring and auditing procedures to ensure compliance and resident safety.
Deficiencies (2)
F279: The facility failed to develop comprehensive care plans that include goals and timetables to direct staff in the use of personal alarms. Care plans were revised and staff received in-service training to address this issue.
F323: The facility failed to provide an environment free of accident hazards with adequate supervision and assistive devices to prevent accidents. Policies were updated, staff trained, and monitoring procedures implemented to prevent falls and elopement.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 2
Date: Aug 1, 2012
Visit Reason
The inspection was conducted as a result of complaint investigations #58134, 58175, and 58726 concerning resident care and safety issues.
Complaint Details
The inspection was triggered by complaint investigations #58134, 58175, and 58726. The complaints involved failure to develop adequate care plans and failure to provide adequate supervision and assistive devices, resulting in resident falls and elopements.
Findings
The facility failed to develop comprehensive care plans with measurable goals and timetables for residents at risk of falls and failed to provide adequate supervision and assistive devices to prevent accidents. Two residents sustained injuries due to inadequate supervision, including a fractured hip and multiple elopements.
Deficiencies (2)
F279: The facility failed to develop a comprehensive care plan including goals and timetables for a resident's use of a personal alarm to prevent falls.
F323: The facility failed to ensure the resident environment was free of accident hazards and failed to provide adequate supervision and assistive devices to prevent accidents for two residents.
Report Facts
Resident census: 59
Fall risk assessment scores: 9
Fall risk assessment scores: 11
Skin tear size: 7
Skin tear size: 3
BIMS score: 3
Elopement incidents: 3
Temperature: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff D | Named in fall incident involving resident #2 left unattended on toilet | |
| Licensed administrative staff B | Provided statements regarding fall and elopement incidents and facility policies | |
| Licensed staff C | Reported on fall supervision and wanderguard checks | |
| Licensed staff E | Verified resident's use of podus boots and lack of alarm on toilet | |
| Direct care staff F | Described resident transfer and alarm use during fall incident | |
| Direct care staff G | Described alarm use on resident while on toilet | |
| Administrative staff A | Reported on facility policies and elopement risk interventions |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040007 POC
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified as State ID N040007.
Findings
No deficiencies or findings are detailed in this document. It only references the Plan of Correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040007 POC 0ZGQ11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report for Diversicare Sedgwick.
Findings
No specific findings or deficiencies are detailed in this document. It serves solely as a Plan of Correction reference with no records found.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N040007 POC 5LVZ11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory finding for the facility identified by State ID N040007 and Event ID 5LVZ11.
Findings
No deficiency details or findings are provided in this Plan of Correction document. It only references the facility and event IDs with no records found for deficiencies.
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