Diversicare of Sedgwick

Inspectors wroteThe facility had a census of 48 residents. The sample included six residents with one resident reviewed for involuntary discharge. Based on interviews and record review, the facility failed to ensure Resident (R) 1's Electronic Health Record (EHR) contained physician documentation of the rationale for the involuntary immediate discharge. This placed the resident at risk for impaired rights and inappropriate discharge.

Inspectors wroteThe facility reported a census of 42 residents. The sample included 15 residents, which included three residents selected for closed record review. Based on interviews and record review the facility failed to provide the necessary care and service needed to manage symptoms when staff failed to promptly identify and react to a change in condition for Resident (R) 29, who had diabetes mellitus. On 05/04/25 R29 refused all his morning medication including his diabetic medications; R29's blood glucose was 388 milligrams (mg) per deciliter (dL) at 05:45 AM that morning. Staff did not notify R29's physician of the medication refusal or the abnormally high blood glucose level. On the evening of 05/04/25, R29 refused all his medications again and had a blood glucose of 513 mg/dL at 09:00 PM but staff did not notify the provider of the dangerously high blood glucose or the medication refusals. [...]

Inspectors wroteThe facility reported a census of 42 residents. Five Ceritifed Nurse Aide (CNA) were reviewed with three reviewed for annual performance evaluations. Based on interview and record review, the facility failed to complete annual performance reviews for two of the three CNA staff that were employed for a year or more. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility reported a census of 42 residents. The sample included 15 residents. Based on interviews, record reviews, and observation, the facility failed to ensure a safe environment in all areas of the facility including the laundry area. This deficient practice created the risk for contaminated laundry and fires.

Inspectors wroteThe facility reported a census of 42 residents. The sample included 15 residents. Based on interviews, record reviews, and observation, the facility failed to implement professional standards of care related to infection control practices during direct care and laundry services. This deficient practice placed the residents at risk for infections.

Inspectors wroteThe facility identified a census of 42 residents. The sample included 15 residents with one reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 21, a resident in a persistent vegetative state (state of wakefulness accompanied by a complete lack of cognitive function) received adequate restorative care, including the application of splints, to minimize further decline. This deficient practice placed R21 at risk for increased pain and contractures (abnormal fixation of joints or muscles).

Inspectors wroteThe facility identified a census of 42 residents. The sample included 15 residents with one reviewed for enteral nutrition (provision of nutrients through the gastrointestinal tract when the resident cannot ingest, chew, or swallow food). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 21, a resident fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding when staff failed to monitor R21's weight routinely and/or as ordered. This placed the resident at risk for continued weight loss and malnutrition.

Inspectors wroteThe facility reported a census of 42 residents. There were 15 residents in the sample, with one resident reviewed for trauma-informed care. Based on observation, interview, and record review the facility failed to develop and implement approaches to care that were both clinically appropriate and person-centered for Resident(R) 12, who had a history of personal trauma and substance abuse. This placed the resident at risk for decreased quality of life and re-traumatization.

Inspectors wroteThe facility reported a census of 40 residents. Based on interview and record review, the facility failed to ensure sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being.

Inspectors wroteThe facility reported a census of 40 residents. Based on interview and record review the facility failed to complete annual competency performance reviews at least once every 12 months for five of the five Certified Nurse Aides (CNA) and Certified Medication Aides (CMA) reviewed, CNA N, CNA NN, CNA OO and CMA T and CMA S, to ensure adequate appropriate cares and services provided to the residents of the facility.

Inspectors wroteThe facility reported a census of 40 residents. Based on observation, interview and record review, the facility failed to store, prepare, serve food to the residents in a sanitary [NAME] to prevent the outbreak of foodborne illness, regarding the failure of wearing hairnets, dirty reach-in freezers, and reach-in refrigerators and six plastic drawers which contained cooking utensils.

Inspectors wroteThe facility reported a census of 40 residents. Based on observation, interview and record review, the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) program identified resident care issues to enhance the residents' quality of life, failed to implement appropriate and effective action plans for environmental issues and resident care issues.

Inspectors wroteThe facility reported a census of 40 residents. Based on observation, interview, and record review the facility failed to ensure an effective infection control program in the facility with the failure to maintain accurate tracking and trending of infections in the facility, failure to store supplies in a sanitary manner, and failure to ensure housekeeping staff were knowledgeable on the effective use of cleaning chemicals.

Inspectors wroteThe facility reported a census of 40 residents. Based on observation, interview and record review, the facility failed to ensure a safe, sanitary, and homelike environment for the residents residing in seven resident rooms of the facility.

Inspectors wroteThe facility reported a census of 40 residents with 16 residents sampled, including four residents reviewed for Activities of Daily Living (ADL). Based on observation, interview and record review, the facility failed to provide facial grooming for two Residents (R)10 and R 7, failed to ensure one R 4 changed into clean clothing and failed to get one R 34 out of bed and dressed for the entirety of a day.

Inspectors wrote- Review of Resident (R)24's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) and weakness. The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. She required extensive assistance of one for locomotion on the unit and had impairment on one side of her lower extremity. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/20/22, did not trigger. The Cognitive Loss/Dementia CAA, dated 12/20/22, documented the resident had a diagnosis of dementia. The quarterly MDS, dated 06/02/23, documented the resident had a BIMS score of four, indicating severe cognitive impairment. [...]

Inspectors wroteThe facility reported a census of 40 residents with five residents reviewed for immunizations. Based on interview and record review. The facility failed to offer residents COVID-19 vaccinations per the CDC (Center for Disease Control) guidelines.

Inspectors wroteThe facility reported a census of 40 residents, with 16 sampled for review. Based on observation, interview, and record review the facility failed to review and revise the plan of care for two sampled residents including Resident (R)13 with psychotrophic medications and )13 for foot pedals on the wheelchair.

Inspectors wroteThe facility reported a census of 40 residents with 16 residents sampled, including three residents reviewed for bowel and bladder. Based on observation, interview and record review, the facility failed to toilet one dependent Resident (R)8 timely and failed to complete a 72-hour voiding diary to assist the staff in the development of an individualized toileting program to assist R 30 improve or maintain his bladder continence.

Inspectors wroteThe facility reported a census of 40 residents with 16 residents sampled, including three residents reviewed for respiratory care. Based on observation, interview and record review, the facility failed to ensure one of the three sampled resident's (R)10 oxygen concentrator had a humidifier bottle.

Inspectors wroteThe facility reported a census of 40 residents with 16 residents sampled, including two residents reviewed for pain. Based on observation, interview and record review, the facility failed to provide adequate pain relief for one of the two sampled residents, Resident (R)10 in order to remain free from pain as possible.

Inspectors wroteThe facility reported a census of 40 residents with 16 residents selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to follow up on pharmacy recommendations for one Resident (R) of the five residents reviewed for unnecessary medications.

Inspectors wroteThe facility reported a census of 40 residents with 16 residents sampled, including five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure Resident (R)4 was kept free from unnecessary medications, by failing to notify the physician of blood sugars (BS) outside of ordered parameters, in case of the need for change in the medication.

Inspectors wroteThe facility reported a census of 40 residents with 16 residents selected for review, which included five residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure two Residents (R)34 and R36, of the five residents had Abnormal Involuntary Movement Scale (AIMS) assessments for monitoring, when they received antipsychotic medications.

Inspectors wroteThe facility census totaled 39 residents, with five residents reviewed for skin issues. Based on observation, interview, and record review the facility failed to order and provide four days (11/01/21-11/04/21) of continued intravenous antibiotic treatment as ordered for Resident (R)7, who was continuing post-surgical recovery for osteomyelitis and gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) treatment to his left foot. On 11/01/21 R7's Infectious Disease Provider prescribed Zosyn (antibiotic) intravenously (IV, through the vein) three times a day for an additional two weeks. The interruption in the IV antibiotic treatment for R7 resulted in worsening of wound and the potential for regrowth of the infection, osteomyelitis, and gangrene. [...]

Inspectors wroteThe facility reported a census of 39 residents. Based on observation, interview, and record review, the facility failed to provide maintenance services to ensure a safe and sanitary environment for residents and staff in the facility laundry area.

Inspectors wroteThe facility reported a census of 39 residents, with 21 sampled and five residents for medication review as well as concerns of abuse, neglect and exploitation (ANE). Based on observation, interview, and record review the facility failed to complete an investigation, for Resident (R) 7, when the facility failed to administer four days of Zosyn (antibiotic) intravenously (IV; through the vein) from 11/01/21 through 11/04/21, resulting in a medication error. The facility also failed to administer ordered STAT (immediately) IV fluids to R10 as ordered by the physician, resulting in the fluids being administered over 24 hours later and creating an error in followoing physician orders. [...]

Inspectors wroteThe facility reported a census of 39 residents with 21 selected for review which included four residents reviewed for activities of daily living (ADL). Based on observation, record review, and interview the facility failed to provide necessary services to maintain good personal hygiene for one resident, Resident (R)23, related to nail care.

Inspectors wroteThe facility reported a census of 39 residents with five residents reviewed for pressure ulcers. Based on interview and record review, the facility failed to provide necessary treatment and services to promote healing for two of the five sampled residents, Resident (R) 4 and R17, who had pressure ulcers.

Inspectors wroteThe facility reported a census of 39 residents with 21 sampled including two residents reviewed for hydration. Based on interview and record review, the facility failed to administer IV (intravenous) fluids in accordance with the physician orders for one of the two residents (R)10, when the physician ordered IV fluids given stat (immediately) and the staff failed to implement the IV fluids for over 24 hours for the resident's dehydration.

Inspectors wroteThe facility reported a census of 39 residents with 21 selected for review, which included three residents sampled for respiratory care. Based on observation, interview, and record review, the facility failed to provide appropriate respiratory care related to maintaining respiratory equipment to prevent the spread of infection, consistent with standard of practice and person centered care plan for two residents (R)29, and R 11 related to storage of oxygen/nebulizer tubing and cannula when not in use and changing of the oxygen concentrator humidifier bottle and tubing cannula.

Inspectors wroteThe facility reported a census of 39 residents with 21 sampled. Based on record review and interview, the facility failed to maintain medical records in accordance with accepted professional standards and practices for two of the 21 sampled residents, including Resident (R) 10, that were complete and accurately documented, when R10 discharged from the facility on [DATE] at approximately 09:40 AM to the hospital and the attending nurse failed to update and complete the resident's medical record with these changes in condition. In addition, the facility failed to document a request in the medical record from R29 related to obtaining a mammogram.