Sedgwick County Memorial Nursing Home

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#7) of four residents reviewed for accidents out of 18 sample residents remained free of accidents. Resident #7, who was identified as a high fall risk, sustained a fall on 2/27/25 resulting in bruising to her forehead. The facility failed to review the resident's care plan after the fall to determine if the resident's fall interventions were effective or if new interventions were needed to prevent further falls. Additionally, documentation failed to indicate the resident was assessed by a registered nurse (RN) following the fall. On 5/31/25, Resident #7 sustained another fall which resulted in a hospitalization for a hip fracture. Again, documentation failed to indicate the resident was assessed by a RN following the fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. Specifically, the facility failed to use the services of a RN for at least eight consecutive hours a day for seven days a week.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide nursing services according to accepted professional standards of clinical practice for two (#17 and #18) out of 18 residents reviewed out of 18 sample residents. Specifically, the facility: -Failed to transcribe physician's orders into the electronic medical record (EMR) correctly for Resident #17 and Resident #18; and,-Failed to notify a provider when Resident #17 had a change in condition and obtain a physician's order to hold a routinely scheduled medication

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#17) of one resident reviewed for significant medication errors out of 18 sample residents. Specifically, the facility failed to ensure that Resident #17 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper storage of medications in one of one medication carts and one of one medication storage rooms. Specifically, the facility failed to: -Ensure medications were labeled with the date they were opened; and,-Ensure expired medications were removed and discarded from medication carts.

Inspectors wroteBased on observations, record review and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of one units. Specifically the facility failed to:-Ensure an effective process to identify residents who required enhanced barrier precautions (EBP); -Ensure staff were aware of which residents required EBP; -Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing direct care to residents who required EBP; and,-Ensure staff sanitized the rubber stop on an insulin pen before administering to Resident #17.

Inspectors wroteBased on observations and interviews, the facility failed to maintain the emergency response cart and equipment in safe operating condition for one of one emergency response (crash) cart. Specifically, the facility failed to: -Ensure staff completed the daily equipment checks; -Ensure expired items were removed from the crash cart; and, -Ensure emergency oxygen canister on the emergency response cart was maintained and ready for use.

Inspectors wroteBased on observations and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the possible development and transmission of Coronavirus (COVID-19) on one of one unit. Specifically, the facility failed to: -Ensure staff wore and removed personal protective equipment (PPE) correctly; and, -Ensure infection control practices were followed during medication pass.

Inspectors wroteBased on resident observation, record review, and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for one (#12) of one resident with a pressure ulcer out of 15 sample residents. Resident #12, who was totally dependent on the assistance of two staff members for bed mobility, transfers, dressing, and toilet use, was known to be at risk for skin impairment due to her immobility, poor nutrition, and diagnosis of diabetes. The resident developed a pressure injury to the left heel on 3/23/22. The facility initially classified the pressure injury as a stage 2 pressure injury, despite documentation indicating the wound was covered by eschar (dead/necrotic tissue) which would classify the wound as an unstageable pressure injury as indicated by staff interviews. [...]

Inspectors wroteBased on observations, record review, and interviews; the facility failed to maintain acceptable parameters of nutritional status for one (#12) of four residents reviewed for nutrition out of 15 sample residents. The facility failed to identify and implement appropriate interventions to prevent a significant weight loss for Resident #12. On 2/20/22, the resident weighed 165.4 pounds (lbs). On 8/14/22, the resident weighed 144.1 lbs, which was a loss of 21.3 pounds in six months. During the six month time frame, the facility failed to reassess Resident #12's nutritional supplement for effectiveness, despite nutrition assessments which indicated the resident was malnourished. The facility's failure to reassess Resident #12's nutritional status resulted in the resident sustaining a significant weight loss of 12.88% in six months. [...]

Inspectors wroteBased on record review and interviews, the facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full time basis. Specifically, the facility utilized the nursing home administrator (NHA) to also serve as the DON and she was unable to work full time hours as the DON. Cross-reference F686 for the facility's failure to monitor and prevent pressure ulcers.

Inspectors wroteBased on record review and interviews, the facility failed to employ a director of food and nutrition services with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 23 census residents. Specifically, the facility utilized the nursing home administrator (NHA) to also serve as the dietary manager (DM) and she was unable to work full time hours as the DM. Cross-reference F692 for the facility's failure to monitor and prevent significant weight loss.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were as free from unnecessary psychotropic drugs as possible for three (#6, #8 and #14) of six residents out of 15 sample residents. Specifically, the facility failed to: -Provide documentation that a risk versus benefit statement to justify the resident's continual use of the medications was provided to the resident and/or the resident's representative for Resident #6, Resident #8, and Resident #14; -Attempt a gradual dose reduction (GDR) of an antipsychotic medication for a resident with dementia for Resident #6 and Resident #8; and, -Appropriately assess Resident #14's need for the use of an antipsychotic medication for a diagnosis of nausea.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection, including COVID-19 for two of two rooms. Specifically, the facility failed to: -Ensure housekeeping staff followed proper hand hygiene protocols when cleaning resident rooms; -Ensure proper room cleaning procedures were followed; -Ensure spray bottles were properly labeled with the disinfectant they contained; and, -Ensure housekeeping staff adhered to the appropriate wet/contact/dwell time (the time a chemical must remain in contact on a surface in order to eradicate organisms) for disinfection.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all staff had current abuse and dementia care training. Specifically, the facility failed to ensure five out of five licensed nurses and CNAs reviewed within the previous year received dementia management training and abuse prevention training.