Sedgwick County Memorial Nursing Home

In the surveyor’s words

From the most serious findings on record at Sedgwick County Memorial Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 10, 2025

  Based 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. […]

• Actual harm, isolatedF686Aug 31, 2022

  Based 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 [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF692Aug 31, 2022

  Based 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. […]

• No harm, potential for more than minimal, widespreadF727Sep 10, 2025

  Based 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.Findings include: I. Facility policy and procedure The Staffing policy, undated, was received from the director of nursing (DON) on 9/10/25. It documented in pertinent part, It is the policy of this facility to employ appropriately qualified staff that shall consist of registered nurses (RN) and licensed practical nurses (LPN), who maintain current licensure or certification in the state of Colorado, and also certified nurse aides. […]

• No harm, potential for more than minimal, widespreadF908Dec 13, 2023

  Based 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. Findings include: I. Professional references A. According to [NAME], [NAME], (2022). Crash cart preparedness and failure to rescue a case study review. […]