A list of the most recent deficiencies for Diversicare of Sedgwick. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-02 | 2023-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-02 | 2023-09-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-02 | 2023-09-12 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-02 | 2023-09-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-02 | 2023-09-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-02 | 2023-09-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-02 | 2023-09-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-19 | 2023-08-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-19 | 2023-08-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-19 | 2023-08-25 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-07-19 | 2023-08-25 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-07-19 | 2023-08-25 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-07-19 | 2023-08-25 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-07-19 | 2023-08-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-07-19 | 2023-08-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-19 | 2023-08-25 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-07-19 | 2023-08-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-19 | 2023-08-25 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-07-19 | 2023-08-25 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-07-19 | 2023-08-25 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-07-19 | 2023-08-25 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-19 | 2023-08-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-19 | 2023-08-25 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-11 | 2022-03-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-11 | 2022-03-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-11 | 2022-03-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-11 | 2022-03-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-11 | 2022-03-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-11 | 2022-03-15 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-01-11 | 2022-03-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-11 | 2022-03-15 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-07 | 2022-03-07 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-02-07 | 2022-03-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-07 | 2022-03-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-02-07 | 2022-03-07 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-07 | 2022-03-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-07 | 2022-03-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-07 | 2022-03-07 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-07 | 2022-03-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-02-07 | 2022-03-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-07 | 2022-03-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-02-07 | 2022-03-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-29 | 2021-10-13 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Use approved construction type or materials. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-01-06 | 2021-02-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-11-03 | 2020-12-11 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-11-03 | 2020-12-11 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-11-03 | 2020-12-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2020-11-03 | 2020-12-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-11-03 | 2020-12-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-11-03 | 2020-12-11 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-11-03 | 2020-12-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-11-03 | 2020-12-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-11-03 | 2020-12-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-11-03 | 2020-12-11 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-11-03 | 2020-12-11 | N |
| Post nurse staffing information every day. | Health | 2020-11-03 | 2020-12-11 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-11-03 | 2020-12-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-11-03 | 2020-12-11 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-11-03 | 2020-12-11 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2020-11-03 | 2020-12-11 | N |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2020-11-03 | 2020-12-11 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2020-11-03 | 2020-12-11 | N |
