Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sedgwick County Memorial Nursing Home during CMS and state inspections, most recent first.
A resident with dementia, osteoporosis, severe cognitive impairment, and high fall risk had repeated unwitnessed falls with injury, including forehead bruising and later a hip fracture requiring hospitalization and surgery. The record did not show that the resident’s fall care plan was reviewed after either fall to determine whether interventions were effective or needed changes, and documentation also failed to show an RN assessed the resident after the falls. Staff interviews indicated LPNs were performing post-fall assessments and were not aware an RN assessment was required.
Failure to Maintain Required RN Coverage: The facility did not have an RN on duty for at least 8 consecutive hours a day, 7 days a week. Schedule review showed multiple days with no RN scheduled, and the DON confirmed there was no RN in the building on those dates. The DON said she was on-call by phone to assist the LPN, and the CEO stated the facility had long lacked consistent RN coverage despite recruitment efforts and attempts to obtain a federal staffing waiver.
Failure to Prime Insulin Pen Before Administration: An LPN administered Humalog insulin to a resident with type 1 DM after checking a blood sugar of 316 mg/dl, but did not prime the insulin pen before giving the 10-unit dose. The resident had multiple sclerosis and severe cognitive impairment. The DON stated insulin pens must be primed before administration to ensure the full correct dose is delivered.
Medication Storage and Labeling Deficiencies: An LPN was observed with a medication cart containing open inhalers that were labeled for residents but lacked open dates, along with multiple expired medications including house stock tablets, suppositories, and eye drops. The DON stated the pharmacist completed monthly audits and night shift nurses were expected to audit the cart every two weeks during pharmacy changeover.
Infection Control Program Failures: Staff did not consistently identify residents who required EBP, and an LPN provided feeding tube care to a resident with a feeding tube without wearing the required gown. Interviews showed staff were unclear about when EBP applied and what PPE was required for device care. The facility also failed to wipe the rubber seal on a Humalog insulin pen before administration to a resident, and the DON stated the seal should be sanitized before use.
An LPN incorrectly transcribed physician orders into the EMR for two residents, including a sliding-scale Humalog order that did not match the prescribed glucose ranges and a morphine order entered at 2.5 ml instead of 0.25 ml. The DON said the incorrect morphine order was signed off without verifying it matched the prescription and an automated dose warning was missed. The facility also failed to promptly notify the provider when a resident’s blood sugar dropped to 53 mg/dl and Lantus was held.
Failure to reassess fall interventions and obtain RN assessment after resident falls
Penalty
Summary
The facility failed to ensure that a resident identified as a high fall risk remained free from accidents and that fall events were fully evaluated after they occurred. The resident had diagnoses including unspecified dementia, osteoporosis, chronic respiratory failure with hypoxia, chronic fatigue, and urinary incontinence. She used a walker and wheelchair, required extensive staff assistance with many activities of daily living, and had severe cognitive impairment with a BIMS score of 5 out of 15. Her fall care plan identified her as high risk for falls due to gait imbalance, poor safety awareness, and a history of fracture. After a fall with forehead bruising, documentation showed the resident complained of dizziness when standing, and an incident report described swelling and redness to the right forehead after she reportedly hit her head on a bed frame. However, the record did not show that the facility reviewed her fall care plan after this fall to determine whether the existing interventions were effective or whether new interventions were needed. The incident report also did not document that the resident was assessed by an RN after the fall. The resident later sustained another unwitnessed fall that caused injury to the right hip and a skin tear with bruising to the hand. She was unable to perform range of motion, had extreme right hip pain, EMS was called, and she was transported to the hospital, where she was found to have a closed right hip fracture requiring surgical repair. Again, the documentation did not show an RN assessment after the fall, and the record did not show that the facility reviewed the resident’s fall care plan after the event to determine whether the interventions were effective or whether additional interventions were needed. Staff interviews indicated LPNs were assessing residents after falls and that they were not aware an RN assessment was required.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to use the services of an RN for at least eight consecutive hours a day, seven days a week. A review of the facility’s April, May, and June 2025 nursing schedules showed multiple days when no RN was scheduled in the building, including 4/12/25, 4/13/25, 4/27/25, 5/11/25, 5/25/25, 5/26/25, 6/17/25, 6/21/25, 6/22/25, 6/28/25, and 6/29/25. The facility’s Staffing policy stated that the facility would employ appropriately qualified staff, including RNs and LPNs, and that adequate coverage would be determined by routine staffing schedules and additional staffing needs as determined by the charge nurse, DON, or NHA. During interview, the DON confirmed there was no RN in the building on the listed dates and stated she was on-call and available by phone to assist the LPN if an RN assessment was needed. The CEO and DON stated the facility had not had RN coverage seven days a week for eight consecutive hours each day for as long as the CEO was aware. The CEO said the facility was actively recruiting RNs through job postings, social media, and newspaper advertisements, offered sign-on bonuses, covered 80% of health insurance premiums, and offered shift differentials, but still had not obtained consistent RN coverage. The CEO also stated the facility had attempted to obtain a federal staffing waiver and believed the state staffing waiver did not cover the federal requirement.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure that Resident #17 was free from a significant medication error when an LPN administered Humalog insulin without properly priming the insulin pen first. Resident #17 was admitted with multiple sclerosis, type 1 diabetes, and neuromuscular dysfunction of the bladder, and the 6/30/25 MDS documented severe cognitive impairment with a BIMS score of 3 out of 15. On 9/8/25, the LPN checked the resident’s blood sugar in the dining room while he was eating lunch and obtained a result of 316 mg/dl. The LPN removed the resident’s Humalog insulin pen from the medication cart, attached a needle, dialed the pen to 10 units, and administered the insulin to the resident in the dining room. The LPN did not prime the insulin pen before giving the dose. She stated she had been told during orientation that insulin pens were only primed when first opened, although she had previously worked in other facilities where pens were primed before each administration. The DON stated that insulin pens had to be primed to one or two units before dialing up and administering the dose, and that priming was important to ensure the resident received the full correct dose of insulin.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly labeled with the date they were opened and failed to remove expired medications from the main medication cart. During an observation of the cart with an LPN, an open Trelegy inhaler and an open Advair Diskus inhaler were found labeled with resident information but without an open date. The LPN stated she believed the Trelegy inhaler had come from assisted living unlabeled and said she would dispose of both inhalers and ensure the residents who used them had new ones. The facility also failed to remove expired medications from the same medication cart. Observed items included an open bottle of house stock ibuprofen tablets with an expiration date of August 2025, an open bottle of house stock Senokot tablets with an expiration date of August 2025, a bag of bisacodyl rectal suppositories with an expiration date of 3/19/25, and an open bottle of loteprednol-tobramycin eye drops that had been opened on 6/24/25 and expired 30 days after opening. The LPN confirmed the expiration dates and said she would dispose of the expired medications. The DON stated that the pharmacist conducted monthly audits of the medication cart and medication storage room, and that night shift nurses were expected to audit the medication cart every two weeks during medication changeover with the pharmacy.
Infection Control Program Failures
Penalty
Summary
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. Surveyors found that the facility did not ensure an effective process to identify residents who required enhanced barrier precautions (EBP), did not ensure staff were aware of which residents required EBP, and did not ensure staff donned appropriate PPE when providing direct care to residents who required EBP. Resident #5 had a feeding tube and was observed receiving care that included disconnecting and reconnecting tubing, placing a drain sponge around the feeding tube insertion site, flushing the feeding tube with water, hanging and pouring formula into the feeding bag, and performing oral care. During one observation, an LPN wore gloves but did not wear a gown while providing care to the resident. The facility had a policy stating that residents with wounds or indwelling medical devices required EBP and that gown and glove use was required during high-contact resident care activities. Interviews showed one LPN did not know what EBP was or when it was required, and another LPN stated she was not aware she needed to wear PPE for feeding tube device care. The DON stated that residents with any medical devices or openings to the body required EBP and that PPE for residents on EBP included a gown, gloves, and a face shield if there was risk for splashing. The DON also stated that EBP had been overlooked until staff questioned it during the survey, and that the resident was placed on EBP only after the issue was identified. The DON further stated that there were three residents on EBP in the building and that the facility had recently implemented EBP after recognizing the need to do so. The facility also failed to sanitize the rubber seal on a Humalog insulin pen before administration to Resident #17. An LPN removed the insulin pen from the medication cart, attached a needle to the pen without wiping the rubber seal with alcohol, dialed the dose, and administered the insulin after wiping the resident's arm with an alcohol swab. The LPN stated she had been told during orientation that insulin pens were only primed when first opened, and she had not clarified that information with the DON. The DON stated that the rubber seal should be wiped with an alcohol wipe before preparing the pen and that this was important to avoid placing a clean needle onto a dirty surface.
Incorrect EMR order transcription and failure to notify provider for low blood sugar
Penalty
Summary
The facility failed to provide nursing services according to accepted professional standards of clinical practice for two residents by incorrectly transcribing physician orders into the EMR. One resident had multiple sclerosis, type 1 diabetes, neuromuscular bladder dysfunction, and severe cognitive impairment with a BIMS score of 3. After returning from the hospital, an LPN checked the resident’s blood sugar while he was eating lunch and found it was 316 mg/dl, then realized the sliding-scale Humalog order in the EMR did not match the physician’s order. The order in the record listed insulin doses for several glucose ranges but did not include a range for 316-320 mg/dl, and the LPN stated the new order had not been transcribed correctly. A second resident had malignant neoplasm of the uterus, acute kidney failure, hypertension, and moderate cognitive impairment with a BIMS score of 10. The record showed morphine sulfate oral solution orders that were entered incorrectly in the EMR as 2.5 ml instead of 0.25 ml. The DON stated the LPN brought the order to her when entering it into the computer, that the final checkmark was completed without verifying the order matched the prescription exactly, and that an automated warning about the dose being outside the recommended range was not seen. The DON also stated the incorrect order was never corrected and that the controlled substance count sheet showed the resident received 0.25 ml each time. The facility also failed to notify a provider when the first resident had a change in condition and to obtain an order to hold a routinely scheduled medication. A nursing progress note documented a fasting blood sugar of 53 mg/dl at breakfast, and the nurse did not give Lantus; the blood sugar later was 91 mg/dl at lunch. The DON stated blood sugars outside normal limits should be reported to the provider on call right away and should not be placed on a non-urgent provider note list. An LPN stated she would notify the provider, DON, and medical POA right away for a change in condition and would notify the DON and provider if a scheduled medication could not be administered.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Julesburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regent Park Care Center | 28.7 mi | ★★★★★ | 2 | 0 |
| Garden County Hospital & Nursing Home | 29.2 mi | ★★★★★ | 6 | 0 |
| Western Sky Community Care Center Inc | 29.9 mi | — | 0 | 0 |
| Indian Hills Manor | 30.5 mi | ★★★★★ | 2 | 0 |
| Srmc Long Term Care, Llc Dba Pole Creek Estates | 36.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.