Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Diversicare Of Sedgwick during CMS and state inspections, most recent first.
A resident with Huntington's disease, severe behavioral issues, and a history of self-harm was involuntarily discharged following repeated episodes of aggression and suicide attempts. Although staff intervened and documented the events, the EHR did not contain physician documentation specifying the rationale for the discharge or the services the facility could not provide, resulting in a deficiency.
A resident with insulin-dependent diabetes and other comorbidities refused all scheduled medications, including diabetic medications, and had critically high blood glucose readings on two occasions. Staff did not notify the provider of the medication refusals or abnormal blood glucose levels, nor did they document these events, despite facility protocols requiring such actions. The resident was later found unresponsive and required hospitalization due to the lack of timely intervention.
The facility did not complete annual performance evaluations for two out of three CNAs who had been employed for a year or more. One CMA's evaluation lacked the required employee signature, and another CMA's evaluation was not current. The administrative nurse confirmed that annual evaluations are necessary to identify and address staff weaknesses.
Surveyors observed that the laundry area was unsafe and poorly maintained, with uncovered fluorescent light fixtures, rusted housings, cracked and peeling ceiling paint, an open grate drain with standing water, exposed drywall, lint and dust accumulation, and dryer lint covering the wall behind the dryers near electrical boxes. Maintenance staff confirmed recent issues with dryer vent lines, and there was no policy in place for laundry area maintenance.
Staff did not follow infection control protocols during care of a resident with a tracheostomy and Foley catheter, including failing to change gloves, perform hand hygiene, and prevent cross-contamination between soiled and clean items. Additionally, clean laundry was handled in a shared space with non-laundry items and an open drain, with no policy guidance on linen management, leading to unsanitary conditions.
A resident in a persistent vegetative state, fully dependent on staff and with existing contractures, did not receive required restorative care or the application of splints as outlined in the care plan. Staff were unaware of the location or status of the splints, and no restorative program or ROM exercises were provided, contrary to facility guidelines. This resulted in the resident being observed without necessary boots or hand braces, with limbs in contracted positions.
A resident dependent on enteral nutrition due to a persistent vegetative state did not have weights consistently monitored or documented as ordered, despite care plans and physician directives requiring weekly weights. Staff sometimes failed to obtain weights or failed to record them in the EMR, and the resident experienced a gradual weight loss over several months. This failure to follow established protocols placed the resident at risk for ongoing weight loss and malnutrition.
A resident with diagnoses of major depressive disorder, anxiety, PTSD, and a history of substance abuse did not have a care plan that addressed trauma triggers, adjustment difficulties, or substance use history. Facility staff failed to recognize or document these issues, and the facility lacked a trauma-informed care policy.
Lack of Physician Documentation for Involuntary Discharge
Penalty
Summary
The facility failed to ensure that a resident's Electronic Health Record (EHR) contained physician documentation of the rationale for an involuntary immediate discharge. The resident in question had a complex medical history, including Huntington's disease, anxiety, a history of suicidal behavior, and major depressive disorder. The resident exhibited behaviors such as physical and verbal aggression, self-harm, and rejection of care, which were documented in multiple staff progress notes and assessments. Despite these ongoing behavioral issues and repeated hospitalizations for psychiatric evaluation, the EHR lacked physician documentation specifying the services the facility was unable to provide or that the resident posed a risk to the safety of others. On the day of the discharge, the resident became acutely agitated, removed window blinds, expressed suicidal intent, and attempted to strangle himself with the blinds. Staff intervened, administered PRN medications, and called Emergency Medical Services (EMS) when the situation escalated. The resident was transported to a hospital for further evaluation and treatment. The facility notified the resident's representative and documented the discharge in the EHR, stating that the resident's needs could no longer be met and that he posed a safety risk to others. However, the discharge letter and EHR did not include physician documentation detailing the specific reasons for the discharge as required by facility policy. Interviews with administrative staff confirmed that the discharge was unplanned and that the facility had exhausted available resources to manage the resident's behaviors. The facility had attempted to refer the resident to specialized units, but these referrals were declined due to the resident's history of self-harm. Despite these efforts, the required physician documentation supporting the involuntary discharge was not present in the EHR, constituting a deficiency in meeting regulatory requirements for safe and appropriate resident transfer or discharge.
Failure to Notify Provider and Respond to Diabetic Change in Condition
Penalty
Summary
A resident with multiple complex medical conditions, including insulin-dependent type 2 diabetes mellitus, congestive heart failure, depression, anorexia, and acute osteomyelitis, experienced a significant change in condition when he refused all scheduled medications, including diabetic medications, on both the morning and evening of a specific day. Despite a fasting blood glucose reading of 388 mg/dL in the morning and a subsequent reading of 513 mg/dL in the evening—both well above the facility's standing order threshold for physician notification—there was no evidence that staff notified the resident's physician of either the medication refusals or the dangerously high blood glucose levels. The resident's care plan specifically directed staff to observe for symptoms of high blood sugar and to report changes in condition to the nursing staff or physician, but these directives were not followed. The resident's electronic medical record and medication administration records lacked documentation of any provider notification regarding the medication refusals or abnormal blood glucose levels. Additionally, there were no progress notes entered for the days in question, despite the resident's significant change in status. Interviews with nursing staff and administrative personnel confirmed that facility protocol required provider notification for blood glucose levels above 350 mg/dL and for medication refusals, but these protocols were not adhered to in this case. Staff also reported that charting was done by exception, and no notes were made because the resident was perceived as lucid and responding appropriately, despite the abnormal clinical findings. The failure to promptly identify and respond to the resident's change in condition, including the lack of immediate physician involvement, resulted in the resident becoming unresponsive the following morning and requiring emergency hospitalization. The facility's own investigation confirmed that the responsible nurse did not perform required duties related to medication administration and documentation. This series of inactions constituted a failure to provide necessary care and services as required by the resident's care plan and facility policy.
Failure to Complete Annual Performance Evaluations for Direct Care Staff
Penalty
Summary
The facility failed to complete annual performance evaluations for two out of three Certified Nurse Aides (CNAs) who had been employed for a year or more, as determined by employee record review and staff interview. Specifically, one Certified Medication Aide's (CMA) annual performance evaluation was not completed with the required employee signature, and another CMA's most recent evaluation was not current. The administrative nurse confirmed that annual evaluations should be conducted for direct care staff to identify weaknesses and address them to ensure adequate care for residents. Additionally, the facility was unable to provide a policy related to annual performance evaluations.
Unsafe and Poorly Maintained Laundry Area
Penalty
Summary
The facility failed to ensure a safe and properly maintained environment in the laundry area, as evidenced by multiple observations. Fluorescent light fixtures above the washers and dryers lacked covers, and several fixtures had exposed rust on their metal housings. The ceilings above the laundry machines had cracked and peeling paint. An open grate drain with standing water was present in front of the washing machines, and washing machine detergent hoses were routed through an open hole in the wall with exposed drywall beneath a vent covered in lint and dust. The wall behind the dryers was covered in dryer lint, with several electrical boxes located on this wall. Maintenance staff confirmed that lint had been blowing onto the floor and wall due to issues with the dryer vent lines, which had recently been re-taped. Additionally, the facility did not have a policy addressing maintenance requirements for the laundry service areas.
Failure to Implement Infection Control Practices During Resident Care and Laundry Services
Penalty
Summary
Staff failed to follow professional standards of infection control during direct care and laundry services. In one instance, a resident in a persistent vegetative state with a tracheostomy, Foley catheter, and feeding tube was observed being cared for by a CNA and CMA who did not change gloves or perform hand hygiene after handling soiled items. The CMA used soiled gloves to touch clean items, such as a neck pillow and a clean brief, and did not use a fresh wipe for each cleaning pass. Additionally, a pillow that had fallen to the floor was placed back on the resident's bed and near the tracheostomy site. Staff also failed to keep the catheter bag below the level of the bladder during transfers, and some staff were unaware of this requirement. Interviews confirmed that staff were not fully aware of proper infection control practices, despite facility policies outlining these standards. In the laundry area, there was an open grate drain with standing water in front of the washing machines, and clean laundry was folded and stored in a room that also served as the dietary manager's office and housed the time clock. Non-laundry items were present on the clean folding table, and the facility's infection control policy did not address the storage and management of resident linen during the laundry process. These practices failed to ensure a sanitary environment and increased the risk of contamination.
Failure to Provide Restorative Care and Splint Application
Penalty
Summary
The facility failed to provide adequate restorative care for a resident in a persistent vegetative state who was dependent on staff for all care and had documented arm and foot contractures. The resident's care plan included the use of heel boots and positioning with stuffed animals to maintain skin integrity, but lacked interventions for wrist braces. Observations revealed that the resident was not wearing required boots or hand braces, and her limbs were positioned in a way that could contribute to further contractures. Staff interviews confirmed that wrist splints were missing or broken, and that there was no active restorative program in place. Certified Nurse Aides (CNAs) reported not performing range of motion (ROM) exercises or restorative programs, and therapy staff found the splints unused and stored away. Further interviews with nursing and administrative staff revealed that the facility had not had a restorative program for an extended period, and no restorative assessments or evaluations had been completed due to lack of trained staff. The facility's own guidelines required residents to be screened or evaluated for restorative programs when needed, but this was not done for the resident in question. The lack of restorative care and failure to apply necessary splints placed the resident at risk for increased pain and contractures.
Failure to Monitor and Document Weights for Resident on Enteral Nutrition
Penalty
Summary
Staff failed to consistently monitor and document the weight of a resident who was dependent on enteral nutrition due to a persistent vegetative state. The resident's care plan and physician orders required weekly weights to be obtained and recorded, particularly given the resident's risk factors such as swallowing issues, enteral diet, and the presence of a pressure ulcer. Despite these directives, there were multiple instances where weights were either not obtained or not documented in the electronic medical record. On several occasions, nurses indicated that the resident was weighed, but no actual weight was recorded, and on other dates, the weight was not obtained at all. The resident's medical record showed a gradual decrease in weight over several months, with a notable drop from 153.3 pounds to 144.6 pounds. Interviews with nursing staff and administrative personnel confirmed that weights should have been obtained at least weekly for residents receiving enteral feedings. The facility's own competency guidelines for administering enteral feedings also required weights to be taken daily or three times a week as appropriate. The failure to consistently monitor and document the resident's weight as ordered placed the resident at risk for continued weight loss and malnutrition.
Failure to Provide Trauma-Informed and Culturally Competent Care
Penalty
Summary
The facility failed to develop and implement clinically appropriate, person-centered care approaches for a resident with a history of personal trauma and substance abuse. The resident's electronic health record documented diagnoses of major depressive disorder, anxiety, and PTSD, as well as a history of illicit drug use. Despite these documented conditions, the resident's care plan did not address identified triggers, adjustment difficulties, or provide interventions related to trauma or substance abuse history. The care plan also lacked descriptions of the resident's indications of distress and did not include strategies to assist the resident. Progress notes over several months did not document the resident's past trauma, and the facility's assessment listed zero residents with active or current substance use disorders, despite evidence to the contrary in the resident's records. Interviews with facility staff revealed a lack of recognition and documentation of the resident's PTSD and substance abuse history. Social services staff denied the presence of PTSD and substance abuse among residents, contradicting the medical records. Administrative staff indicated that PTSD diagnoses should be coordinated and incorporated into care plans through interdisciplinary meetings, but this was not reflected in the resident's care plan or facility documentation. Additionally, the facility was unable to provide a policy on trauma-informed care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 336 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sedgwick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Halstead Health And Rehabilitation Center | 7.8 mi | ★★★★★ | 17 | 1 |
| Azria Health Wichita | 9.5 mi | ★★★★★ | 11 | 0 |
| Via Christi Village Ridge | 10 mi | ★★★★★ | 23 | 0 |
| Paramount Community Living And Rehab Inc | 10.5 mi | ★★★★★ | 22 | 0 |
| Kansas Christian Home | 11.7 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Diversicare Of Sedgwick.
100% money-back within 48 hours.
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.