Diversicare of Sedgwick: Emergency Discharge Violation - KS
The resident, identified in inspection records only as R1, had wound a television power cord and the cords from his window blinds around his neck in an attempt to strangle himself. It took all three of them. Law enforcement and EMS were called, and R1 was transported to a hospital for psychiatric care. He did not return to Diversicare of Sedgwick.
Federal inspectors cited the facility following a complaint inspection on September 9, 2025, for the circumstances surrounding R1's discharge. The violation was tagged at a level of minimal harm or potential for actual harm.
The facility knew the citation was coming. Administrative Staff B told inspectors that afternoon that the facility expected to be cited. "The facility had exhausted all known resources," the staff member said, "and understood that R1 could not remain at the facility due to ongoing safety concerns for staff and other residents."
That acknowledgment came only after inspectors had already begun piecing together what R1's time at the facility had looked like.
It had not been quiet. R1 had been sent to a hospital multiple times for his behaviors and attempts at self-harm. Each time, the hospital medicated him and discharged him back to Diversicare when he showed no active behaviors or attempts at self-harm. The cycle repeated. Staff stripped his room of anything he might use to hurt himself. They padded the walls and the floor to stop him from banging his head against them.
The facility tried to find somewhere else that could handle his needs. They attempted to refer R1 to a facility with a specialized unit for individuals with Huntington's disease. That facility declined. R1's history of self-harm attempts was the reason given.
There was nowhere else to send him, and the facility could not keep him safe where he was.
On the day of the strangulation attempt, R1 found the cords. The television's power cord. The cords running from the window blinds. He wrapped them around his neck. Three staff members intervened.
Administrative Staff A and Administrative Nurse D were both unavailable for interview on the day of the inspection.
The facility's own transfer and discharge policy, dated November 2016, laid out the conditions under which a resident could be moved. A transfer was permitted if the resident's welfare and needs could not be met, or if the safety of other individuals was endangered. If the basis was safety or welfare of others, physician documentation was required to support the transfer.
Inspectors found the discharge did not meet those documented requirements, at least not as recorded. That gap, between what the situation demanded and what the paperwork reflected, was the basis for the citation.
Diversicare of Sedgwick sits in a small south-central Kansas community. It is not a psychiatric facility. It is not equipped with a specialized behavioral health unit. The staff who padded R1's walls and cleared his room of objects and took turns watching him were nursing home workers, not psychiatric crisis teams. The hospitals that kept sending him back had made their own calculations. The specialized Huntington's facility that turned him away had made theirs.
R1 ended up at a different hospital after the strangulation attempt. Whether that hospital had more to offer him than the previous ones, the inspection report does not say.
What it does say is that three people had to physically restrain a man from strangling himself with the only things left in his reach, and that the facility had been trying, by its own account, for a long time before it came to that.
The citation stands regardless.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diversicare of Sedgwick from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 29, 2026 · Our methodology
DIVERSICARE OF SEDGWICK in SEDGWICK, KS was cited for violations during a health inspection on September 9, 2025.
Law enforcement and EMS were called, and R1 was transported to a hospital for psychiatric care.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.