Sedgwick County Memorial: Fall Care Failures - CO
That gap in basic nursing knowledge sits at the center of a September 2025 complaint inspection at the facility, which found that a single resident fell and sustained injuries on two separate occasions, and that staff put no new safety measures in place after either one.
The resident, identified in inspection records only as Resident 7, fell on February 27, 2025. She was injured. No new fall interventions were initiated. She fell again on May 31, 2025. She was injured again. No new fall interventions were initiated then, either.
The director of nursing, interviewed by inspectors on September 8, acknowledged the failures but said she could not explain them. She told inspectors that she and the social services director would typically meet after a fall to try to put interventions in place and track their effectiveness. For Resident 7, that didn't happen after either fall. The director said she was not sure why.
What inspectors also found was that the facility's system for responding to falls had a structural problem underneath the documentation failures. There were not many registered nurses working at the facility, the administrator told inspectors. When a resident fell, a licensed practical nurse would conduct the assessment. If there were no apparent injuries, the LPN would send the director of nursing a text message. If there were injuries, the LPN would call the physician, and the physician would decide on treatment.
The director of nursing described this arrangement as standard practice for night shift. She said that if she was physically present in the building when a fall occurred, she would go with the LPN to assess the resident. If she wasn't there, the text would come later.
She said she was not aware that a registered nurse was required to assess a resident after a fall.
The administrator who spoke with inspectors said the same thing. She was not aware of the requirement either.
Inspectors cross-referenced the fall care failures to a separate violation, F727, which cited the facility for failing to have a registered nurse present in the building for at least eight consecutive hours every day of the week. The two findings together describe a facility where the person responsible for nursing oversight did not know what oversight required, and where the staffing structure made it easy for that gap to go unnoticed.
The director of nursing told inspectors that Resident 7 was not what she would call a frequent faller. But she acknowledged that when this resident did fall, she got hurt. The February fall resulted in injuries. The May fall resulted in injuries. After each one, the care plan that existed before the fall remained unchanged.
Inspectors rated the violation at the "actual harm" level, meaning the failures were not theoretical. Resident 7 was harmed.
The inspection was conducted as a complaint investigation, meaning someone, a resident, a family member, a staff member, or a visitor, contacted authorities about what was happening inside the building before inspectors arrived. The records do not say who filed the complaint or what specifically prompted it.
What the records do say is that by the time inspectors sat down with the director of nursing on a Monday afternoon in early September, two falls had already come and gone without a response, and the person running nursing at the facility was still describing a system in which text messages substituted for assessments and nobody had thought to ask whether that was enough.
The director of nursing said she was not sure why no interventions were put in place after Resident 7's falls. She offered no other explanation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sedgwick County Memorial Nursing Home from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
SEDGWICK COUNTY MEMORIAL NURSING HOME in JULESBURG, CO was cited for violations during a health inspection on September 10, 2025.
The resident, identified in inspection records only as Resident 7, fell on February 27, 2025.
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.