Sedgwick County Memorial Nursing Home

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

[DATE REDACTED] and discharged on 6/7/25. According to the June 2025 CPO, diagnoses included malignant neoplasm of the uterus (uterine cancer), acute kidney failure and hypertension (high blood pressure).The 5/27/25 MDS assessment documented the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. B. Record review A review of Resident #18's September 2025 CPO revealed the following physician's orders: Morphine sulfate oral solution 100 mg/5 milliliters (ml), give 0.25 ml by mouth every four hours as needed for pain/restlessness, ordered 6/4/25 and discontinued 6/6/25. Morphine sulfate oral solution 100mg/5ml, give 2.5 ml by mouth every two hours as needed for pain/restlessness, ordered 6/6/25 and discontinued 6/9/25. -LPN #1 entered the order for Morphine as 2.5 ml instead of 0.25 ml (see interviews below).C. Staff interviews The DON and the chief executive officer (CEO) were interviewed together on 9/10/25 at 10:30 a.m. The DON said LPN #1 came to her when entering the morphine order into the computer. The DON said that LPN #1 did not check off the final check mark to complete an order to be able to push it through and make it an active order. The DON said she checked off the final checkmark in

the order to make it an active order without double checking the order. She said the order should have been morphine sulfate, 0.25 ml every two hours, but instead was transcribed to 2.5 ml every two hours. The DON said every nurse checking off a physician's order should double check that the order matched exactly what was prescribed. The DON said there was an automated note that came after she signed off on the incorrect order that she did not see saying that the order was outside the recommended dose. The DON said that the next nurse on night shift brought it to the DON's attention, saying the order was incorrect. The DON said that the nurse confirmed she was going to correct the order. The DON said the order never was corrected and she did not know where the breakdown came from. The DON said she reviewed the controlled substance count sheet and confirmed that the dose of 0.25 ml was given each time. The DON said she confirmed the final count of the medication left was the correct amount. III. Failure to notify a physician when Resident #17 had a change in condition and obtain a physician's order to hold a routinely scheduled medicationA. Resident #171. Record review The 6/21/25 nursing progress note documented Resident #17's fasting blood sugar was low today. It was 53 mg/dl at breakfast and the nurse did not give Lantus. The blood sugar was within normal limits at lunch of 91mg/dl. This was on the provider note (see interview below). A

review of Resident #17's September 2025 CPO revealed the following physician's order: Lantus subcutaneous solution, 100 units/ml (long acting insulin), inject 18 units subcutaneously in the morning related to type one diabetes mellitus with other neurological complications, ordered 1/24/25 and discontinued 6/24/25. 2. Staff interviews The DON and the CEO were interviewed together on 9/10/25 at 10:30 a.m. The DON said if a resident's blood sugar was outside of the normal limits, she would expect the provider on call to be notified right away. She said the provider note that the nurse was referring to in the progress note was a once daily note that was sent to the provider from the DON. The DON said this was a list of non-urgent items such as needing a stool softener. The DON said blood sugars outside of the normal limits should not be put on this list and should instead be called into the provider right away. LPN #2 was interviewed on 9/10/25 at 3:00 p.m. She said she would always notify the provider, the DON and the medical power of attorney (POA) right away if a resident experienced a change in condition. She said if she had a scheduled medication due and was unable to administer it to the resident, she would notify the DON and the provider.

Event ID:

Facility ID:

06A173

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

06A173

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Sedgwick County Memorial Nursing Home

901 Cedar St Julesburg, CO 80737

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident's representative. She said there were not many RNs that worked in the facility so the LPNs would assess the resident after a fall. She said she was not aware that a RN was required to assess residents

after a fall. She said Resident #7 did not have any new fall interventions initiated after her last two falls (on 2/27/25 and 5/31/25). The DON was interviewed on 9/8/25 at 4:51 p.m. The DON said if she was in the facility at the time of a resident fall, she would accompany the LPN to assess the resident for injuries. She said on the night shift, the LPNs assessed the resident after a fall and if there were no injuries, the LPN would text her to let her know about the fall. She said if the resident sustained an injury, the LPN would call

the physician and the physician would make the decision of what treatment needed to be ordered. She said

she was not aware that a RN was required to assess a resident after a fall.Cross reference F-F727 for failure to have a RN in the facility for at least eight consecutive hours, seven days a week. The DON said following

a fall, she and the social services director (SSD) would meet and try to put interventions in place after each fall and track the interventions. However, Resident #7's previous interventions were not tracked for their effectiveness. The DON said Resident #7 was not a frequent faller, but when she did fall, she sustained injuries. She said she was not sure why the facility did not put interventions in place after the resident's falls

on 2/27/25 and 5/31/25.

Event ID:

Facility ID:

06A173

If continuation sheet

Federal health inspectors cited SEDGWICK COUNTY MEMORIAL NURSING HOME in JULESBURG, CO for a deficiency under regulatory tag F-F0727 during a standard health inspection conducted on 2025-09-10.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of SEDGWICK COUNTY MEMORIAL NURSING HOME.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-06.

Federal health inspectors cited SEDGWICK COUNTY MEMORIAL NURSING HOME in JULESBURG, CO for a deficiency under regulatory tag F-F0760 during a standard health inspection conducted on 2025-09-10.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure that residents are free from significant medication errors.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of SEDGWICK COUNTY MEMORIAL NURSING HOME.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-04.

Federal health inspectors cited SEDGWICK COUNTY MEMORIAL NURSING HOME in JULESBURG, CO for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-09-10.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of SEDGWICK COUNTY MEMORIAL NURSING HOME.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-04.

Federal health inspectors cited SEDGWICK COUNTY MEMORIAL NURSING HOME in JULESBURG, CO for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-09-10.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of SEDGWICK COUNTY MEMORIAL NURSING HOME.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-04.