Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Buhler Sunshine Home during CMS and state inspections, most recent first.
The facility did not implement a water management program to prevent Legionella disease, which is spread through mist and poses a risk to residents, particularly those over 50 or with weakened immune systems. Maintenance staff were unaware of who managed the prevention program, and administrative staff confirmed the absence of monitoring programs and a waterborne pathogen policy. The facility also failed to map the water system for potential dead-end sources, placing residents at risk of contracting Legionella pneumonia.
A resident with Alzheimer's and other conditions experienced multiple syncope episodes during transfers, but the facility failed to notify the physician, as required by policy. The care plan lacked instructions for handling such episodes, and staff were aware but did not communicate the issue, placing the resident at risk for further decline.
A resident with Alzheimer's, anxiety, diabetes, and heart disease experienced lightheadedness and syncope during transfers, but the care plan was not updated to guide staff on managing these episodes. Despite multiple incidents, the physician was not notified, and staff lacked clear instructions, contrary to the facility's policy requiring immediate care plan updates for changes in condition.
A resident with dementia and other health issues experienced multiple falls despite interventions like gripper socks and alarms. The facility failed to evaluate and modify these interventions, leading to continued falls and injuries. Staff noted the resident's impulsivity and cognitive impairment, which contributed to the falls, but interventions were not adjusted to effectively prevent further incidents.
A consultant pharmacist in an LTC facility failed to ensure proper documentation for the use of Seroquel, an antipsychotic, for a resident with Alzheimer's. Despite a recommendation for a gradual dose reduction, the physician declined and did not provide a written clinical rationale. The pharmacist did not continue to request this documentation, placing the resident at risk of receiving unnecessary medication.
A resident with Alzheimer's disease received Seroquel for severe anxiety without a gradual dose reduction (GDR) being attempted, and the physician did not provide a written clinical rationale for its continued use. Despite a pharmacist's recommendation for a GDR, the facility failed to adhere to its policy on psychotropic medication use, placing the resident at risk of receiving unnecessary antipsychotic drugs.
A resident with dementia and anxiety disorder experienced multiple medication administration errors involving Ativan, including missed doses and incorrect dosages. These errors led to episodes of restlessness and anxiety, as documented by CMAs and in progress notes. The facility's failure to administer the correct dosage as per physician orders placed the resident at risk for adverse effects.
Failure to Implement Water Management Program for Legionella
Penalty
Summary
The facility failed to implement a water management program to prevent Legionella disease, a bacterium spread through mist, which poses a risk to residents, especially those over 50 or with weakened immune systems. During the survey, Maintenance Staff U was unaware of who managed the waterborne pathogen prevention program, and Administrative Staff A confirmed the absence of further monitoring programs for Legionella disease. Additionally, the facility had not mapped the water system for potential dead-end water sources, and upon request, could not provide a waterborne pathogen policy. This lack of a structured program and policy placed residents at risk of contracting Legionella pneumonia.
Failure to Notify Physician of Syncope Episodes
Penalty
Summary
The facility failed to notify the physician of episodes of syncope and lightheadedness experienced by a resident, identified as R32. The resident had a medical history that included Alzheimer's disease, anxiety, diabetes mellitus type two, and arteriosclerotic heart disease. The resident's care plan initially directed staff to use a sit-to-stand lift for transfers, which was later updated to a full mechanical lift with two staff members. However, the care plan lacked specific instructions for staff in the event of lightheadedness or syncope during transfers. Despite multiple episodes of syncope and lightheadedness documented in the nurse's notes, there was no evidence that the physician was notified, which placed the resident at risk for further decline and delayed treatment. Observations and interviews revealed that the resident experienced syncope episodes during transfers with the sit-to-stand lift, leading to a change in the type of lift used. Staff members, including CNAs and licensed nurses, were aware of the episodes but did not notify the physician. The facility's policy required notifying the physician of significant changes in a resident's condition, but this was not followed. Administrative staff were unaware of the episodes and stated that they would have provided interventions in the care plan if they had been informed. The lack of communication and failure to follow the facility's guidelines for notifying physicians contributed to the deficiency.
Failure to Revise Care Plan for Resident with Syncope Episodes
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R32, who experienced periods of lightheadedness and syncope during transfers. R32 had a history of Alzheimer's disease, anxiety, diabetes mellitus type two, and arteriosclerotic heart disease. The care plan initially directed staff to use a sit-to-stand lift for transfers, which was later updated to a full mechanical lift with two staff members. However, the care plan did not provide specific instructions for staff to follow if the resident experienced lightheadedness or syncope during transfers. This oversight was noted despite multiple documented episodes where R32 became lightheaded or experienced syncope during transfers, with no evidence that the physician was notified of these incidents. Observations and interviews revealed that staff were aware of R32's episodes but did not have clear guidance on how to manage them. A nurse confirmed the absence of documentation notifying the physician of the episodes, and another nurse acknowledged that the physician should have been informed. An administrative nurse stated she was unaware of the episodes and would have provided interventions in the care plan if she had known. The facility's care plan revision policy required immediate updates to the care plan when changes in condition occurred, but this was not followed, placing the resident at risk for decline.
Failure to Modify Ineffective Fall Interventions for a Resident
Penalty
Summary
The facility failed to evaluate and modify fall interventions for Resident 16, who was at risk for falls due to dementia, hypertension, anxiety, arteriosclerotic heart disease, and edema. Despite being documented as having moderately to severely impaired cognition, the resident was noted to have multiple falls with injuries over a period of time. The care plan included various interventions such as the use of gripper socks, bed and chair alarms, and verbal reminders to call for assistance, but these measures were not effective in preventing falls. Resident 16 experienced several falls, often due to attempting to ambulate independently or reach for items without assistance. The falls resulted in injuries such as abrasions, skin tears, and bruises. Despite the implementation of interventions like silent pressure alarms and nonskid strips, the resident continued to fall, indicating that the interventions were not adequately addressing the resident's needs. Staff interviews revealed that the resident was impulsive and often did not wait for assistance, which was compounded by the cognitive impairment that affected the resident's ability to remember to call for help. The facility's Fall Prevention and Management Protocol required assessment and modification of interventions after each fall, but the interventions for Resident 16 were not effectively evaluated or adjusted. The facility's failure to modify ineffective interventions placed the resident at risk for further falls and injuries. The report highlights that the interventions in place were not sufficient to prevent falls for Resident 16, and the facility did not adequately address the resident's cognitive limitations in their fall prevention strategies.
Pharmacist's Failure to Ensure Proper Documentation for Antipsychotic Use
Penalty
Summary
The facility's consultant pharmacist failed to ensure compliance with the guidelines for the use of antipsychotic medication, specifically Seroquel, for a resident diagnosed with Alzheimer's disease. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was receiving Seroquel for severe anxiety without a gradual dose reduction (GDR) or a documented clinical rationale from the physician. Despite the pharmacist's recommendation for a GDR, the physician declined to perform it and did not provide the necessary written clinical rationale for the continued use of the medication. The facility's policy required the consultant pharmacist to review medication administration records and communicate any potential or actual problems related to medication therapy to the physician and the director of nursing. However, the pharmacist did not continue to request the required documentation from the physician, which resulted in the resident being at risk of receiving unnecessary antipsychotic drugs. This oversight was confirmed by an administrative nurse, who verified that the consultant pharmacist had not pursued the necessary clinical rationale for the antipsychotic's use.
Failure to Obtain Clinical Rationale for Antipsychotic Use
Penalty
Summary
The facility failed to obtain an approved indication for the use of the antipsychotic drug Seroquel for a resident diagnosed with Alzheimer's disease. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was receiving Seroquel for severe anxiety without a gradual dose reduction (GDR) being attempted. The physician had not provided a written clinical rationale for why a GDR was not performed, despite a recommendation from the pharmacist to do so. The facility's policy on psychotropic medication use required that drug dosages be periodically reduced unless clinically contraindicated by the physician. However, the physician declined to perform a GDR for the resident's Seroquel prescription and failed to document a thorough clinical rationale for its continued use. This oversight placed the resident at risk of receiving unnecessary antipsychotic drugs, as the facility did not adhere to its policy of ensuring appropriate use, evaluation, and monitoring of psychotropic medications.
Medication Administration Errors with Ativan
Penalty
Summary
The facility failed to administer the correct physician-ordered dose of Ativan at the scheduled time for a resident diagnosed with dementia and anxiety disorder. The resident's care plan required staff to monitor for signs of anxiety and restlessness and to administer Ativan as prescribed. However, multiple instances of medication errors were documented, including missed doses, incorrect dosages, and failure to administer the medication at the scheduled times. These errors were reported by Certified Medication Aides (CMAs) and documented in the resident's progress notes. The resident experienced episodes of restlessness and anxiety, which were not effectively managed due to the medication errors. The errors included administering a lower dose than prescribed, missing doses entirely, and administering a higher dose than ordered. These incidents were reported to the nursing staff, and the facility's policy required such errors to be reported to the Director of Nursing and discussed in high-risk meetings. Despite these protocols, the facility continued to fail in administering the correct dosage of Ativan, placing the resident at risk for adverse effects.
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 111 citations issued within 25 miles in the last 12 months — including the 1 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 Buhler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant View Home | 7 mi | ★★★★★ | 0 | 0 |
| Diversicare Of Hutchinson | 7.9 mi | ★★★★★ | 1 | 0 |
| Good Samaritan Society - Hutchinson Village | 8.1 mi | ★★★★★ | 17 | 0 |
| Hutchinson Operator, Llc | 8.2 mi | ★★★★★ | 25 | 0 |
| Wesley Towers Inc | 9.4 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.