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 Diversicare Of Hutchinson during CMS and state inspections, most recent first.
A resident with severe dementia and a history of sexually focused behaviors repeatedly sought male companionship, entered other residents’ rooms, attempted to disrobe, used sexually explicit language, and was found partially undressed with a male resident touching her peri-area. Documentation showed a pattern of inappropriate sexual and social behaviors over time, but the care plan remained limited to general behavior and redirection strategies and did not comprehensively address the resident’s ongoing desire for physical engagement or provide clear guidance on distinguishing voluntary engagement from unsafe situations. Staff reported only generic dementia training, were unsure about managing sexual or intimate desires in confused elders, and the facility’s dementia policy did not address sexuality, resulting in a lack of a specific dementia care plan that identified and honored the resident’s physical engagement needs while directing staff on monitoring for negative outcomes.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with multiple areas showing broken tiles, missing door trim, exposed insulation, holes in walls, and damaged or stained ceiling tiles. Administrative staff confirmed these issues and stated that no plans had been made to repair them, contrary to facility policy.
A resident with severe cognitive impairment, physical limitations, and a history of falls did not have grip strips installed in front of the toilet or anti-rollback devices on the wheelchair, despite these interventions being documented in the care plan. Staff interviews confirmed awareness of the care plan, but observations showed the interventions were not implemented as required.
Two residents with PTSD did not have trauma-based triggers identified or individualized interventions included in their care plans. Staff were unaware of the residents' PTSD diagnoses or appropriate responses to potential triggers, and the facility did not obtain or document information about specific triggers from residents or families. This failure to follow trauma-informed care policies placed the residents at risk for decreased psychosocial well-being and ineffective treatment.
Two residents with severe cognitive impairment and multiple diagnoses were found to have bed rails in use without proper assessment or measurement of the gaps between the rails and mattress. The facility did not document or evaluate the safety of the actual rails in use, and administrative staff confirmed that required measurements were not performed. The facility also lacked a bed rail policy, placing the residents at risk for preventable entrapment or injury.
A consultant pharmacist did not identify or report an inappropriate indication for an antipsychotic medication prescribed to a resident with dementia and Alzheimer's disease. The resident's records lacked a documented physician rationale for the medication, and pharmacy reviews did not address the appropriateness of its use, contrary to facility policy.
Surveyors found expired medications, including aspirin and GeriMox, in the medication room. An LN confirmed these drugs should have been disposed of according to facility policy, which requires removal and destruction of expired medications. The presence of expired drugs indicated a failure to follow established medication management procedures.
A cognitively impaired resident left a facility through an unsecured gate, remaining unsupervised for 55 minutes until found by law enforcement 2.8 miles away. The resident's care plan did not include a wandering alarm despite a history of elopement risk. The incident occurred after a lawn care contractor left the gate unlocked, and staff were unaware of the resident's departure until alerted by another resident.
Failure to Develop Dementia Care Plan Addressing Resident’s Sexual and Physical Engagement Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an adequate dementia-focused plan of care that identified and honored a resident’s desire for physical and sexual engagement, and to provide staff with clear direction on recognizing voluntary engagement and monitoring for negative outcomes. The resident had diagnoses including dementia, major depressive disorder, anxiety, and unspecified sexual dysfunction, and was documented as having severely impaired cognition, being inattentive, and having disorganized thinking. The resident was dependent on staff for most care and could not complete a BIMS interview. Early care plan entries focused on potential physical aggression related to dementia and included general behavioral interventions such as administering medications, analyzing triggers, anticipating needs, providing cues, and monitoring for danger to self or others, but did not address the resident’s expressed sexual desires or patterns of seeking male companionship. Over time, the resident repeatedly demonstrated sexually focused and socially inappropriate behaviors that were documented in the EHR and behavior monitoring reports. Nursing notes and behavior logs described the resident transferring into other residents’ beds, attempting to disrobe in common areas, approaching male residents with sexually driven remarks, and being found in a male resident’s room with her pants down while the male resident touched her peri-area. Additional notes documented the resident verbally expressing that she wanted a man, being verbally inappropriate with sexually explicit language, attempting to expose her breasts to a male resident, and entering other residents’ rooms while looking for a man. Behavior monitoring reports showed a pattern of inappropriate behaviors, including entering other residents’ rooms and public sexual acts on multiple dates over several months. Despite this pattern, the care plan revisions that were eventually made focused on redirecting the resident, avoiding triggers, and offering diversions such as baby dolls, without a comprehensive dementia care plan that addressed her ongoing desire for physical engagement or guidance on distinguishing voluntary engagement from nonconsensual or unsafe situations. Interviews with administrative staff and direct care staff further demonstrated gaps in the facility’s approach to dementia care related to sexuality and physical engagement. Administrative staff acknowledged that the resident had gravitated toward males since admission and had vocalized multiple past marriages, but also stated that there was very little social history available on admission and that the care plan interventions for sexually inappropriate behaviors were opened only after a specific incident and finalized later. Certified medication aides, CNAs, and a licensed nurse reported receiving general dementia training via online modules but were unsure or could not recall receiving specific training on managing sexual or intimate desires in elders with dementia. Staff described their responses as separating residents, using distraction, and notifying a nurse, and some were unaware of specific incidents of sexual or intimate interactions despite documented events. The facility’s Dementia Care policy did not address sexuality or intimate relationships in residents with dementia, and while the Behavioral Health Services Guideline mentioned inappropriate sexual behavior and the need to respect sexual behaviors between consenting, competent adults, it did not translate into a resident-specific dementia care plan that identified and honored this resident’s desire for physical engagement or provided clear direction on monitoring for potential negative outcomes.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple maintenance issues throughout the facility, including a broken tile with a missing piece on the dining room floor, missing door trim with exposed foam insulation at the dining room exit, and a large hole in the dining room wall behind the ice machines exposing pipes and the inside wall. Additional deficiencies were noted on two resident halls, where numerous ceiling tiles were either damaged, ill-fitting, or stained. In the northeast hall shower room, a framed hole in the wall exposed pipes and the inner wall. Administrative staff confirmed these findings and acknowledged that the facility had not developed plans to address or repair the maintenance issues observed. The facility's own Room Audit policy required that such damages be noted and addressed to maintain a homelike standard, but this was not followed.
Failure to Implement Fall Prevention Interventions for Resident with Cognitive and Physical Impairments
Penalty
Summary
The facility failed to implement required fall prevention interventions for a resident with a history of falls and significant cognitive and physical impairments. The resident's medical record documented multiple diagnoses, including dementia, psychosis, mood disorder, and physical impairment on one side of the body. The resident had experienced several falls, including one with injury, and care plans specified interventions such as removing wheelchair pedals, placing grip strips in front of the toilet, and evaluating the need for anti-rollback devices on the wheelchair. Despite these documented interventions, observations on multiple occasions revealed that grip strips were not installed in front of the resident's toilet and anti-rollback devices were not present on the wheelchair. Interviews with staff confirmed that care plans and fall interventions were accessible and that the management team was responsible for ensuring interventions were implemented. However, the required interventions were not in place as directed by the care plan and post-fall analyses. The facility's fall policy outlined procedures for assessing falls, developing interventions, and ensuring their implementation, but these steps were not followed for this resident, resulting in a failure to provide adequate accident hazard prevention and supervision.
Failure to Identify Trauma Triggers and Implement Individualized Trauma-Informed Care
Penalty
Summary
The facility failed to identify and address trauma-based triggers and implement individualized interventions for residents diagnosed with posttraumatic stress disorder (PTSD). For one resident with a history of PTSD, lupus, depression, and other chronic conditions, the care plan noted potential psychosocial well-being problems but did not document specific trauma-based triggers or individualized interventions related to PTSD. Staff interviews revealed a lack of awareness regarding the resident's PTSD diagnosis and uncertainty about how to respond to potential triggers, with some staff unaware of the diagnosis entirely and others unsure of appropriate actions to take. Another resident with diagnoses including Alzheimer's disease, PTSD, and depression had a care plan that referenced PTSD but did not include information on specific triggers or strategies to avoid re-traumatization. Staff members reported not being informed about the resident's PTSD or what triggers to avoid, and administrative staff confirmed that the facility had not pursued information from the resident's family regarding potential triggers. The care plan included general directions for providing a calm environment and using the resident's preferred name but lacked individualized trauma-informed interventions. The facility's own trauma-based care policy emphasized the importance of recognizing trauma, identifying triggers, and incorporating care strategies to prevent re-traumatization. Despite this, the facility did not ensure that care plans for residents with PTSD included identification of trauma-based triggers or individualized interventions, as evidenced by staff interviews and care plan reviews. These deficiencies placed the affected residents at risk for decreased psychosocial well-being and ineffective treatment, as directly stated in the report.
Failure to Assess and Ensure Bed Rail Safety for Residents with Cognitive Impairment
Penalty
Summary
The facility failed to properly assess and ensure the safety of bed rails for two residents with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease, bipolar disorder, cerebrovascular accident, osteoarthritis, PTSD, depression, and insomnia. For one resident, the medical record documented the use of assist rails and noted poor safety awareness due to decreased cognitive function, but the side rail assessment did not include measurements of the rail gaps or an evaluation of whether the openings between the rails and between the rails and mattress were safe for the individual. Observation revealed a one-half side rail with large openings, and administrative staff confirmed that the gaps were too large and should have been measured quarterly or with a significant change in status. The facility was unable to provide a side rail policy upon request. For the second resident, the care plan did not mention bed rail use, and the side rail assessment was incomplete, lacking documentation of gap measurements. The resident, who was a high fall risk and exhibited confusion and impulsive behaviors, was observed with both bedside rails up, each having large gaps between the bars. Administrative staff verified that the gaps exceeded the recommended width and that staff should have measured them quarterly. The facility's failure to assess the actual rails in use and to measure the gaps placed both residents at risk for preventable entrapment, accidents, or injury.
Consultant Pharmacist Failed to Report Inappropriate Antipsychotic Use
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist identified and reported an inappropriate indication for the use of an antipsychotic medication for one resident. The resident had diagnoses of dementia with agitation, Alzheimer's disease, and cerebral infarction, and was dependent on staff for multiple activities of daily living. The resident's care plan and physician's order documented the use of Rexaulti for dementia with agitation, but the electronic medical record lacked evidence of a physician-documented rationale, including an assessment of risks versus benefits and documentation of unsuccessful nonpharmacological interventions. Pharmacy consult reviews over several months did not include recommendations regarding the appropriateness of the medication's indication. The facility's policy required identification and reporting of medication irregularities, including immediate notification and physician documentation if no changes were made. However, the Consultant Pharmacist did not report the inappropriate indication to the facility, DON, medical director, or physician, resulting in the continued use of the antipsychotic medication without proper justification.
Expired Medications Not Disposed of Per Policy
Penalty
Summary
Surveyors observed that the facility failed to dispose of expired medications in a timely manner. During an inspection of the facility's only medication room, a bottle of 325 mg aspirin tablets with an expiration date of 08/2024 and a bottle of GeriMox, expired 11/2024, were found. A licensed nurse confirmed that these expired drugs should have been disposed of according to facility policy. The facility's policy, dated April 2020, requires that all expired medications be removed from the active supply and destroyed, and that no expired medications be administered to residents. This lapse in medication management resulted in expired drugs being present in the medication room, contrary to the facility's established procedures.
Resident Elopement Due to Unsecured Gate
Penalty
Summary
The facility failed to ensure a cognitively impaired resident, identified as R1, remained free from accident hazards. On the morning of 07/15/24, R1 left the facility through an unsecured gate in the west courtyard. This occurred after an independent lawn care contractor left the gate unlocked and unsecured. R1 was not wearing a wandering or elopement alarm, and staff were unaware of R1's departure until another resident alerted them. R1 was found by law enforcement officers outside a local business approximately 2.8 miles away from the facility, 55 minutes after leaving unsupervised. R1's electronic health record documented several diagnoses, including unspecified psychosis, a history of traumatic brain injury, schizophrenia, and cognitive communication deficits. The resident's admission Minimum Data Set (MDS) indicated severely impaired cognition, with no documented wandering behaviors. Despite being at risk for elopement due to previous attempts and a history of wandering, R1's care plan did not include wearing a wandering or elopement alarm at the time of the incident. The care plan interventions focused on redirecting R1 away from exit doors and involving R1 in activities, but these measures were insufficient to prevent the elopement. The facility's investigation revealed that staff initiated an elopement protocol after being alerted by another resident. A room-to-room search was conducted, and law enforcement was notified. The facility's failure to secure the courtyard gate and adequately supervise R1 led to the resident's unsupervised departure, placing R1 in immediate jeopardy. The incident highlighted deficiencies in the facility's processes to prevent elopement and ensure resident safety.
Removal Plan
- The facility initiated 1:1 supervision of R1 and continued.
- The facility changed the locks on the gates to require keys that only Administrative Staff A and Maintenance Director F carry.
- The facility informed lawn care contractors that in order to enter or exit the courtyard that staff must be present to allow access and/or egress.
- The facility immediately initiated a facility wide re-education related to elopement of all staff and no staff that were off duty were allowed to return to work without completing the education.
- The facility initiated daily lock checks on all locked gates.
- The facility performed new admission elopement evaluations on all newly admitted residents.
- The facility initiated weekly elopement drills every shift for one month, then every shift monthly for three months and then reevaluate in with the quality assurance process improvement (QAPI) meetings.
- The facility addressed elopement in QAPI and audited/updated elopement evaluations on all existing residents.
- The facility assessed and updated R1's care plan to include checking of WanderGuard every shift and updating photo in elopement book.
- The facility requested a psychological evaluation to be completed by psych provider to rule out any additional underlying causes for elopement and exit-seeking behavior.
- The facility requested a medication regimen review (MRR) requested from pharmacist.
- The elopement policy was reviewed by Administrative Staff A and corporate staff to ensure that no updates were required.
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What surveyors actually found near you
We read the 87 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hutchinson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hutchinson Operator, Llc | 0.3 mi | ★★★★★ | 25 | 0 |
| Good Samaritan Society - Hutchinson Village | 0.7 mi | ★★★★★ | 17 | 0 |
| Wesley Towers Inc | 2.2 mi | ★★★★★ | 17 | 0 |
| Mennonite Friendship Communities Inc | 4.4 mi | ★★★★★ | 2 | 0 |
| Buhler Sunshine Home | 7.9 mi | ★★★★★ | 0 | 0 |
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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.