Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Hutchinson Operator, Llc during CMS and state inspections, most recent first.
Missing annual performance evaluations for multiple nurse aides. Review of personnel files showed that four of five CNAs/CMAs reviewed did not have an annual performance evaluation on file, despite facility policy requiring an annual evaluation for each nurse aide and use of that information to guide in-service education.
The facility failed to ensure the daily staff posting included the actual hours worked by nursing staff. An observation found the staff posting lacked actual hours worked, and review of multiple daily postings showed the same omission. Administrative Staff B stated she had never been educated to post actual hours worked, while Administrative Staff C said she expected the actual hours to be posted. The facility did not provide a policy for posted nursing staff.
Infection control practices were not followed during resident care, including Droplet Precautions and EBP. Staff entered rooms without the required PPE, failed to perform hand hygiene before and after glove use, reused contaminated gloves during wound and incontinent care, and moved shared equipment such as a full body lift between residents without sanitizing it. Residents with COVID, catheters, a PICC, and wound care needs were observed during these events, and wound supplies were also carried between rooms and placed on resident surfaces.
Unqualified Infection Preventionist Designated: The facility failed to ensure the designated IP had the required certification for the infection prevention and control program. During interview, an Administrative Nurse stated she was the designated IP but had not completed the infection control certification course before being appointed about a month earlier and was only about halfway through the course. The facility could not provide proof of certification or a policy on IP qualification.
A facility failed to ensure dependent residents received needed ADL help with bathing and personal hygiene. Several residents with intact cognition and care plans for regular showers reported missed or delayed showers, and observations showed long, dirty, jagged fingernails with debris under the nails. Staff said showers were limited by one working shower room, daytime-only showering, and missed baths were not always made up; nail care was also not consistently provided.
Failure to file and acknowledge pharmacist MRRs. The facility had pharmacy consultant notes showing that MRRs were completed for several residents and that irregularities were noted, but the actual recommendations were not in the clinical record and there was no evidence that the facility or MD acknowledged and responded. An RN reported she could not locate the MRRs and expected them to be answered within seven days of receipt from the pharmacist.
Several insulin pens were found in medication storage without an open date, including Lantus, glargine, and insulin lispro pens in use. An LN stated insulin pens should be labeled when opened, and the DON stated staff were expected to label them with an open date. The facility did not provide a medication storage policy.
Facility staff failed to ensure informed consent and resident/representative education were documented for psychotropic meds for two residents. One resident had an increased olanzapine order without evidence of consent, and another had trazodone and citalopram orders without evidence of prior consent or education; staff interviews showed inconsistent understanding of when psychotropic consents were to be completed.
The facility failed to provide required Medicare non-coverage notices for multiple residents. Two residents had ABN forms that were missing the resident selection in section G, and another resident had no evidence that the required ABN or NOMNC forms were issued after Medicare Part A coverage ended. An Administrative Nurse stated the ABN should be given to the resident or representative before the last day of Part A coverage, and the facility policy stated the SNF ABN is issued when the resident intends to continue services that may no longer be covered by Medicare.
Unclean resident rooms and poor environmental maintenance were observed for multiple residents. One resident’s room had a strong foul odor and dirty, gray bed linens that remained unchanged the next day, while another resident’s room repeatedly smelled of urine and had an uncovered catheter bag. A third resident’s chair was broken with peeling vinyl, and the room had food crumbs, dirt, dried smears on the tray table, and duct tape on the table. Staff reported the odors and messes were ongoing and that one room had not been cleaned as expected.
A facility failed to ensure two residents had PRN psychotropic medication orders with required 14-day stop dates or a documented duration with physician rationale. One resident had PRN haloperidol and lorazepam orders without stop dates, and another had a PRN trazodone order without a stop date. Staff stated PRN psychotropic orders required 14-day stop dates, and the facility policy reflected that requirement.
Failure to provide written bed hold notices and LTCO discharge notification. Two residents with intact cognition were transferred to the hospital, but the record lacked evidence that a written bed hold notice with the duration was provided; one resident reported no knowledge of any bed hold, and the other was unresponsive at transfer. A third resident was discharged with paperwork provided to the resident and family, but the facility could not show that the LTCO was notified of the discharge.
The facility failed to develop comprehensive care plans for two residents. One resident had major depressive disorder, anxiety, and multiple psychotropic medication orders, but the care plan lacked interventions related to those meds. Another resident had impaired mobility, required total assistance with personal hygiene, and had long, dirty, jagged fingernails with debris under them, yet the care plan did not address nail care or hygiene assistance.
Failure to secure Foley tubing and cover drainage bags affected three residents with indwelling catheters. One resident’s tubing hung freely and her bag touched the floor, another had a strong urine odor in the room with no securement device and an uncovered bag, and a third reported she had no anchor device and had to ask for catheter care. The facility policy required a leg strap for securement and a dignity bag for privacy.
Missing Pneumococcal Vaccine Education and Documentation: The facility failed to document education, offer, consent, or informed declination for the pneumococcal vaccine for three residents. Records for two residents also lacked historical pneumovax status, and an RN confirmed the missing education documentation needed for informed decision-making.
Laundry Area Not Maintained in Safe, Sanitary Condition: Surveyors observed multiple sanitation and maintenance issues in the laundry area, including cracked soiled laundry bins, missing paint on the sorting room floor, USB cables on the clean laundry folding table, cardboard boxes and a chemical tray carrier stored on the floor, uncovered pillows stored under a table against the wall, missing baseboard, and broken or missing tile at the door transition. Housekeeping/Maintenance Staff U confirmed the findings.
Unsafe Shower Chair Transport Caused Resident Fall and Fractures A resident with DM2, morbid obesity, weakness, and high fall risk was transported down a hallway in a shower chair when her footrest folded and her legs became entangled, causing her to fall face first and sustain right tibia and fibula fractures. Staff found her on the floor, noted swelling and leg deformity, covered her for privacy, and transferred her by EMS after the incident. Interviews showed mixed staff understanding about whether residents could be moved in shower chairs, and the facility’s policies did not address shower chair transport.
A resident with a full code status did not receive CPR when found unresponsive, despite her documented wishes and facility policy. The resident's spouse initially requested CPR but then declined, leading to staff not performing resuscitative measures. This failure placed the resident and others with full code status in immediate jeopardy.
The facility failed to provide the services of a full-time certified dietary manager for its 42 residents, as observed on multiple occasions. Dietary staff preparing meals were not certified, and the facility's policy requiring a certified dietary manager or another qualified nutritional professional was not met, placing residents at risk for inadequate nutrition.
The facility failed to store food safely and did not adequately sanitize dishes for 42 residents, with outdated food found in the refrigerator and the dishwasher operating below the required sanitization temperature.
The facility failed to ensure an environment free from accident hazards with hot water temperatures exceeding safe limits and did not provide effective interventions to prevent further falls for a resident with a history of multiple falls, placing residents at risk for injuries.
The facility failed to discard outdated insulin flex pens for three residents and expired stock medications, placing residents at risk for ineffective medication. Observations and staff confirmations revealed that the facility's policies on labeling and storage of medications were not followed.
The facility failed to provide five residents with the most recent CDC vaccination information statement (VIS) before administering flu and pneumonia vaccinations. The residents' records showed the use of outdated consent forms, confirmed by an administrative nurse, placing the residents at risk for uninformed decision-making.
A resident with a history of protein-calorie malnutrition, neuropathy, and a Stage 2 pressure ulcer on the left heel experienced recurring blisters due to the facility's failure to provide consistent off-loading and timely care plan revisions. Despite the care plan's directives, the facility did not adequately address the resident's pressure ulcer prevention needs, leading to ongoing skin breakdown issues.
A facility failed to provide necessary behavioral health care for a resident with PTSD, major depressive disorder, and anxiety disorder. Despite recommendations from an APRN to increase the resident's Sertraline dosage and refer her to psychotherapy, the facility did not follow up with the referral. This resulted in untreated and ongoing mental health concerns for the resident.
The facility failed to ensure a coordinated plan of care for a resident receiving hospice services. Despite the resident's diagnoses of malignant neoplasm of the lung, COPD, and shortness of breath, the facility's care plan lacked information regarding hospice services and coordination of care. Observations and interviews confirmed the absence of necessary hospice documentation, placing the resident at risk for inappropriate end-of-life care.
Missing Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews at least once every 12 months for four of five CNAs reviewed. Review of CNA personnel files showed that CNA P, hired on 12/31/24, lacked an annual performance evaluation; CNA Q, hired on 09/04/24, lacked an annual performance evaluation; CMA S, hired on 07/07/22, lacked an annual performance evaluation; and CNA T, hired on 11/21/24, lacked an annual performance evaluation. During an interview on 01/29/26 at 01:52 PM, the Administrative Nurse stated she expected 100 percent compliance with annual performance evaluations. The facility policy, Inservice Training Program, Nurse Aide, dated 11/2025, stated the facility would complete an annual evaluation on each nurse aide and use that information to validate or change required in-service education.
Failure to Post Actual Nursing Staff Hours
Penalty
Summary
The facility failed to ensure the daily staff posting included the actual hours worked by nursing staff as required. During an observation on 01/29/26 at 11:50 AM, the daily staff posting document did not document actual hours worked. Review of the daily staff posting documents from 01/26/26 through 01/29/26 showed the same lack of documentation of actual hours worked. During interviews, Administrative Staff B stated at 11:52 AM that she had never been educated to post the actual hours worked on the staff sheet, and Administrative Staff C stated at 01:36 PM that she expected the actual hours to be posted on the staff sheet. The facility did not provide a policy for posted nursing staff.
Infection Control Failures With PPE, Hand Hygiene, and Shared Equipment
Penalty
Summary
The facility failed to ensure adequate infection control practices related to Enhanced Barrier Precautions, Transmission Based Precautions, hand hygiene, and sanitization of shared equipment. During observations, staff entered residents’ rooms and provided care without consistently using the PPE required by the posted precautions, and in several instances did not perform hand hygiene before donning gloves, after removing gloves, or after leaving resident rooms. Shared equipment, including a full body lift, was also observed being moved between residents without being sanitized between uses. Resident R38 had signage at the room entrance directing staff to use gloves, mask, and gown for Droplet Precautions due to COVID. A CNA delivered a meal tray to the room wearing only a mask that she had been wearing elsewhere in the facility, entered the room, set the tray down, and exited without removing the mask or sanitizing her hands. Resident R25 also had Droplet Precautions signage and PPE set up outside the room, but he was observed sitting in an adjoining room with a family member who was also a resident; the adjoining room lacked signage indicating shared occupancy with a resident on TBP, and neither resident wore a mask or PPE. A CNA entered that room, spoke with R25, and exited without removing her mask or performing hand hygiene. Multiple residents requiring EBP were observed receiving care without the required infection control practices. R21, who had a catheter and was on EBP, was treated by an LN who did not perform hand hygiene before gloving, did not add the required PPE, reused the same gloves throughout wound care, touched supplies and surfaces with soiled gloves, and left the room carrying supplies while still wearing the same gloves. R4, who had an indwelling catheter and required EBP, was transferred and provided incontinent care by CNAs who did not wash hands before gloving, did not wear gowns, did not perform hand hygiene after glove removal, and handled feces-contaminated items and surfaces with the same gloves. R20, who had a PICC, CPAP mask, nebulizer equipment, and oxygen tubing present in the room, had no signage directing staff on PPE use. During wound care rounds, staff also carried the same open wound supplies from one resident room to another, placed supplies on a tray table with resident items already present, and handled wound care materials without proper hand hygiene or barrier use. A full body lift was later observed being taken from one resident room to another without being sanitized between residents, and staff confirmed it should have been sanitized.
Unqualified Infection Preventionist Designated
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) possessed the required certification for the infection prevention and control program. The facility had a census of 42 residents. During interview and record review, the facility was unable to provide proof of certification for the designated IP. On 01/28/2026 at 05:30 PM, Administrative Nurse E stated that she was the designated IP and reported that she had not completed the infection control certification course before being appointed to the position about a month earlier. She stated that she was about halfway through the course requirements for certification. The facility also did not provide a policy related to certification and qualification of the IP.
Missed showers and inadequate personal hygiene assistance
Penalty
Summary
The facility failed to ensure residents who were dependent on staff for activities of daily living received needed assistance with bathing and personal hygiene, including fingernail care. The cited residents had intact cognition or were able to communicate their needs, and their MDS assessments documented dependence on staff for showering, toileting hygiene, dressing, and personal hygiene. Facility care plans identified bathing preferences for some residents, and the shower schedule showed residents were assigned regular showers, but the records and observations showed repeated missed showers and lack of nail care. R4 was dependent on staff for most ADLs, including showering and personal hygiene, and preferred afternoon showers twice weekly. Shower records showed many scheduled showers, but only a small number were completed, with some refusals and some bed baths. During interview, R4 reported going over a week without a shower and said she was sad about not receiving one. R21 was dependent on staff for toileting hygiene, showers, and personal hygiene, and preferred afternoon showers, but her shower record showed only one shower with several bed baths and missed opportunities due to hospitalization. She reported that she did not always get showers at least twice a week and that she missed an activity because her shower was scheduled before BINGO and there was no dry lift sling available afterward. R7 was dependent on staff for toileting hygiene, showers, and dressing, had an indwelling catheter, and had a care plan that did not address personal hygiene or nail care assistance. Observations showed long, dirty, jagged fingernails with brown debris under the nails over multiple days, and R7 stated she could not cut her nails and would need help. R40 was dependent for showering and required extensive assistance with personal hygiene; he preferred evening baths twice weekly. He reported it had been almost two weeks since his last shower, and observations showed very long jagged fingernails with brown residue underneath. Staff interviews confirmed showers were limited to daytime hours, the facility had only one working shower room for both hallways, missed showers were not always made up, and staff were expected to trim and clean residents’ nails on bath days or as needed.
Failure to File and Acknowledge Pharmacist Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist’s monthly medication regimen review (MRR) was properly acknowledged and that the pharmacist’s recommendations were filed in the clinical record for five residents: R1, R3, R6, R20, and R33. The report states that the pharmacy consultant documented MRRs for these residents and noted irregularities, but the actual recommendations were not present in the residents’ records, and there was no evidence that the facility or the physician acknowledged and responded to the findings. For R1, R3, R6, R20, and R33, the electronic medical record showed multiple pharmacy consultant notes indicating that MRRs were completed and irregularities were noted, but the clinical records lacked the separate written reports with the resident’s name, relevant drug, and identified irregularity. During an interview on 01/29/26 at 11:32 AM, Administrative Nurse D stated she would not have any of the MRRs before 12/02/25 and could not locate the requested MRRs, and she stated she expected the MRRs to be answered within seven days after receipt from the pharmacist. The facility policy dated 02/2025 required the consultant pharmacist to review the medication regimen per state and federal guidelines and to report irregularities to the attending physician, medical director, and DON on a separate written report.
Unlabeled Insulin Pens in Medication Storage
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles because several insulin pens in use were stored without an open date. During observation on 01/28/26 at 08:29 AM, R2's Lantus pen had no label or open date, R2's insulin lispro had no legible open date, R15's insulin lispro had no open date, R4's Lantus had no open date, and R17's glargine had no cap and no open date. The facility had two medication rooms and four medication carts for a census of 42 residents. During interview, the LN stated insulin pens should be labeled when opened, and the Administrative Nurse stated staff were expected to label insulin pens with an open date. The facility did not provide a medication storage policy.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform Resident 3 and Resident 20, and/or their representatives, about the risks related to psychotropic medications. Resident 3’s EMR documented an order for olanzapine 5 mg by mouth once daily dated 06/25/25, but the record lacked evidence that Resident 3 or the representative received education or informed consent regarding the dose and frequency increase. Resident 20’s EMR documented orders for trazodone 50 mg by mouth every 24 hours at bedtime as needed for insomnia, without a stop date, and citalopram hydrobromide 40 mg daily by mouth dated 10/10/25. The EMR lacked evidence that Resident 20 or the representative received education or informed consent for Celexa and trazodone. During interviews, the LN stated the SSD would complete informed consents for psychotropic medications, while the SSD reported she could not locate the consents for Resident 20 and produced signed consents dated 01/29/26. The SSD also stated she would have the resident or responsible party complete consent when a new psychotropic medication was ordered. The Administrative Nurse stated she expected informed consents for psychotropic medications to be obtained prior to administration.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to give residents notice of Medicare coverage and potential liability for services not covered by Medicare. For Resident 4, the facility documented that Medicare Part A coverage ended on 11/20/25, but the resident remained in the facility and the ABN Form CMS-R-131 dated 11/20/25 did not include a selection in section G. For Resident 6, the facility documented that Medicare Part A coverage ended on 07/23/25, the resident remained in the facility, and the ABN Form CMS-R-131 dated 11/20/25 also lacked a section G selection. For Resident 35, the facility documented that Medicare Part A services ended on 12/24/25 and the resident remained in the facility, but the facility could not provide evidence that Form CMS-10055 or Form CMS-10123 had been given to the resident. An Administrative Nurse stated that the ABN should be provided to the resident or resident's representative so the notification can be appealed before the last day of Part A coverage. The facility policy stated that the Skilled Nursing Facility ABN is issued to the resident if the resident intends to continue services that may no longer be covered by Medicare.
Unclean Resident Rooms and Poor Environmental Maintenance
Penalty
Summary
The facility failed to maintain a clean, homelike environment for three residents. Resident 33’s room was observed with a strong foul odor, and his bed linens were dirty and gray in color. The next day, the same dirty sheets were still on the bed, and the strong odor remained evident from the room into the hallway. Staff interviews indicated that Resident 33’s room was scheduled for daily cleaning, but housekeeping staff reported the room smelled foul all the time and that the resident sometimes would not leave the room so staff could not always clean under the bed. Resident 33 stated he would allow staff to clean his room and reported no staff had spoken to him about the odor in his room. Resident 7’s room was observed with a strong urine odor on multiple occasions, and staff reported her room smelled of urine quite often. On one observation, her catheter bag was not covered and there was no urine visible in the bag. Resident 40’s recliner was observed with vinyl peeling off the chair, and he stated the recliner was broken and he thought he had reported it. His room also had a pile of food crumbs and dirt in front of the chair, red dried smears on the tray table, and duct tape on the tray table in two places. Housekeeping staff reported Resident 40’s room was typically cleaned twice a day because he was messy, but also stated the room had not been cleaned the previous day or that day.
PRN Psychotropic Orders Missing Required Stop Dates
Penalty
Summary
The facility failed to ensure that Resident 6 and Resident 20 had as-needed psychotropic medication orders with a 14-day stop date or a specified duration with a physician rationale for extended use. Resident 6’s EMR showed an order for haloperidol 0.5 mg by mouth every four hours as needed for agitation/aggression, dated 10/18/25, and an order for lorazepam 0.5 mg by mouth every two hours as needed for anxiety/seizure, dated 11/04/25; both orders lacked stop dates. On 01/28/26 at 09:50 AM, Resident 6 was observed walking in the hall with a walker, with no behaviors and answering questions with ease. Resident 20’s EMR showed an order for trazodone 50 mg by mouth every 24 hours at bedtime as needed for insomnia, dated 10/10/25, and the order also lacked a stop date. On 01/28/26 at 07:35 AM, Resident 20 was observed sitting in a recliner and reported not getting much sleep the previous night. During interviews, a LN stated that all as-needed psychotropic medication orders required a 14-day stop date and that the nurse entering the order in the EMR was responsible for documenting it. An Administrative Nurse stated she expected all as-needed psychotropic medications to have a 14-day stop date so the medication could be reassessed. The facility policy on psychotropic drugs stated that as-needed orders for antipsychotics and other psychotropics enter a 14-day stop date and require physician evaluation to renew.
Failure to Provide Bed Hold Notices and LTCO Discharge Notification
Penalty
Summary
The facility failed to provide a written bed hold notice, including the duration of the bed hold, for two residents who were transferred to the hospital. One resident had a Quarterly MDS documenting a BIMS score of 15 and was admitted to the hospital with urosepsis after a nursing progress note documented that a verbal bed hold was given before departure, but the record lacked evidence that a written bed hold notice was provided. During interview, the resident stated she did not know anything about a bed hold. Another resident also had a Quarterly MDS documenting a BIMS score of 15 and was sent to the emergency room when found unresponsive; the nursing note documented that he was unable to sign a bed hold because he was unresponsive, but there was no evidence that a written bed hold was sent with the resident or provided to the party responsible. The resident later stated he had no knowledge of what the bed hold policy was or whether one had been done. The facility also failed to notify the Office of the Long-term Care Ombudsman of a resident discharge. A resident with an admission MDS documenting a BIMS score of 15 was discharged from the facility by private vehicle with a family member, and the discharge summary and medication orders were provided to the resident and representative. However, the facility could not provide evidence that the LTCO received notification of the discharge. The Social Service Designee stated she had not updated the LTCO since 08/25/25 for transferred or discharged residents, while other staff stated bed holds were expected to be completed at transfer and that the LTCO should be updated monthly on all transfers.
Incomplete Care Plans for Psychotropic Medications and ADL Assistance
Penalty
Summary
The facility failed to develop a comprehensive care plan for R20’s psychotropic medications. R20 had diagnoses of major depressive disorder and anxiety, a BIMS score of 15 indicating intact cognition, and MDS documentation showing no behaviors and minimal depression. His MDS and CAA identified use of high-risk medications, and the record showed orders for trazodone as needed for insomnia, Celexa daily for depression, Caplyta at bedtime for depression, and lorazepam twice daily for anxiety. However, R20’s care plan, revised 01/05/26, only documented that he used antidepressant, psychotropic, and antianxiety medications and did not include any interventions related to his mental health medications. During observation, R20 was sitting in his recliner and reported he did not get much sleep the night before. The facility also failed to develop a comprehensive care plan for R7’s ADL needs related to personal hygiene and nail care. R7 had diagnoses of major depressive disorder and anxiety, a BIMS score that varied from 10 to 13, impairments in both upper and lower extremities, and required total assistance with personal hygiene. Her CAA triggered for self-care deficit, and her care plan documented an ADL self-care performance deficit related to weakness and limited mobility, but it did not include documentation about assistance needed for personal hygiene or nail care. Observations showed R7 had long, dirty, jagged fingernails with brown debris under the nails on multiple occasions, and she stated she could not cut her nails and would need help.
Failure to Secure and Cover Foley Catheters
Penalty
Summary
The facility failed to provide adequate catheter-related care for three residents with indwelling urinary catheters by not securing catheter tubing to prevent pulling or dislodgement and by not keeping urine collection bags covered and sanitary. The facility census was 42 residents, and the sample included 12 residents, with three residents reviewed for urinary catheters. The report identified these failures for R4, R7, and R21 based on observation, interview, and record review. R4 had diagnoses including bladder dysfunction and inflammatory reaction due to an indwelling urethral catheter, intact cognition, and dependence on staff for most ADLs. Her care plan directed staff to provide foley catheter care, change the catheter as needed, observe tubing for kinks, and keep the catheter below bladder level. During observation, her catheter tubing was hanging freely without being secured to her skin, and later her urine collection bag was hanging on a garbage can without a cover and touching the floor. A CNA stated there were no securement devices available, and R4 reported she was being treated for another possible UTI. R7 had diagnoses of urinary retention and anxiety, intact cognition, and dependence on staff for toileting hygiene, showers, and dressing. Her care plan directed foley catheter care and keeping the catheter below bladder level, and her record noted a history of frequent UTI with resistant bacteria. During observation, her room smelled strongly of urine, her catheter tubing had no securement device, and her catheter bag was not covered. R21 had diagnoses of sepsis and neuromuscular dysfunction of the bladder, intact cognition, and dependence on staff for toileting hygiene, showers, and personal hygiene. Her care plan directed foley catheter care and keeping the catheter below bladder level. During observation, her urine collection bag was not covered and was positioned toward the doorway, and she reported she had no anchor or securement device, was lucky if she got catheter care, and had to ask for her catheter to be cleaned. An administrative nurse stated staff were expected to apply securement devices and cover catheter drainage bags with a dignity bag, and the facility policy required both covering the urine bag and securing the catheter with a leg strap.
Missing Pneumococcal Vaccine Education and Documentation
Penalty
Summary
The facility failed to provide education and obtain consent or informed declination for the pneumococcal vaccine for three residents. Review of Resident 1's immunization record showed no documentation that the facility provided education about the risks versus benefits of the pneumococcal vaccine after the resident received the vaccine on 10/11/22, despite the resident having been in the facility since 08/29/19. Review of Resident 20's immunization record showed no documentation of education regarding the risks versus benefits and/or the offer of the pneumococcal vaccine since the resident's admission on 09/25/25, and the record also lacked historical information about the resident's pneumovax status. Review of Resident 25's immunization record likewise lacked documentation that education was provided regarding the risks versus benefits and/or the offer of the pneumococcal vaccine since admission on 04/06/23, and the record also lacked historical information about the resident's pneumococcal vaccine status. On 01/29/2026 at 11:05 AM, Administrative Nurse E confirmed the facility failed to provide these residents with education regarding the risks versus benefits of pneumococcal vaccination so they could make an informed decision. The facility policy titled F883, F884, F887 Vaccination of Residents including Influenza, Pneumococcal, and COVID-19, Reporting stated that residents will be offered pneumovax vaccinations and that education about benefits and potential side effects will be provided and documented in the medical record.
Laundry Area Not Maintained in Safe, Sanitary Condition
Penalty
Summary
The facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment in the laundry area. During an inspection of the laundry with Housekeeping Staff/Maintenance Staff U, surveyors observed three soiled laundry bins with an unsanitary cracked top on the outer edge rim, paint missing from the sorting room floor creating an unsanitary surface, and two USB cables lying across the folding table where staff processed clean laundry. Four cardboard boxes were stored directly on the floor, and a tray carrier with chemicals was also placed directly on the floor. Four uncovered pillows were stored under a table leaning in direct contact with the wall. Additional findings included about four feet of missing baseboard at the junction of the soiled linen sorting room wall and floor, and broken and missing tile at the soiled laundry sorting room door transition. Housekeeping/Maintenance Staff U confirmed the findings and agreed the laundry needed repairs to ensure a safe and sanitized area for staff to process residents' clothing and linen.
Unsafe Transport in Shower Chair Led to Resident Fall and Fractures
Penalty
Summary
The facility failed to ensure a resident remained free of accident hazards when staff transported her down the hallway in a shower chair and her right lower leg became entangled, causing her to fall out of the chair. The resident had diagnoses including DM2, morbid obesity, abnormal involuntary movements, and generalized muscle weakness. Her MDS documented intact cognition with a BIMS score of 15, wheelchair use for locomotion, dependence on staff for all transfers, and use of a mechanical lift for transfers. Her care area assessments identified impaired balance during transfers and high fall risk, and her care plan directed two staff for transfers and later a full lift with two staff assistance. According to the progress notes and investigation, staff were wheeling the resident from the shower room to her room in a shower chair when her foot slipped off the foot rail and she fell face first onto the floor. A nurse found her face down in the hallway in front of the shower chair with a CNA kneeling beside her. The resident complained of right leg pain, and staff observed swelling, discoloration, right leg shape displacement, and shortening compared to the left leg. Staff covered her with a bath blanket, rolled her onto a full lift sling, contacted EMS, and later moved her onto the EMS cot with a mechanical lift for transport to the hospital. The resident reported that a CNA was hurrying because of an upcoming appointment and was propelling her back to her room in the shower chair when the footrest folded back under the chair, her legs dropped to the floor, and her legs became caught under the front of the chair as she fell forward. She stated she was naked on the floor and staff closed nearby doors to protect her dignity. The facility’s investigation documented that the root cause was the resident tipping forward in the shower chair while being transferred down the hall. Staff interviews showed that some staff believed residents should never be transported in shower chairs down hallways, while one nurse stated that transporting bariatric residents in shower chairs down hallways was acceptable when wheelchairs would not fit into the shower room. The facility’s shower policy described transporting residents to and from the bath area in a bath chair and ensuring feet did not drag on the floor, but the accident policy did not address shower chair transportation.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to provide cardiopulmonary resuscitation (CPR) to a resident, R1, who was designated as full code, indicating she desired resuscitative measures. On the day of the incident, Licensed Nurse (LN) G left R1's room to obtain a breathing treatment, and upon returning, was informed by Certified Medication Aide (CMA) R that R1 was unresponsive. LN G assessed R1 and found a weak apical pulse. Despite R1's full code status, CPR was not initiated after R1's spouse, who was not the designated power of attorney, initially requested CPR but then recanted and instructed staff not to start compressions. R1's medical history included chronic obstructive pulmonary disease (COPD), lymphedema, congestive heart failure, and hypertension. Her electronic medical record and care plan clearly documented her full code status, and she had signed a Full-Code Resuscitate Directive. Despite this, staff did not perform CPR when R1 was found without a heartbeat, placing her and other residents with full code status in immediate jeopardy. The facility's policy required CPR to be initiated unless a Do Not Resuscitate (DNR) order was in place, which was not the case for R1. Interviews with staff revealed confusion and hesitation in following the resident's code status. LN G confirmed that she asked R1's spouse multiple times about starting compressions, and despite his initial agreement, he later declined. Administrative Nurse D stated that the staff should have followed the resident's code status, but CPR was not initiated due to the spouse's instructions. This failure to act according to the resident's documented wishes and facility policy led to the deficiency being cited.
Removal Plan
- Nursing staff were re-educated on initiating the current code status. Review the code status with the resident and/or DPOA and if changes are desired, notify the provider.
- Educated nurses to initiate advance directives as ordered until new orders are obtained from the provider.
- Residents were audited and updated as needed for desired code status.
- Residents' code statuses were audited for validation of code status.
Failure to Employ Certified Dietary Manager
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for the 42 residents who resided in the facility and received their meals from the kitchen. On multiple occasions, it was observed that the dietary staff preparing meals were not certified dietary managers. Specifically, on 04/09/24, Dietary Staff BB, who was preparing breakfast, confirmed she was not a certified dietary manager. This was further verified by Administrative Staff A on 04/11/24. The facility's policy required the employment of a certified dietary manager or another qualified nutritional professional if the dietician was not full-time, but this requirement was not met. The facility's Food Service Staffing policy dated 10/2024 documented that the community would employ sufficient staff with the appropriate competencies and skills to carry out the function of the food and nutrition services. The policy outlined specific qualifications for the dietary manager role, including certification or relevant experience and education. The failure to employ a full-time certified dietary manager placed the residents at risk for inadequate nutrition, as there was no qualified individual to evaluate residents' nutritional concerns and oversee the ordering, preparing, and storage of food.
Improper Food Storage and Dish Sanitization
Penalty
Summary
The facility failed to store food in a safe and sanitary manner and did not adequately sanitize dishes for the 42 residents who resided in the facility and received meals from the kitchen. During an initial kitchen tour, it was observed that the upright refrigerator-freezer contained outdated food items, including a bag of pepperoni circles and Salisbury steak patties, both of which were past their expiration dates. Dietary Staff verified the presence of outdated food that needed to be discarded. Additionally, the dishwasher was found to be operating at temperatures below the required 120 degrees Fahrenheit for chemical sanitization, with recorded temperatures consistently between 105-110 degrees Fahrenheit. This was confirmed by both the Dishwasher Temperature Logs and observations of the dishwasher in use. The facility's policies on Food Safety Requirements and Dishwashing Machine Use were not adhered to, as food was not stored according to safe food handling practices, and the dishwashing machine did not maintain the necessary sanitization temperature. Maintenance Staff later adjusted the water heater to 140 degrees Fahrenheit after being informed of the low dishwasher temperatures. However, the failure to store food properly and sanitize dishes adequately placed the residents at risk for foodborne illness.
Failure to Prevent Accident Hazards and Falls
Penalty
Summary
The facility failed to ensure an environment free from accident hazards when the accessible hot water at the dining room sink was found to be 131 degrees Fahrenheit. Maintenance staff had recently adjusted the hot water thermostat, which resulted in the elevated temperature. The facility's Safety of Water Temperatures policy mandates that water temperatures should not exceed 115 degrees Fahrenheit to prevent scalding. Despite periodic checks indicating temperatures above this limit, no corrective action was taken until the surveyor's observation, placing residents at risk for accidental skin injury. Additionally, the facility failed to provide effective interventions to prevent further falls for a resident with a history of multiple falls. The resident, who had diagnoses including heart disease, COPD, and psychosis, had a care plan that included various fall prevention measures such as wearing non-skid socks and using a call light for assistance. Despite these measures, the resident continued to experience falls, indicating that the interventions were not effective. The facility's Fall Risk Assessment policy requires the interdisciplinary team to review and update care plans based on the root cause of falls, but this was not adequately done for this resident. The resident's electronic medical record documented multiple falls over several months, with interventions such as education and medication reviews being implemented but proving ineffective. Observations and interviews with staff confirmed that the resident continued to self-transfer and fall despite repeated education and reminders. The facility's failure to implement different, effective interventions placed the resident at continued risk for injuries related to falls.
Failure to Discard Outdated Medications
Penalty
Summary
The facility failed to discard outdated insulin flex pens for three residents, placing them at risk for ineffective medication. Observations revealed that Resident 1's Lantus flex pen, Resident 32's Basaglar flex pen, and Resident 144's insulin glargine flex pen were all expired but still in use. Licensed Nurse I and Administrative Nurse D confirmed that the flex pens should have been labeled with the resident's name and discard dates, and that outdated pens should have been discarded. The facility's policies on labeling and storage of medications were not followed, leading to this deficiency. Additionally, an inspection of the north hall medication cart revealed expired stock medications, including acetaminophen, B1 vitamins, and Vitamin B complex tablets. Certified Medication Aide T verified the expiration dates and acknowledged that the medications were expired. The facility's Storage of Medications policy clearly states that outdated drugs should be returned to the pharmacy or destroyed, but this was not adhered to, resulting in the presence of expired medications in the cart.
Failure to Provide Updated CDC VIS Before Vaccinations
Penalty
Summary
The facility failed to provide five residents with the most recent CDC vaccination information statement (VIS) before administering flu and pneumonia vaccinations. The residents' records showed that the facility used outdated consent forms with information from the 08/15/19 influenza, the 10/30/19 PCV13, and the 10/30/19 PPSV23 CDC guidelines. This deficiency was confirmed by Administrative Nurse E, who verified that the residents had not been provided the most recent VIS before vaccinations. The facility's Vaccination of Residents policy, dated 09/2023, required that residents or their representatives be provided with information and education regarding the benefits and potential side effects of the vaccinations before receiving them. The failure to provide the most recent CDC VIS placed the residents at risk for uninformed decision-making.
Failure to Prevent Pressure Ulcer in Resident
Penalty
Summary
The facility failed to provide appropriate interventions to prevent a pressure injury for a resident (R22) who had recurring blisters on the left heel and was at risk for skin breakdown. Despite having a care plan that identified the risk for skin breakdown due to muscle loss, the facility did not revise the care plan when heel blisters were first noted in December 2023 and re-occurred in February 2024. The resident's medical history included protein-calorie malnutrition, adult failure to thrive, neuropathy, chronic pancreatitis, and a Stage 2 pressure ulcer on the left heel. The resident required moderate assistance for eating and was dependent on staff for all other activities of daily living. The care plan directed staff to complete weekly skin assessments and notify the primary care physician if abnormalities were noted, and to keep off-loading boots on 24 hours a day except during transfers. Observations and documentation revealed that the resident had a recurring blister on the left heel that was not adequately addressed. The facility's Pressure Injury Treatment Guidelines policy directed staff to determine the cause of pressure, relieve and redistribute pressure, implement pressure-redistributing devices, notify the physician and family, and initiate a skin documentation protocol and care plan. However, the facility failed to provide consistent off-loading and timely revisions to the care plan, which contributed to the resident's ongoing pressure ulcer issues. The resident was observed with different types of foot protectors and inconsistent wound care, indicating a lack of adherence to the prescribed interventions.
Failure to Provide Necessary Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident diagnosed with PTSD, major depressive disorder, and anxiety disorder. The resident's care plan included monitoring for symptoms such as crying, wandering, and aggression, and directed staff to closely monitor the resident for clinical worsening and suicidal thoughts. Despite recommendations from an APRN to increase the resident's Sertraline dosage and refer her to psychotherapy, the facility did not follow up with the referral for psychotherapy. This lack of follow-up was confirmed by administrative staff and a nurse consultant, who also noted that staff lacked information related to the resident's triggers. Observations revealed that the resident was receiving her morning medications, including Sertraline, but there was no evidence in the clinical record of a psychotherapy appointment or follow-up on mental health services. The facility's Behavioral Health Services policy stated that residents should receive necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. However, the facility did not adhere to this policy, resulting in untreated and ongoing mental health concerns for the resident.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to ensure a coordinated plan of care for Resident 141, who was receiving hospice services. The resident's electronic health record revealed diagnoses of malignant neoplasm of the lung, COPD, and shortness of breath. Despite being admitted with a hospice provider of choice, the facility's nursing baseline care plan lacked any information regarding the resident's hospice services and evidence of coordination of care between the hospice and the facility. Observations and interviews confirmed that the facility did not have the necessary hospice documentation, such as admitting notes, assessments, and a hospice care plan, in the electronic health records or in a separate binder at the nurse's station as required by the facility's policy. Consultant GG and Administrative Nurse D verified the absence of hospice information, and Social Service X instructed the hospice provider to bring a binder to the facility. The facility's Hospice Program policy required written identification of hospice services and coordination between the hospice medical director and the attending physician. The lack of coordination and documentation placed Resident 141 at risk for inappropriate end-of-life care.
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 54 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 Hutchinson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diversicare Of Hutchinson | 0.3 mi | ★★★★★ | 1 | 0 |
| Good Samaritan Society - Hutchinson Village | 0.5 mi | ★★★★★ | 17 | 0 |
| Wesley Towers Inc | 1.9 mi | ★★★★★ | 17 | 0 |
| Mennonite Friendship Communities Inc | 4.2 mi | ★★★★★ | 2 | 0 |
| Buhler Sunshine Home | 8.2 mi | ★★★★★ | 0 | 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.