Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Sutton Community Home, Inc. during CMS and state inspections, most recent first.
QAPI failed to identify hand hygiene as a systemic issue despite repeat prior infection control deficiencies and ongoing hand hygiene audits showing 100% compliance. The LPN-IP confirmed there was no active hand hygiene PIP and that audits were only completed based on Nebraska ICAP recommendations, while the ADON and ADM confirmed the facility had repeat hand hygiene issues on prior state surveys but no current hand hygiene PIP.
Hand hygiene was not consistently performed during meal service, catheter care, and wound care. A dietary aide and a medication aide served lunch trays while wearing gloves without proper hand hygiene, and a nursing assistant failed to clean hands between catheter care tasks. During a dressing change for a resident with a stage 4 sacral pressure ulcer and multiple diagnoses, an LPN and a nursing assistant also failed to perform hand hygiene at required points, including before gloving and between clean and dirty tasks.
Inaccurate MDS Coding for PASARR Status: The facility failed to code a resident’s annual MDS as a Level 2 PASARR. The resident had schizoaffective disorder and bipolar disorder, a BIMS score of 14, and a prior Level II PASARR identifying Serious Mental Illness and medical necessity based on psychiatric history and medication needs. The AA confirmed the MDS should have reflected Level 2 PASARR status, and the DON stated the facility did not have an MDS policy and relied on the RAI manual for accuracy.
Failure to post complete daily staffing information: the facility’s Daily Staffing Logs did not show the total number of hours worked by discipline or by shift for staff directly responsible for resident care. The RN confirmed the log was updated by the night shift only, and the ADON confirmed there was no Daily Staff Posting policy and that the logs did not separate staff by discipline or include total hours worked by shift.
The facility failed to properly store and label food items and did not adhere to hand hygiene protocols during meal service. Observations revealed unlabeled and improperly stored food in the kitchen and outdoor refrigerator. Additionally, staff did not wash hands between glove changes and after handling non-food items, increasing the risk of foodborne illness for all residents.
The facility failed to review pre-employment health history screenings for four staff members, including dietary aides and nurse aides, which is essential for preventing the transmission of contagious diseases. The Infection Control Coordinator did not review the completed Medical History and Screening Forms, as confirmed in interviews, indicating a lapse in the infection prevention and control program.
A facility failed to conduct timely AIMS assessments for a resident receiving Olanzapine, an antipsychotic medication. The resident, with severe cognitive impairment, was not assessed as per the facility's policy, which required AIMS assessments upon medication changes. The oversight was confirmed by the DON, highlighting a deficiency in monitoring the resident's well-being.
The facility failed to implement and monitor interventions for two residents at risk of elopement, particularly one resident with severe cognitive impairment who eloped after exhibiting exit-seeking behavior. Despite having a care plan and a wander guard, no new interventions were added following the elopement incident, as confirmed by the DON and documented in the resident's progress notes.
QAPI failed to identify hand hygiene as a systemic issue
Penalty
Summary
The facility failed to identify hand washing as a systemic issue before the survey and failed to correct previously cited quality issues related to infection control. Survey review of the facility’s Medicare.gov Nursing Home Compare history showed prior infection control deficiencies on 6.11.2021, 7.26.2022, 9.14.2023, and 9.12.2024. The facility’s QAPI program, revised in July 2025, listed monitoring the efficacy and outcomes of the Infection Prevention program as a focus area and stated that QAPI decisions were to be based on data and used to guide day-to-day operations. The facility’s Infection Prevention and Control Risk Assessment dated 9/2025 rated staff non-compliance with hand hygiene as having a low probability of occurrence. Facility QAPI meeting records from 9.11.2025, 10.9.2025, and 11.13.2025 showed hand hygiene audits and related infection control audits with 100% compliance, and the 12.11.2025 QAPI meeting listed infection control and monthly infection surveillance under old business. During interviews, the LPN-IP confirmed there was no active PIP for hand hygiene and that the facility only completed hand hygiene audits based on Nebraska ICAP recommendations. The ADON and Administrator also confirmed there was no current hand hygiene PIP, despite repeat hand hygiene issues on prior state surveys and ongoing audit results showing 100% compliance.
Hand Hygiene Not Performed During Meal Service, Catheter Care, and Wound Care
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not perform hand hygiene during meal service, during catheter care, and during wound care. The report states that the facility census was 20 and that the practice had the potential to affect all residents in the facility. Facility policies reviewed by surveyors required hand hygiene before putting on gloves, after glove removal, and between clean and dirty tasks. During meal service, a dietary aide served lunch trays in the dining room while wearing gloves and then returned to the dining room with the same gloves on without performing hand hygiene. The dietary aide later confirmed that hand hygiene was usually done before serving and that the same gloves were worn when going in and out of resident rooms. A medication aide also failed to perform hand hygiene before putting on gloves while helping serve lunch trays, and a nursing assistant completed foley catheter care and peri care without performing hand hygiene when changing gloves between tasks. During wound care for a resident admitted with arthritis, high blood pressure, malnutrition, mild intellectual difficulties, and a stage 4 sacral pressure ulcer, a nursing assistant entered the room without hand hygiene, handled gowns in a way that caused one gown to rub against the hair, and then put on gloves without hand hygiene. The LPN performing the dressing change removed the old dressing, removed gloves, performed hand hygiene, cleaned the wound, changed gloves without hand hygiene, and applied the clean dressing. Both the LPN and the nursing assistant confirmed the actions observed, and the infection preventionist confirmed that hand hygiene should be performed when entering a resident room, before and after glove use, and between removing an old dressing, cleaning the wound, and applying a new dressing.
Inaccurate MDS Coding for PASARR Status
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident whose annual MDS was not coded to reflect a Level 2 PASARR. Record review showed the resident was admitted with a PASARR Level 1 preliminary screening, had a BIMS score of 14 indicating cognitively intact, and carried diagnoses of schizoaffective disorder and bipolar disorder. The resident’s Level II PASARR dated 10/22/18 identified Serious Mental Illness, noted medical necessity based on schizoaffective disorder and the need for medication to manage symptoms, and documented a history of psychiatric hospitalization and psychiatrist follow-up. The resident’s comprehensive care plan revision dated 8/9/2022 also identified that the resident had a Level 2 PASARR. During interview, the Assistant Administrator confirmed the annual MDS should have been coded as a Level 2 PASARR. The Director of Nursing further confirmed the facility did not have an MDS policy and stated the facility uses the RAI manual to ensure MDS accuracy.
Failure to Post Complete Daily Staffing Information
Penalty
Summary
The facility failed to post daily staffing information that included the total number and actual hours worked by discipline for staff directly responsible for resident care per shift. Record review showed that Daily Staffing Logs dated 7.3.2025, 7.13.2025, 7.19.2025, 8.24.2025, 8.31.2025, and 9.27.2025 did not include the total number of hours by discipline or the total hours worked by shift. Additional review of Daily Staffing Logs dated 12.15.2025, 12.16.2025, and 12.17.2025 showed hours were not totaled by shift or for the 24-hour period, no changes were made to indicate actual hours worked, and the CNA hours column was left blank on 12.15.2025 and 12.16.2025. On 12.17.2025, one change was documented for a call-in and replacement staff member, but the log still did not total hours by shift. During interviews, the RN confirmed the Daily Staffing Log was updated by the night shift only and did not include the total number of hours worked by shift, and the ADON confirmed the facility did not have a Daily Staff Posting policy and that the logs did not separate staff by discipline or include total hours worked by shift.
Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of food items in accordance with the Food Code, as well as failed to perform necessary hand hygiene during meal service. Observations in the kitchen food storage areas revealed several issues: containers of food items in the main kitchen refrigerator were not labeled or dated, including grapefruit sections and a container of light pink food items. In the freezer, a food item labeled 'Turkey Noodle' and egg patties were not properly dated or sealed. Additionally, in the outdoor walk-in refrigerator, limp celery and raw sliced ham were improperly stored, with the ham placed above other food items, which is against food safety protocols. The Dietary Manager confirmed these storage and labeling deficiencies. During meal service, the Dietary Manager and Dietary Cook-H were observed not following proper hand hygiene protocols. The Dietary Manager did not wash hands between glove changes after handling paperwork and before assisting with meal service. Similarly, Dietary Cook-H did not perform hand hygiene after handling bread and cupboard doors before returning to serve meals. Both staff members acknowledged their failure to adhere to hand hygiene requirements, which is a critical step in preventing foodborne illness. These deficiencies had the potential to affect all residents who consumed food prepared in the facility's kitchen.
Failure to Review Pre-Employment Health Screenings
Penalty
Summary
The facility failed to ensure that pre-employment health history screenings were reviewed to prevent the potential transmission of contagious diseases among staff. This deficiency was identified through record reviews, interviews, and observations. Specifically, four staff members, including two dietary aides and two nurse aides, were hired without their Medical History and Screening Forms being reviewed by the Infection Control Coordinator (ICC). These forms, although completed and signed by the staff members, were undated and not reviewed, which is a critical step in preventing the spread of contagious diseases within the facility. During interviews, both the ICC and the Facility Administrator confirmed that the ICC was responsible for reviewing these forms to prevent potential disease transmission. However, the ICC admitted to not having reviewed the Medical History and Screening Forms or the Medical History Questionnaires submitted by the employees. This oversight in the infection prevention and control program highlights a significant lapse in the facility's procedures for safeguarding against the transmission of contagious diseases by staff.
Failure to Conduct Timely AIMS Assessment for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure proper monitoring of a resident who was receiving antipsychotic medication, specifically Olanzapine. The resident, who was admitted with diagnoses including mild cognitive impairment, anxiety disorder, and dementia, was severely cognitively impaired as indicated by a BIMS score of 4/15. Despite the facility's policy requiring an Abnormal Involuntary Movement Scale (AIMS) assessment to be conducted upon admission, quarterly, with significant changes in condition, or changes in antipsychotic medication, the resident did not receive an AIMS assessment until several months after starting the medication. The resident's care plan included interventions such as administering psychotropic medications as ordered, monitoring for side effects, consulting with the pharmacy and provider for dosage reduction, and educating the resident and family about the medication's risks and benefits. However, the facility did not adhere to its policy of conducting an AIMS assessment when the resident's antipsychotic medication was changed. This oversight was confirmed by the Director of Nursing, who acknowledged that the required AIMS assessment was not completed in a timely manner, leading to a deficiency in monitoring the resident's well-being while on antipsychotic medication.
Failure to Implement Interventions for Elopement Risk
Penalty
Summary
The facility failed to develop, evaluate, and monitor interventions to prevent further elopement for two residents, specifically Resident 12, who was identified as being at risk for elopement due to severe cognitive impairment and a history of wandering. Despite having a wander guard device and a care plan that included interventions such as ensuring adequate lighting and proper fitting clothing, no new interventions were implemented after Resident 12's actual elopement incident on December 10, 2023. The care plan was not updated to address the resident's exit-seeking behavior, which was documented multiple times on the same day as the elopement. The facility's records and interviews with the Director of Nursing confirmed that Resident 12 was actively exit-seeking and had eloped from the facility without any new interventions being put in place to prevent further incidents. The resident's progress notes indicated multiple instances of exit-seeking behavior on December 10, 2023, yet there was no evidence of any changes to the current interventions or the implementation of new strategies to mitigate the risk of elopement. This lack of action and failure to update the care plan contributed to the deficiency identified by the surveyors.
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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.
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Nursing homes near Sutton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy Square | 11.8 mi | ★★★★★ | 10 | 1 |
| Harvard Rest Haven | 12.2 mi | ★★★★★ | 0 | 0 |
| Fairview Manor | 14.2 mi | ★★★★★ | 5 | 0 |
| Heritage Crossings | 15 mi | ★★★★★ | 9 | 0 |
| Westfield Quality Care Of Aurora | 19.3 mi | ★★★★★ | 1 | 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.