Hutchinson Operator, LLC

Inspectors wroteThe facility reported a census of 42 residents. The facility identified five Certified Nurse Aides (CNA) employed for more than 12 months. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for four of the five CNAs reviewed.

Inspectors wroteThe facility reported a census of 42 residents. Based on observation, interview, and record review, the facility failed to ensure the daily staff posting included the actual hours worked by the nursing staff as required.

Inspectors wroteThe facility identified a census of 42 residents. The sample included 12 residents. Based on observation, interviews, and record reviews, the facility failed to ensure adequate infection control practices related to Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) and Transmission Based Precautions (TBP-infection control procedures to limit the transmission of infectious agents), sanitization of shared equipment and hand hygiene.

Inspectors wroteThe facility identified a census of 42 residents. Based on interview and record review, the facility failed to ensure the designated Infection Preventionist (IP) possessed the required certification.

Inspectors wroteThe facility identified a census of 42 residents. The sample included 12 residents with five residents reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to ensure staff provided ADL assistance with personal hygiene for Resident (R) 4, R21, R7 and R40, who did not receive fingernail care and/or showers.

Inspectors wroteThe facility reported a census of 42 residents; the sample included 12 residents with five residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to acknowledge the Consultant Pharmacist's monthly medication regimen review (MRR) and failed to ensure the MRR recommendations were filed in the clinical record for Resident (R) 1, R3, R6, R20, and R33.

Inspectors wroteThe facility identified a census of 42 residents, two medication rooms and four medications carts. Based on observation, record review, and interview, the facility failed to store insulin (a hormone that lowers the level of glucose in the blood) appropriately to include an opened date on insulin pens in use.

Inspectors wroteThe facility reported a census of 42 residents; the sample included 12 residents with five reviewed for unnecessary medications. Based on interview and record review, the facility failed to inform Resident (R) 3 and R20 and/or their representatives regarding the risks related to psychotropic (alters mood or thoughts) medications.

Inspectors wroteThe facility identified a census of 42. The sample included 12 residents with three reviewed for beneficiary notifications. Based on interviews and record review, the facility failed to use the appropriate Advance Beneficiary Notice of Notice of Non-coverage (ABN) Form CMS-10055 and failed to ensure section G recorded the resident's selection for Resident (R) 4 and R6 and failed to issue the ABN to R35. The facility failed to issue the Notice of Medicare Non-Coverage for R35.

Inspectors wroteThe facility identified a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to maintain a clean, homelike environment for Resident 33, R7, and R40.

Inspectors wroteThe facility identified a census of 42 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 6 and R20's as needed (PRN) psychotropic medication (alters mood or thoughts) had a 14 day stop date, or a specified duration with a physician rationale for extended use. The facility failed to ensure R6's PRN antipsychotic (a psychotropic medication used to treat severe mental disorders) had the required 14 day stop date.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents with two reviewed for discharge and three for hospitalization. Based on interviews and record review, the facility failed to provide a written bed hold policy including duration for Resident (R)21, and R20. The facility also failed to notify the Office of the Long-term Care Ombudsman (LTCO) of a transfer for R46.

Inspectors wroteThe facility identified a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 20's psychotropic (alters mood or thought) medications, and R7's activities of daily living (ADLs) for a dependent resident.

Inspectors wroteThe facility identified a census of 42 residents. The sample included 12 residents with three residents reviewed for urinary catheters (a tube inserted directly into the bladder to drain urine). Based on observation, interview, and record review, the facility failed to ensure adequate catheter related care for Resident (R) 4, R7 and R21 when staff did not ensure each resident's catheter tubing was secured to prevent pulling or dislodgement. The facility additionally failed to ensure each resident was provided with a dignity bag to cover the urine collection bag and failed to ensure the urine collection bags remained sanitary and off the floor.

Inspectors wroteThe facility identified a census of 42 residents. The sample included 12 residents with five reviewed for immunizations. Based on record review and interview, the facility failed to provide education and obtain consent or informed declination for the pneumococcal (type of bacterial infection) vaccine for Resident (R) 1, R20 and R25.

Inspectors wroteThe facility reported a census of 42 residents. Based on observation and interview, the facility failed to provide housekeeping and maintenance services to ensure a safe and sanitary environment in the facility laundry.

Inspectors wroteThe facility reported a census of 41 residents. The sample included six residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 1 remained free of accident hazards when on 10/07/25 at approximately 12:15 PM, staff pushed R1 down the hallway in the shower chair. R1's right lower leg became entangled in the shower chair causing R1 to fall out of the chair, resulting in a right tibia (the large bone in the lower leg) and right fibula (the small bone in the lower leg) fractures.

Inspectors wroteThe facility identified a census of 42 residents with three residents reviewed for code status. Based on interviews and record review, the facility failed to ensure staff provided cardiopulmonary resuscitation (CPR) to Resident (R) 1, who desired resuscitative measures indicated by her full code status. At 05:20 PM on [DATE] Licensed Nurse (LN) G left R1's room to obtain a breathing treatment for R1. Before she could return to the room, Certified Medication Aide (CMA) R told LN G that R1's spouse reported R1 was unresponsive. LN G assessed R1 and noted a weak apical pulse. LN G asked R1's spouse if he wanted staff to start CPR and R1's non-DPOA spouse nodded and confirmed that was what R1 wanted. R1's spouse then recanted and told staff not to start compressions. At 05:29 PM R1 had no heartbeat but staff did not initiate resuscitative measures despite her full code status. [...]

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents. Based on observation, record review, and interview, 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. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 42 residents. Based on observation, record review, and interview the facility failed to store food in a safe and sanitary manner and failed to adequately sanitize dishes for the 42 residents that resided in the facility and received meals from the kitchen. This placed the residents at risk for foodborne illness. Findings Included: - On 04/09/24 at 08:30 AM, observation during the initial kitchen tour revealed the upright refrigerator-freezer contained the following items in the bottom freezer drawer: One bag of approximately 50 pepperoni circles with an open date of 09/15/23 and an expiration date of 03/15/24. One bag of eight Salisbury steak patties with an open date of 03/18/24 and an expiration date of 03/25/24. [...]

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents with four reviewed for falls. Based on observation, interview, and record review the facility failed to ensure an environment free from accident hazards when the accessible hot water at the dining room sink was 131 degrees F (Fahrenheit) and further failed to provide effective interventions to prevent further falls for Resident (R) 13. This placed the residents at risk for injuries related to hot water hazards and falls.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to discard Resident (R)1, R32, and R144s' insulin (a hormone that lowers the level of glucose in the blood) flex pens when outdated and failed to discard expired stock medications. This deficient practice placed the affected residents at risk for ineffective medications.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents with five reviewed for immunizations. Based on observation, interview, and record review the facility failed to provide Residents (R) 11, R13, R19, R25, and R143 with the most recent Center for Disease Control and Prevention (CDC) vaccination information statement (VIS) before administering vaccinations. This placed the residents at risk for uninformed decisions related to vaccinations.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents with three reviewed for pressure ulcers (PU-localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review the facility failed to provide interventions to prevent a pressure injury for Resident (R) 22 who had recurring blisters to the left heel and was at risk for skin breakdown. This placed the resident at risk for pressure injury and delayed healing.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents with three reviewed for mood and behavior. Based on observation, record review, and interview, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident (R)21. This placed her at risk for impaired quality of life due to untreated and ongoing mental health concerns.

Inspectors wroteThe facility had a census of 42 residents. The sample included 12 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R)141. This placed R141 at risk for inappropriate end-of-life care.

Inspectors wroteThe facility reported a census of 42 residents. Based on observation, interview, and record review the facility failed to provide all residents with a safe, functional, and comfortable environment by failure to repair, clean, or maintain several environmental areas to include carpets (which ran down all resident hallways) and baseboards throughout the facility, as well as the walls in two resident rooms. This failure had the ability to affect all residents, staff, and visitors in the facility. The facility further failed to replace a cover over light bulbs, leaving them open above a residents head. Findings Included: - Observation during the initial tour on 08/11/22 at 08:51 AM revealed two resident rooms on the south hall had holes noted in the walls. [...]

Inspectors wroteThe facility reported a census of 42 residents. The facility had one main kitchen serving one dining room. Based on observation, interview, and record review the facility failed to employ a certified dietary manager or a certified dietary food service manager. This failure affected all residents who receive meals at the facility. Findings Included: - Interview on 08/08/22 at 08:59 AM Dietary Manager N revealed she started at the facility in March 2022 and had begun classes for Certified Dietary Manager (CDM) in August 2022, but verified she was not a CDM. On 08/12/22 at 08:21 AM Administrative Nurse B confirmed they should have a CDM and thought they did but had confirmed they did not. On 08/12/22 at 11:56 AM Administrative Staff A confirmed they should employ a CDM. [...]

Inspectors wroteThe facility reported a census of 42 residents. The facility had one main kitchen where food was stored and prepared serving one dining room. Based on observation, interview, and record review the facility failed to properly store food in the main kitchen refrigerators and freezers due to the lack of temperature monitoring; failed to store clean dishes in upright positions; and failed to store opened food products per their policy and in accordance with professional standards for food service safety.

Inspectors wroteThe facility reported a census of 42 residents. Based on observation, interview, and record review the facility failed to administer the facility effectively by the failure to have resident care supplies in stock for staff to care of the residents, and failed to keep the building in good, sanitary, clean repair.

Inspectors wroteThe facility reported a census of 42 residents. Based on observation, interview, and record review the facility failed to ensure a sanitary environment by the failure to know wet times of the disinfectant used to clean the facility, lack of access to ABHR in the facility, lack of hand hygiene with cares, catheter tubing on the floor, and dirty/stained carpet observed throughout the facility. This had the potential to affect all residents residing in the facility.

Inspectors wroteThe facility reported a census of 42 residents. Based on observation, interview, and record review the facility failed to provide a safe, functional, and comfortable environment by failure to repair, clean, or maintain several environmental areas accessible to all staff and visitors, to include carpets (which ran down all resident hallways) and baseboards throughout the facility. Findings Included: - Observation during the initial tour on 08/11/22 at 08:51 AM revealed the carpet from the entry tiled floor on either side, down both north and south halls, lacked transition strips and the carpet was fraying. The carpet was the walkway to all resident rooms. The baseboards on both north and south halls were peeling back away from the wall, some sticking out and could catch a visitor's pants or ankles causing injury. [...]

Inspectors wroteThe facility census totaled 42 residents, with 12 sampled, including one for indwelling urinary catheters (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review the facility failed to promote dignity when staff failed to provide a dignity bag for the indwelling urinary catheter drainage bag for Resident (R) 31.

Inspectors wroteThe facility reported a census of 42 residents with 12 in the sample. Based on interview and record review the facility failed to ensure the staff reported all allegations of neglect. On 07/04/22 Transportation Staff Q reported a fall while transporting Resident (R)34 to an appointment and required emergency room evaluation. Licensed Nurse (LN) D made a nurse's note but did not report the fall to administrative staff.

Inspectors wroteThe facility reported a census of 42 residents with 12 sampled including one for Activities of Daily Living (ADL). Based on observation, interview, and record review the facility failed to provide ADL assistance to include bathing services to maintain good grooming for Resident (R) 41, who required limited assistance of two staff with bathing. Findings Included: - The 08/09/22 Electronic Health Record (EHR) documented R41 had the following diagnoses: Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) and dementia (progressive mental disorder characterized by failing memory, confusion). The 07/28/22 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 99, indicating he could not finish the assessment. [...]

Inspectors wroteThe facility reported a census of 42 residents with 12 included in the sample. Based on observation, interview, and record review the facility failed to provide a safe environment free of falls when Transportation Staff Q did not secure all straps on Resident (R)34's three wheeled scooter prior to driving. During transportation to an appointment, R34's three wheeled scooter tipped over, causing R34's head to hit the side of the van hurting her ear and she required hospital assessment in response. This failure placed R34 at risk of serious harm and injury. The facility also failed to ensure a safe enviroment for R18 by the failure to ensure the bed locks worked appropriately to prevent him from falling from the bed.

Inspectors wroteThe facility reported a census of 42 residents with 12 sampled including one for an indwelling urinary catheter. Based on observation, interview, and record review the facility failed to obtain a physician's appropriate diagnosis for the use of an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) for Resident (R) 31.

Inspectors wroteThe facility census totaled 42 residents, with 12 sampled, including five for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure adequate follow up of the consultant pharmacist recommendations regarding as needed (PRN) Haldol (antipsychotic medication) for Resident (R) 32, and R2's behavior monitoring regarding antidepressant medications. These failures placed the residents at risk for adverse effects related to medication use. Findings Included: [...]

Inspectors wrote- R32's Physician's Orders in the Electronic Health Record (EHR) dated 08/09/22 documented diagnosis of schizoaffective disorder (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, wanting to die were more intense and persistent than what may normally be felt from time to time), and hallucinations (sensing things while awake that appear to be real, but the mind created). The 06/22/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The assessment documented the use of an antipsychotic medication daily for R32. The 05/02/22 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15. [...]