PEABODY, KS — Federal health inspectors identified seven deficiencies at Access Mental Health during a standard health inspection completed on December 10, 2025, including a citation for inadequate bowel and bladder care that poses infection risks for residents. The facility has not submitted a plan of correction for any of the violations.
Continence and Catheter Care Failures
The inspection found that Access Mental Health failed to meet federal standards for providing appropriate care to residents who are continent or incontinent of bowel and bladder function. The citation, issued under regulatory tag F0690, also encompasses inadequate catheter care and insufficient measures to prevent urinary tract infections.
Inspectors classified the deficiency at Scope/Severity Level D, indicating an isolated incident where no actual harm was documented but the potential existed for more than minimal harm to residents. While this classification falls on the lower end of the federal severity scale, the underlying care failures carry meaningful clinical consequences for a vulnerable population.
Proper continence care is a foundational element of nursing facility standards. When facilities fail to manage bowel and bladder function appropriately, residents face elevated risks of skin breakdown, pressure injuries, and infections. For residents with indwelling urinary catheters, the stakes are particularly high — catheter-associated urinary tract infections remain one of the most common healthcare-associated infections nationwide, and they are largely preventable with proper protocols.
Why Catheter and Continence Protocols Matter
Urinary tract infections can escalate rapidly in elderly and medically complex individuals. What begins as a localized infection can progress to urosepsis, a serious bloodstream infection that carries significant mortality risk in older adults. The progression from UTI to sepsis can occur within hours, making prevention and early detection critical components of resident care.
Standard medical protocols require that catheterized residents receive regular assessment of catheter necessity, proper hygiene around the catheter insertion site, adequate hydration, and timely catheter removal when no longer clinically indicated. Each additional day a catheter remains in place increases the cumulative risk of bacterial colonization and subsequent infection.
For residents managing incontinence without catheters, appropriate care includes regular toileting schedules, prompt changing of soiled garments or briefs, barrier cream application to protect skin integrity, and ongoing assessment of each resident's individual continence patterns. Failure to maintain these practices can lead to moisture-associated skin damage, fungal infections, and significant discomfort.
Seven Deficiencies and No Correction Plan
The bladder care citation was one of seven total deficiencies identified during the December inspection. While the full scope of the remaining violations was not detailed in this report, the volume of citations during a single inspection visit suggests broader compliance challenges at the facility.
Perhaps more concerning than the deficiencies themselves is the facility's response — or lack thereof. Access Mental Health has been documented as "Deficient, Provider has no plan of correction" on file. Federal regulations under the Centers for Medicare & Medicaid Services require that facilities submit a plan of correction outlining specific steps they will take to address each deficiency, the timeline for implementation, and measures to prevent recurrence.
The absence of a correction plan raises questions about the facility's commitment to addressing the identified care gaps. Without a documented plan, there is no formal accountability mechanism to ensure that the conditions leading to these citations are remedied in a timely manner.
Federal Standards and Resident Protections
Under CMS regulations, all Medicare- and Medicaid-certified facilities must provide care that maintains or improves each resident's functional abilities, including continence management. The F0690 tag specifically addresses the facility's obligation to ensure residents receive services that are consistent with professional standards of practice and tailored to individual needs.
Facilities that fail to submit correction plans or demonstrate continued non-compliance may face escalating enforcement actions, including civil monetary penalties, denial of payment for new admissions, or in severe cases, termination from federal healthcare programs.
Residents and family members with concerns about care quality at Access Mental Health can file complaints with the Kansas Department for Aging and Disability Services or contact the Kansas Long-Term Care Ombudsman program for advocacy support. The full inspection report, including all seven deficiencies, is available through the CMS Care Compare database at medicare.gov.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Access Mental Health from 2025-12-10 including all violations, facility responses, and corrective action plans.
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