Medicalodges Great Bend

observation revealed R1 sat in a wheelchair, watching other residents in the dining room while waiting for his lunch. R2 sat at an assisted table in the dining room, and people watched.

Continued observation revealed R3 sat at a dining room table in his wheelchair, visiting with tablemates. R5 sat in his wheelchair at the assisted table at lunch time and was assisted with eating by staff. R6 sat in a wheelchair at the assisted resident dining room table, and staff assisted R6 to eat.On 12/22/25 at 01:30 PM, R4 laid in bed after lunch and waved his hands in the air.On 12/22/25 at 12:15 PM, CNA N stated she was just so overwhelmed with everything she witnessed from CNA M and trying to get everyone up for breakfast that when she finally got a chance to think, she told CMA R what had happened, and CMA R told her to go and tell the administrator.

CNA N stated she was trained on ANE. On 12/22/25 at 12:30 PM, CNA O stated CNA M always seemed aggravated with residents while assisting with cares. CNA O stated she would tell CNA M to stop being rude to residents, but she did not want to start anything with someone she was working with, so she just let it go. CNA O stated R5 heard everything CNA M was saying about him, but he just let them continue to change him and get him ready for supper. CNA O stated she did not think R5 really understood what CNA M was saying.On 12/22/25 at 12:45 PM, CMA R stated when she saw CNA M trying to force R4 up and out of bed against his will, she did not report it because she thought it was an isolated incident. CNA M stated she realized she should have reported it. CMA R stated she was trained on ANE and knew she needed to report any suspected abuse.On 12/22/25 at 01:00 PM, LN G stated she did not suspect abuse at the time of the occurrence, but in retrospect, she should have notified someone CNA M was having a bad day. LN G stated she was trained in ANE and knew who to report suspected abuse to.On 12/22/25 at 01:15 PM, Administrative Nurse D stated she expected the staff to report any suspected incident of physical or verbal abuse to the administration when it occurred.

Administrative Nurse D stated the good thing, if there was a good thing, was all of the residents this happened to were not alert and oriented, so even if they heard what CNA M said, they probably did not understand it.The facility's Abuse, Neglect, and Exploitation Policy, revised October 2022, documented the resident has the right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. It is the policy of the facility to treat each resident with respect, kindness, dignity, and care, to keep them free from abuse and neglect, and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect.The facility identified and implemented immediate corrective actions, which were completed on 12/12/25 and included: All nursing staff re-educated on Abuse, Neglect, and Exploitation Policy, an emergency Quality, Assurance, and Performance Improvement (QAPI) meeting was held with the facility's medical director. An emergency resident council meeting was conducted to discuss abuse and neglect.

The local police department was contacted, and a report was filed. SSD will meet with each affected resident weekly for four weeks to check on any psychosocial impact.

Due to the corrective actions completed before the onsite survey, the citation was deemed past noncompliance at an F scope and severity to represent R1, R2, R3, R4, R5, and R6's potential psychological harm of embarrassment and/or humiliation.

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