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Access Mental Health

📍 500 Peabody, Peabody, KS 66866 📞 (620) 983-2165 🛏️ 45 beds

Inspection History Overview

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Detailed Inspection Reports

Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.

December 10, 2025 Health Inspection

Fines and Penalties by Year

2022 21 penalties totaling $29,719

$8,391
Dec 27, 2022

Fine

$4,276
May 30, 2022

Fine

$4,276
May 23, 2022

Fine

$12,827
May 2, 2022

Fine

$4,225
Apr 18, 2022

Fine

$4,225
Apr 11, 2022

Fine

$4,225
Apr 4, 2022

Fine

$4,225
Mar 28, 2022

Fine

$4,225
Mar 21, 2022

Fine

$4,225
Mar 14, 2022

Fine

$4,225
Mar 7, 2022

Fine

$4,225
Feb 28, 2022

Fine

$4,225
Feb 21, 2022

Fine

$4,225
Feb 14, 2022

Fine

$4,225
Feb 7, 2022

Fine

$4,225
Jan 31, 2022

Fine

$4,225
Jan 24, 2022

Fine

$4,225
Jan 17, 2022

Fine

$0
Jan 14, 2022

Payment Denial

$4,225
Jan 10, 2022

Fine

$4,225
Jan 3, 2022

Fine

2021 44 penalties totaling $11,700

$4,225
Dec 27, 2021

Fine

$4,225
Dec 20, 2021

Fine

$4,225
Dec 13, 2021

Fine

$4,225
Dec 6, 2021

Fine

$4,225
Nov 29, 2021

Fine

$4,225
Nov 22, 2021

Fine

$4,225
Nov 15, 2021

Fine

$4,225
Sep 27, 2021

Fine

$4,225
Sep 20, 2021

Fine

$4,225
Sep 13, 2021

Fine

$4,225
Sep 6, 2021

Fine

$4,225
Aug 30, 2021

Fine

$4,225
Aug 23, 2021

Fine

$4,225
Aug 16, 2021

Fine

$4,225
Aug 9, 2021

Fine

$4,225
Aug 2, 2021

Fine

$4,225
Jul 26, 2021

Fine

$4,225
Jul 19, 2021

Fine

$4,225
Jul 12, 2021

Fine

$4,225
Jul 5, 2021

Fine

$4,225
Jun 28, 2021

Fine

$4,225
Jun 21, 2021

Fine

$4,225
Jun 14, 2021

Fine

$4,225
Jun 7, 2021

Fine

$4,225
May 31, 2021

Fine

$4,225
May 24, 2021

Fine

$4,225
May 17, 2021

Fine

$4,225
May 10, 2021

Fine

$4,225
May 3, 2021

Fine

$4,225
Apr 26, 2021

Fine

$4,225
Apr 19, 2021

Fine

$4,225
Apr 12, 2021

Fine

$4,225
Apr 5, 2021

Fine

$4,225
Mar 29, 2021

Fine

$4,225
Mar 22, 2021

Fine

$4,225
Mar 15, 2021

Fine

$4,225
Mar 8, 2021

Fine

$4,225
Mar 1, 2021

Fine

$4,225
Feb 22, 2021

Fine

$4,225
Feb 15, 2021

Fine

$4,225
Feb 8, 2021

Fine

$4,225
Feb 1, 2021

Fine

$3,900
Jan 11, 2021

Fine

$3,575
Jan 4, 2021

Fine

2020 10 penalties totaling $17,550

$3,250
Dec 28, 2020

Fine

$2,925
Dec 21, 2020

Fine

$2,600
Nov 16, 2020

Fine

$2,275
Nov 9, 2020

Fine

$1,950
Nov 2, 2020

Fine

$1,625
Oct 5, 2020

Fine

$1,300
Sep 28, 2020

Fine

$975
Sep 21, 2020

Fine

$0
Aug 20, 2020

Payment Denial

$650
Jul 6, 2020

Fine

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Health Violations by Year

2025 17 violations

Tag 0622 D Jan 15, 2025

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

✓ Corrected: Feb 12, 2025
Tag 0623 D Jan 15, 2025

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

✓ Corrected: Feb 12, 2025
Tag 0641 D Jan 15, 2025

Ensure each resident receives an accurate assessment.

✓ Corrected: Feb 12, 2025
Tag 0656 D Jan 15, 2025

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Feb 12, 2025
Tag 0657 D Jan 15, 2025

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

✓ Corrected: Feb 12, 2025
Tag 0688 D Jan 15, 2025

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

✓ Corrected: Feb 12, 2025
Tag 0690 D Jan 15, 2025

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

✓ Corrected: Feb 12, 2025
Tag 0692 G Jan 15, 2025

Provide enough food/fluids to maintain a resident's health.

✓ Corrected: Feb 12, 2025
Tag 0699 D Jan 15, 2025

Provide care or services that was trauma informed and/or culturally competent.

✓ Corrected: Feb 12, 2025
Tag 0740 D Jan 15, 2025

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

✓ Corrected: Feb 12, 2025
Tag 0756 D Jan 15, 2025

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

✓ Corrected: Feb 12, 2025
Tag 0757 D Jan 15, 2025

Ensure each resident’s drug regimen must be free from unnecessary drugs.

✓ Corrected: Feb 12, 2025
Tag 0758 D Jan 15, 2025

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

✓ Corrected: Feb 12, 2025
Tag 0801 F Jan 15, 2025

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

✓ Corrected: Feb 12, 2025
Tag 0812 F Jan 15, 2025

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Feb 12, 2025
Tag 0883 E Jan 15, 2025

Develop and implement policies and procedures for flu and pneumonia vaccinations.

✓ Corrected: Feb 12, 2025
Tag 0887 D Jan 15, 2025

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

✓ Corrected: Feb 12, 2025

2024 8 violations

Tag 0689 J Feb 1, 2024

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Feb 29, 2024
Tag 0741 G Feb 1, 2024

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

✓ Corrected: Feb 29, 2024
Tag 0835 F Feb 1, 2024

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

✓ Corrected: Feb 29, 2024
Tag 0867 F Feb 1, 2024

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

✓ Corrected: Feb 29, 2024
Tag 0600 K Jan 16, 2024

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

✓ Corrected: Feb 20, 2024
Tag 0609 L Jan 16, 2024

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

✓ Corrected: Feb 20, 2024
Tag 0610 L Jan 16, 2024

Respond appropriately to all alleged violations.

✓ Corrected: Feb 20, 2024
Tag 0689 J Jan 16, 2024

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Feb 20, 2024

2023 6 violations

Tag 0600 E Jun 14, 2023

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

✓ Corrected: Jul 14, 2023
Tag 0636 D Jun 14, 2023

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

✓ Corrected: Jul 14, 2023
Tag 0656 D Jun 14, 2023

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Jul 14, 2023
Tag 0689 J Jun 14, 2023

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Jan 31, 2023
Tag 0695 D Jun 14, 2023

Provide safe and appropriate respiratory care for a resident when needed.

✓ Corrected: Jul 14, 2023
Tag 0727 F Jun 14, 2023

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

✓ Corrected: Jul 14, 2023

2022 13 violations

Tag 0689 D Jul 21, 2022

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Jul 28, 2022
Tag 0689 D May 17, 2022

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Jun 2, 2022
Tag 0567 E Jan 14, 2022

Honor the resident's right to manage his or her financial affairs.

✓ Corrected: Feb 28, 2022
Tag 0584 E Jan 14, 2022

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

✓ Corrected: Feb 28, 2022
Tag 0636 E Jan 14, 2022

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

✓ Corrected: Feb 28, 2022
Tag 0657 D Jan 14, 2022

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

✓ Corrected: Feb 28, 2022
Tag 0661 D Jan 14, 2022

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

✓ Corrected: Feb 28, 2022
Tag 0689 E Jan 14, 2022

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Feb 28, 2022
Tag 0812 F Jan 14, 2022

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Feb 28, 2022
Tag 0880 F Jan 14, 2022

Provide and implement an infection prevention and control program.

✓ Corrected: Feb 28, 2022
Tag 0885 E Jan 14, 2022

Report COVID19 data to residents and families.

✓ Corrected: Feb 28, 2022
Tag 0921 F Jan 14, 2022

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

✓ Corrected: Feb 28, 2022
Tag 0923 F Jan 14, 2022

Have enough outside ventilation via a window or mechanical ventilation, or both.

✓ Corrected: Feb 28, 2022

2021 8 violations

Tag 0584 L Nov 3, 2021

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

✓ Corrected: Dec 10, 2021
Tag 0835 F Nov 3, 2021

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

✓ Corrected: Dec 10, 2021
Tag 0838 F Nov 3, 2021

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

✓ Corrected: Dec 10, 2021
Tag 0908 F Nov 3, 2021

Keep all essential equipment working safely.

✓ Corrected: Dec 10, 2021
Tag 0610 J Sep 13, 2021

Respond appropriately to all alleged violations.

✓ Corrected: Oct 8, 2021
Tag 0567 F Jan 7, 2021

Honor the resident's right to manage his or her financial affairs.

Tag 0568 F Jan 7, 2021

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Tag 0609 D Jan 7, 2021

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

2020 22 violations

Tag 0580 D Sep 30, 2020

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

✓ Corrected: Oct 31, 2020
Tag 0626 D Sep 30, 2020

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

✓ Corrected: Oct 31, 2020
Tag 0645 E Sep 30, 2020

PASARR screening for Mental disorders or Intellectual Disabilities

✓ Corrected: Oct 31, 2020
Tag 0661 D Sep 30, 2020

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

✓ Corrected: Oct 31, 2020
Tag 0625 E Sep 17, 2020

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

✓ Corrected: Oct 31, 2020
Tag 0692 G Sep 17, 2020

Provide enough food/fluids to maintain a resident's health.

✓ Corrected: Oct 31, 2020
Tag 0561 D Aug 20, 2020

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

✓ Corrected: Sep 30, 2020
Tag 0567 E Aug 20, 2020

Honor the resident's right to manage his or her financial affairs.

✓ Corrected: Sep 30, 2020
Tag 0584 E Aug 20, 2020

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

✓ Corrected: Sep 30, 2020
Tag 0641 E Aug 20, 2020

Ensure each resident receives an accurate assessment.

✓ Corrected: Sep 30, 2020
Tag 0655 D Aug 20, 2020

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

✓ Corrected: Sep 30, 2020
Tag 0656 E Aug 20, 2020

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Sep 30, 2020
Tag 0688 E Aug 20, 2020

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

✓ Corrected: Sep 30, 2020
Tag 0689 J Aug 20, 2020

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Sep 30, 2020
Tag 0725 F Aug 20, 2020

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

✓ Corrected: Sep 30, 2020
Tag 0745 D Aug 20, 2020

Provide medically-related social services to help each resident achieve the highest possible quality of life.

✓ Corrected: Sep 30, 2020
Tag 0812 F Aug 20, 2020

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Sep 30, 2020
Tag 0880 F Aug 20, 2020

Provide and implement an infection prevention and control program.

✓ Corrected: Sep 30, 2020
Tag 0881 F Aug 20, 2020

Implement a program that monitors antibiotic use.

✓ Corrected: Sep 30, 2020
Tag 0947 D Aug 20, 2020

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

✓ Corrected: Sep 30, 2020

2019 20 violations

Tag 0689 J Jul 1, 2019

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Jul 1, 2019
Tag 0561 D Feb 28, 2019

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

✓ Corrected: Apr 5, 2019
Tag 0572 C Feb 28, 2019

Give residents a notice of rights, rules, services and charges.

✓ Corrected: Apr 5, 2019
Tag 0576 E Feb 28, 2019

Ensure residents have reasonable access to and privacy in their use of communication methods.

✓ Corrected: Apr 5, 2019
Tag 0580 D Feb 28, 2019

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

✓ Corrected: Apr 5, 2019
Tag 0584 E Feb 28, 2019

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

✓ Corrected: Apr 5, 2019
Tag 0655 D Feb 28, 2019

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

✓ Corrected: Apr 5, 2019
Tag 0656 D Feb 28, 2019

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

✓ Corrected: Apr 5, 2019
Tag 0660 D Feb 28, 2019

Plan the resident's discharge to meet the resident's goals and needs.

✓ Corrected: Apr 5, 2019
Tag 0730 F Feb 28, 2019

Observe each nurse aide's job performance and give regular training.

✓ Corrected: Apr 5, 2019
Tag 0732 C Feb 28, 2019

Post nurse staffing information every day.

✓ Corrected: Apr 5, 2019
Tag 0756 D Feb 28, 2019

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

✓ Corrected: Apr 5, 2019
Tag 0757 D Feb 28, 2019

Ensure each resident’s drug regimen must be free from unnecessary drugs.

✓ Corrected: Apr 5, 2019
Tag 0758 D Feb 28, 2019

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

✓ Corrected: Apr 5, 2019
Tag 0805 D Feb 28, 2019

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

✓ Corrected: Apr 5, 2019
Tag 0812 F Feb 28, 2019

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Apr 5, 2019
Tag 0814 C Feb 28, 2019

Dispose of garbage and refuse properly.

✓ Corrected: Apr 5, 2019
Tag 0838 F Feb 28, 2019

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.

✓ Corrected: Apr 5, 2019
Tag 0880 F Feb 28, 2019

Provide and implement an infection prevention and control program.

✓ Corrected: Apr 5, 2019
Tag 0881 F Feb 28, 2019

Implement a program that monitors antibiotic use.

✓ Corrected: Apr 5, 2019

2018 19 violations

Tag 0689 J Dec 13, 2018

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Dec 13, 2018
Tag 0567 F Nov 29, 2018

Honor the resident's right to manage his or her financial affairs.

Tag 0568 F Nov 29, 2018

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Tag 0569 D Nov 29, 2018

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Tag 0584 E Nov 29, 2018

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Tag 0755 D Nov 29, 2018

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Tag 0812 F Nov 29, 2018

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Tag 0842 F Nov 29, 2018

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Tag 0660 D Aug 2, 2018

Plan the resident's discharge to meet the resident's goals and needs.

✓ Corrected: Aug 30, 2018
Tag 0689 D May 17, 2018

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Jun 15, 2018
Tag 0584 E Mar 5, 2018

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

✓ Corrected: Apr 9, 2018
Tag 0657 D Mar 5, 2018

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

✓ Corrected: Apr 9, 2018
Tag 0660 D Mar 5, 2018

Plan the resident's discharge to meet the resident's goals and needs.

✓ Corrected: Apr 9, 2018
Tag 0689 D Mar 5, 2018

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

✓ Corrected: Apr 9, 2018
Tag 0756 E Mar 5, 2018

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

✓ Corrected: Apr 9, 2018
Tag 0758 E Mar 5, 2018

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

✓ Corrected: Apr 9, 2018
Tag 0812 F Mar 5, 2018

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

✓ Corrected: Apr 9, 2018
Tag 0880 F Mar 5, 2018

Provide and implement an infection prevention and control program.

✓ Corrected: Apr 9, 2018
Tag 0883 D Mar 5, 2018

Develop and implement policies and procedures for flu and pneumonia vaccinations.

✓ Corrected: Apr 9, 2018

2017 1 violations

Tag 0225 D May 25, 2017

1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

✓ Corrected: May 26, 2017

2016 1 violations

Tag 0441 F May 18, 2016

Have a program that investigates, controls and keeps infection from spreading.

✓ Corrected: Jun 15, 2016
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