Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Azria Health Great Bend during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of wandering eloped from the facility without staff knowledge and was found outside in a facility van during extreme heat, after the door alarm failed to activate and the care plan lacked elopement interventions. Additionally, another resident sustained skin tears of unknown origin during a transfer, but the facility did not complete a thorough investigation or obtain required witness statements.
The facility did not employ a full-time certified dietary manager to oversee food and nutrition services for its residents. Dietary staff confirmed they were not certified, and administrative staff verified this. The facility also lacked a policy for employing a certified dietary manager, affecting residents on specialized diets.
Staff did not consistently use Enhanced Barrier Precautions (EBP) or properly disinfect shared medical equipment. For example, a nurse failed to disinfect a glucometer after use on a resident, and staff did not wear gowns or gloves during high-contact care for residents with open wounds or indwelling devices, despite facility policy and posted instructions. These lapses were confirmed by administrative staff and placed residents at risk for infection.
Surveyors found that two residents' insulin pens were not properly labeled with opened or expiration dates, and one pen was used well past its expiration. Additionally, a treatment cart containing medications was left unlocked and unattended in a hallway, making medications accessible to unauthorized individuals. Both issues were confirmed by nursing staff as contrary to facility policy.
A resident with severe cognitive impairment and multiple diagnoses received PRN lorazepam for agitation without a 14-day stop date or documented physician rationale for continued use. Staff confirmed the medication was administered without the required documentation, contrary to facility policy requiring a specified duration and rationale for ongoing PRN psychotropic medication orders.
A resident with multiple medical conditions and moderate cognitive impairment sustained skin tears and bruising on the left lower leg during a staff-assisted transfer. The facility did not thoroughly or promptly investigate the injury, failed to obtain proper witness statements, and did not follow its own policy for investigating injuries of unknown origin.
The facility did not notify the Office of the Long-Term Care Ombudsman when two residents with significant medical conditions were transferred to the hospital. In both cases, documentation and staff interviews confirmed that the required notifications were missed, despite facility policy mandating written notice to the Ombudsman at the time of transfer or discharge.
Two residents with significant medical needs did not consistently receive required bathing assistance, as documented by extended periods without baths or showers and confirmed by staff interviews and resident observations. Despite some refusals being recorded, there were numerous undocumented gaps in care, and both residents were observed with poor hygiene. Staff reported offering alternative bathing times and notifying nursing staff of refusals, but facility records and observations showed that consistent bathing services were not provided according to care plans and policy.
A resident with hemiplegia and a partially contracted right hand did not receive appropriate range of motion (ROM) services or restorative care, as required by facility policy. The care plan lacked interventions to prevent contractures, staff were unaware of the need for splint use, and there was no active restorative program in place. The resident reported not receiving ROM exercises, and the splint was not consistently applied.
A resident with a history of constipation experienced an eight-day period without a documented bowel movement, during which staff failed to provide or document required bowel management interventions and assessments, despite existing care plans, standing orders, and facility policy.
A certified medication aide crushed and administered an extended-release metoprolol tablet to a resident, despite the medication label stating it should not be crushed. The aide continued with administration after being questioned, and a review found that the medication order and the medication card did not match, with the pharmacy not being notified of the order change in a timely manner. This resulted in a significant medication error due to failure to follow prescriber orders and facility policy.
A resident with multiple chronic conditions and severe cognitive impairment was admitted to hospice care, but the facility did not update the care plan to reflect hospice services as required by policy. This failure to coordinate care planning between the facility and hospice provider placed the resident at risk for inadequate end-of-life care.
The facility did not submit complete and accurate direct care staffing information through the PBJ system, as required by CMS. Although internal schedules showed adequate staffing, the PBJ reports indicated excessively low weekend staffing for two quarters. Administrative staff stated that daily schedules and updates were sent to the regional office, but the data submitted did not accurately reflect actual staffing levels.
A resident with significant mobility limitations and cognitive impairment developed a facility-acquired unstageable pressure ulcer on the left heel after the care plan failed to include timely interventions for repositioning and offloading. Staff were unable to confirm consistent use of pressure-relieving boots or clear communication of preventive measures, and the facility lacked documentation of a pressure ulcer prevention policy.
A resident with Alzheimer's and at risk for elopement exited a facility unsupervised due to inadequate staff supervision and inaudible door alarms. The resident, who used a wheelchair, was found in the parking lot after leaving the smoker's room. Staff failed to hear the alarm, contributing to the incident.
Failure to Prevent Elopement and Incomplete Investigation of Injury
Penalty
Summary
A cognitively impaired resident with a history of falls and wandering was not adequately supervised, resulting in the resident eloping from the facility. The resident, who required staff supervision for ambulation and used a walker, was last seen in the lobby by staff, with her walker left behind. Staff discovered the resident missing and found her outside in the facility van during high temperatures, without knowledge of how she exited the building. The door alarm did not activate, and the care plan lacked specific interventions for elopement risk, despite documented wandering behavior and a history of elopement attempts. Additionally, the facility failed to conduct a complete investigation when another resident sustained two skin tears of unknown origin. The resident, who was dependent on staff for transfers and had moderate cognitive impairment, reported that her leg was injured during a transfer. The incident report did not include a dated witness statement, and the facility was unable to provide documentation from the staff member involved in the transfer. The facility's policy required thorough investigation and documentation of all injuries of unknown origin, but this was not completed as required. Both deficiencies were identified through observation, record review, and staff interviews. The lack of adequate supervision and incomplete investigation placed the residents at risk, with one incident resulting in immediate jeopardy due to the resident's unsupervised exit and exposure to unsafe conditions.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to provide the services of a full-time certified dietary manager for its 61 residents who received meals from the kitchen. Observations showed that dietary staff prepared meals, but the staff member present was not a certified dietary manager. Interviews with dietary staff and an administrative nurse confirmed the absence of a certified dietary manager. Additionally, the facility was unable to provide a policy regarding the employment of a certified dietary manager. The sample included 17 residents, with three on a pureed diet and 15 on a mechanical soft diet, all of whom were affected by this deficiency.
Failure to Implement Enhanced Barrier Precautions and Disinfection Protocols
Penalty
Summary
Staff failed to consistently implement Enhanced Barrier Precautions (EBP) and proper disinfection protocols, as observed during care of residents with open wounds and indwelling devices. On multiple occasions, staff did not don gowns or gloves when providing high-contact care, such as incontinence care, wound care, and catheter care, to residents who had open wounds or urinary catheters. For example, two CNAs transferred a resident with open wounds and provided incontinence care without wearing EBP gowns, and a licensed nurse performed wound care on the same resident without donning an EBP gown. Administrative staff confirmed that EBP should have been used in these situations, and facility policy required gown and glove use for such high-contact care activities. Additionally, staff failed to properly disinfect a blood glucose meter used for multiple residents. A licensed nurse was observed obtaining a blood sugar reading for a resident and then placing the glucometer back in a drawer without cleaning or disinfecting it. The facility had two glucometers in use for seven residents, and the manufacturer's instructions, as well as facility policy, required cleaning and disinfection of the device after each use. Administrative staff verified that the glucometer should have been disinfected between uses. One resident with a urinary catheter was also not provided care according to EBP protocols. A CNA emptied the resident's catheter bag without wearing gloves or a gown, despite signage and care plan instructions indicating that EBP should be used for catheter care. The CNA acknowledged the omission when questioned, and administrative staff confirmed that EBP was required for such care. These failures were in direct violation of the facility's infection prevention and control policies and placed residents at risk for infection.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Surveyors observed that the facility failed to properly label and store medications in accordance with professional standards and facility policy. Specifically, two residents' insulin flex pens were not labeled with the date opened, and one pen was found in use 46 days past its expiration date. Additionally, another medication lacked both an opened date and an expiration date. These deficiencies were confirmed by both a licensed nurse and an administrative nurse, who acknowledged that insulin flex pens should be labeled with the date opened and discarded once expired. Facility policy and external medication guidelines require that such medications be labeled and discarded after a specified period, which was not followed in these instances. Furthermore, the facility failed to ensure that medications were only accessible to licensed staff. During the survey, a treatment cart containing insulin and other medications was found unlocked and unattended in a hallway, with no staff in sight. The responsible nurse was located in a resident's room, out of view of the cart, and later confirmed that the cart should have been locked when not under direct supervision. The facility's policy mandates that medication carts remain locked and inaccessible to unauthorized individuals when not attended by licensed staff.
Failure to Specify Duration and Rationale for PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure that a resident's as-needed (PRN) antianxiety medication, lorazepam (Ativan), had a 14-day stop date or a specified duration with a documented physician rationale for ongoing use. The resident in question had diagnoses including cerebral infarction, Alzheimer's disease, and dysphagia, and was noted to have severely impaired cognition, requiring extensive assistance with activities of daily living. The resident's care plan indicated the use of Ativan for end-of-life restlessness, and the physician's order directed staff to administer lorazepam 1 mg as needed for agitation, but did not include a stop date or specified duration. Review of the electronic health record revealed no evidence of a physician's rationale for the extended use of PRN lorazepam. Staff confirmed that the medication was administered without the required 14-day stop date or documentation supporting continued use. The facility's policy required that PRN psychotropic medications not be renewed beyond 14 days without a healthcare practitioner's evaluation and documented rationale, and that the duration be indicated in the order. This policy was not followed in this case.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly and promptly investigate an injury of unknown origin sustained by a resident with multiple medical conditions, including a stable burst fracture of two vertebrae, chronic respiratory failure, chronic lymphocytic leukemia in remission, pain, osteoarthritis, and dorsalgia. The resident, who had moderately impaired cognition and was dependent on staff for transfers, was found with two bruised areas and skin tears on her left lower leg after being assisted by CNAs for supper. The resident reported that her leg was bumped during a transfer, but the care plan did not provide specific staff direction for transfers and mobility, and there was no history of falls since admission. The incident report for the injury did not include a dated witness statement, and the facility was unable to provide a witness statement documenting what happened during the transfer, despite the resident's claim. The facility's policy required all injuries of unknown origin to be thoroughly investigated and documented, but the investigation was incomplete and not conducted in a timely manner. The interdisciplinary team reviewed the incident, but the required documentation and witness statements were missing or undated, resulting in a failure to meet the facility's own policy for investigating potential abuse, neglect, or exploitation.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO) regarding the hospital transfers of two residents, resulting in a deficiency related to required documentation and notification. For one resident with a history of Alzheimer's disease, hypertension, diabetes, and a recent femur fracture, the clinical record did not show evidence that the Ombudsman was notified when the resident was transferred to the hospital for treatment. The resident's care plan and progress notes documented the transfer and subsequent readmission, but the omission of notification was confirmed by facility staff, who stated the resident was mistakenly missed during the notification process. Another resident, also with Alzheimer's disease and additional diagnoses including chronic kidney disease and encephalopathy, was transferred to the hospital following a decline in condition, including confusion, weakness, and respiratory symptoms. The resident's niece was notified of the transfer, and the resident was later readmitted to the facility. However, the clinical record lacked documentation that the LTCO was notified of the discharge to the hospital. Facility staff confirmed that this resident was not included in the monthly report sent to the Ombudsman office, as required by facility policy. Facility policy states that residents or their representatives must be notified in writing of impending transfers or discharges, and a copy of this notice must be sent to the Office of the State Long-Term Care Ombudsman at the same time. In both cases, the required notification to the Ombudsman was not completed, as confirmed by staff interviews and review of the clinical records.
Failure to Provide Consistent Bathing Assistance to Residents
Penalty
Summary
The facility failed to provide consistent bathing services to two residents who required assistance with activities of daily living, specifically bathing. One resident with diagnoses including Parkinson's disease, hypertension, anxiety, and depression, and who had intact cognition but required supervision with bathing, did not receive a bath or shower for multiple extended periods as documented in the facility's records. Although some refusals were recorded in the electronic medical record, there were numerous days with no documentation of bathing or refusal, and observations noted the resident with uncombed hair and unresponsiveness to questions. Another resident, diagnosed with a displaced femur fracture, Alzheimer's disease, hypertension, and diabetes, and who required partial to substantial staff assistance for bathing, also experienced significant gaps in receiving showers. Facility records showed long intervals without showers, with only a few refusals documented. Observations found this resident with greasy, uncombed hair, unshaven, and wearing soiled socks, and the resident was unable to recall if staff offered different bathing choices. Interviews with staff indicated that when residents refused bathing, alternative days or times were offered, and refusals were documented and reported to nursing staff. The facility's policy required staff to observe residents' skin condition, notify supervisors of refusals, and report according to policy and professional standards. Despite these procedures, the documentation and observations revealed that the facility did not consistently ensure that residents received the necessary assistance with bathing, as required by their care plans and facility policy.
Failure to Provide Range of Motion Services for Resident with Hemiplegia
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) services to a resident with hemiplegia and hemiparesis following a stroke, resulting in a partially contracted right hand. The resident's medical record documented the need for assistance with activities of daily living due to hemiplegia and generalized weakness, but the care plan lacked specific interventions to prevent contractures. Although the care plan instructed staff to monitor and report signs of immobility, it did not include any restorative or splint/brace therapy interventions. The resident reported not receiving ROM exercises or restorative services for his right hand, and his splint was out of reach, requiring staff assistance to apply it. Interviews with facility staff revealed that there was no active restorative program, and restorative aides were not available. Nursing staff were unaware of the resident's need for the hand splint, and the care plan did not address contracture prevention. The therapy consultant confirmed the resident's hand did not open fully and that he was educated on splint use, but the facility did not ensure consistent application or ROM services. The facility's own policy required restorative nursing care as needed, but this was not provided to the resident.
Failure to Provide Bowel Management Interventions for a Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate interventions for bowel management for one resident with a history of constipation. The resident had diagnoses including dementia, anxiety, hypertension, and constipation, and was noted to have moderately impaired cognition but remained independent in activities of daily living. The care plan directed staff to administer medications as ordered, monitor for side effects of constipation, report changes in bowel patterns to the physician, and document daily bowel movement patterns. Standing orders and physician orders were in place for the administration of stool softeners and laxatives, with instructions to notify the physician if there was no result after specific interventions. Despite these directives, the resident's bowel monitoring record showed an eight-day period without a documented bowel movement, and the medication administration record lacked evidence that interventions were provided during this time. There was also no documentation of a bowel assessment for the period in question. Staff interviews confirmed that there were procedures for reporting and initiating standing orders after three days without a bowel movement, but the records did not reflect that these actions were taken for the resident during the identified period. The facility's policy required assessment and intervention for bowel dysfunction, but these were not documented as completed.
Crushing of Extended-Release Medication Results in Significant Medication Error
Penalty
Summary
A certified medication aide crushed and administered an extended-release (ER) metoprolol tablet to a resident by mixing it with applesauce, despite the medication label indicating 'Do not crush.' The aide proceeded with this action even after being questioned about the appropriateness of crushing the ER medication, stating she would consult the nurse later. Review of the medication records revealed that the current physician order was not for ER metoprolol, but the medication card still reflected the ER formulation, leading to confusion. The administrative nurse confirmed that the medication administration did not align with the current physician order and that the pharmacy had not been notified of the order change in a timely manner, resulting in an incorrect Medication Administration Record (MAR). The facility's policy requires medications to be administered according to prescriber orders and verified for correct method of administration prior to delivery.
Failure to Update Care Plan for Resident Receiving Hospice Services
Penalty
Summary
The facility failed to ensure coordinated care and services between the facility and hospice for a resident who was admitted to hospice care. The resident had multiple diagnoses, including Alzheimer's disease, chronic kidney disease, encephalopathy, acute bronchitis, and congestive heart failure, and required significant staff assistance with activities of daily living (ADLs) due to severe cognitive impairment and functional limitations. Although the resident was admitted to hospice care and had a physician's order for hospice services, the facility did not update or create a facility care plan reflecting the resident's hospice status. The care plan in the electronic health record did not indicate that the resident was receiving hospice services, despite documentation from the hospice provider and orders from the primary care physician. The facility's policy required comprehensive, person-centered care plans to be developed and revised as residents' conditions changed, including when a resident was admitted to hospice. The lack of an updated care plan coordinating hospice and facility services placed the resident at risk for inadequate end-of-life care.
Failure to Accurately Report Direct Care Staffing Data via PBJ
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through the Payroll-Based Journal (PBJ) system as required by CMS. During the review period, the PBJ report for two consecutive fiscal quarters indicated excessively low weekend staffing, despite the facility's own nursing staffing schedules showing adequate staff on duty. Administrative staff confirmed that daily schedule sheets, including updates, were sent to the regional office, and any changes were also communicated. The facility's policy required that direct staffing information be collected daily and reported electronically in a uniform format, but the submitted PBJ data did not accurately reflect the actual staffing levels provided, leading to the deficiency.
Failure to Provide Timely Pressure Ulcer Prevention and Care
Penalty
Summary
A resident with multiple comorbidities, including diabetes, immobility, and cognitive impairment, was admitted to the facility with existing pressure ulcers and was identified as being at risk for further skin breakdown. The resident required substantial to maximum assistance for mobility and personal care and was dependent on staff for transfers and repositioning. The care plan directed staff to use pressure-relieving devices and follow protocols for skin breakdown prevention, but it did not include specific interventions for repositioning or offloading until after the resident developed a new pressure ulcer on the left heel. Despite the resident's risk factors and care needs, documentation and staff interviews revealed uncertainty about whether pressure-relieving boots were in use prior to the development of the left heel ulcer. Staff could not confirm if turning and repositioning were consistently implemented or if these interventions were clearly communicated in the care plan. The resident developed a facility-acquired unstageable pressure ulcer on the left heel, which progressed in size and severity, eventually becoming necrotic and malodorous, and was later diagnosed as osteomyelitis by a hospital. The facility's records lacked evidence of timely care plan updates and did not provide a policy on pressure ulcer prevention. Staff interviews indicated gaps in communication and training regarding pressure ulcer prevention interventions. The care plan was not updated to include offloading and heel protectors until after the pressure ulcer had developed, and there was no documentation of a systematic approach to ensure at-risk residents received necessary preventive care.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a cognitively impaired resident, identified as R1, from exiting the facility without staff knowledge. R1, who had a history of Alzheimer's disease, muscle weakness, and was at risk for elopement, was able to propel his wheelchair from the dining room to the smoker's room. Despite being identified as an elopement risk, R1 was left unsupervised in the smoker's room by CNA N, who was informed of R1's location by Housekeeping Staff U. CNA N left R1 in the room to attend to other duties, assuming R1 was not attempting to exit. At approximately 08:20 AM, Administrative Staff A found R1 in the parking lot, sitting in his wheelchair, expressing a desire to go home to see his family. The investigation revealed that the door alarm to the smoker's room was sounding, but staff could not hear it due to its low volume. This lack of audible alarm contributed to the staff's failure to respond promptly to R1's elopement. The facility's incident report confirmed that R1 exited through the smoker's room door, and the alarm was not heard by staff who were occupied in other areas of the facility. R1's care plan documented his risk for elopement and outlined strategies for intervention, including redirection and structured activities. However, these measures were not effectively implemented, leading to R1's unsupervised exit. The facility's Wandering and Elopement Policy aimed to identify and manage residents at risk, but the failure to ensure the alarm was audible and the lack of immediate staff response resulted in R1's elopement, placing him in immediate jeopardy.
Removal Plan
- All nursing staff were re-educated on wandering/elopement.
- R1 is one-on-one with staff until it is determined he is not exiting seeking.
- Maintenance fixed the smoke room door alarm, so it would alarm not only in the room and outside but at the alarm panel to alert staff.
- Maintenance staff and the manager on duty are checking all door alarms.
- Care plans of residents at risk for elopement were reviewed and new elopement risk evaluations were completed on all residents.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Great Bend
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medicalodges Great Bend | 2.1 mi | ★★★★★ | 3 | 0 |
| Diversicare Of Larned | 22.2 mi | ★★★★★ | 11 | 0 |
| Leisure Homestead At Stafford | 30.1 mi | ★★★★★ | 32 | 0 |
| Locust Grove Village | 30.5 mi | ★★★★★ | 1 | 1 |
| Sterling Village | 32.6 mi | ★★★★★ | 0 | 0 |
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