Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Medicalodges Great Bend during CMS and state inspections, most recent first.
Failure to supervise a wandering resident resulted in an assault and serious injury. A resident with severe dementia, wandering, and poor safety awareness walked down the hall, stopped to look over another resident’s wheelchair, and was shoved by another resident, causing him to fall. Staff found him scared and shaken with skin tears and left hip/leg pain, and the hospital confirmed a comminuted left femoral neck fracture.
Several residents experienced verbal and mental abuse when a CNA made derogatory remarks about their hygiene, attempted to physically force a resident out of bed, and neglected basic care tasks. Other staff members witnessed these actions but did not promptly report them, despite being trained on abuse and neglect policies.
Staff failed to promptly report observed and suspected abuse, including aggressive and verbally abusive behavior by a CNA toward multiple residents. Several staff members witnessed or were informed of inappropriate comments, harsh treatment, and attempts to physically force a resident, but did not immediately notify administration as required by policy. The affected residents included individuals with limited alertness, some of whom showed signs of distress.
A resident with severe cognitive impairment and a history of wandering exited the facility through an unsecured, unalarmed door, traversed hazardous outdoor areas, and suffered a fall resulting in facial abrasions and a UTI. Staff did not immediately notice the resident's absence, and the door alarm was found to be nonfunctional at the time, leading to inadequate supervision and failure to prevent the elopement.
The facility failed to ensure CNAs completed the required 12-hour in-service education, with CNA N completing only three hours and CMA T lacking dementia care training. This deficiency was confirmed by the Administrative Nurse and placed residents at risk for decreased quality of care.
The facility failed to secure an oxygen storage room, leaving it accessible to wandering residents, and did not update a resident's care plan with new interventions after multiple falls. This placed residents at risk for preventable accidents and injuries.
A facility failed to maintain a medication error rate below five percent, resulting in a 7.69% error rate. A CMA administered amlodipine and benazepril to a resident despite physician orders to hold these medications if blood pressure was below 100/65 mmHg. The resident's blood pressure was 128/60 mmHg, indicating the medications should not have been given. Both the CMA and a Licensed Nurse confirmed the error, and the facility lacked a policy on medication errors.
A facility failed to ensure that a Consultant Pharmacist identified and reported repeated medication administration errors for a resident with hypertension and severely impaired cognition. Despite physician orders to hold blood pressure medications if the resident's blood pressure was below certain parameters, staff administered the medications multiple times over several months. The CP's reviews lacked notes on these irregularities, and the facility's policy for reporting such errors was not followed.
A resident with hypertension received unnecessary medications due to the facility's failure to follow physician-ordered blood pressure parameters. Despite orders to withhold amlodipine and benazepril if blood pressure was below 100/65 mm/Hg, staff administered these medications multiple times over several months when the resident's blood pressure was below the threshold. Observations and interviews confirmed the errors, and the facility lacked a medication administration policy.
Failure to Supervise a Wandering Resident Resulted in Assault and Hip Fracture
Penalty
Summary
The facility failed to provide adequate supervision to a resident with severe cognitive impairment, wandering behavior, and a documented history of needing staff to make safe decisions for him daily. The resident’s record showed diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, anxiety, and panic disorder. His assessments and care plan documented that he wandered, could be exit-seeking, had poor safety awareness, and required staff to monitor him when he wandered and redirect him as needed. He was also identified as a high fall risk. On the evening of the incident, the resident was walking in the 100 hall and stopped to look over another resident’s wheelchair that was left in the hallway. A resident came out of a room, interacted with him, and then shoved him four to five feet, causing him to fall to the floor. Staff later found him lying supine with his knees bent and a folded blanket under his head. He was scared and shaken, had three skin tears on his left elbow, and complained of left leg and hip pain when he tried to move. Witness statements and staff accounts confirmed that the resident had wandered down the hall before the assault and fall occurred. One CNA reported seeing him on the floor after being waved down the hall, and another resident and a witness reported that the other resident pushed him. The hospital radiology report documented a comminuted transverse transcervical fracture of the left femoral neck with mild impaction, superior displacement, moderate apex angulation, and external rotation. The facility’s own staff stated they did not know what could have been done to prevent the accident other than keeping wheelchairs out of the hall.
Failure to Protect Residents from Verbal and Mental Abuse by CNA
Penalty
Summary
Multiple residents were subjected to verbal and mental abuse by a Certified Nurse's Aide (CNA), who made derogatory and inappropriate comments about residents' hygiene and physical condition. Witness statements documented that the CNA made repeated negative remarks about a resident's smell and food intake, used sarcasm, and laughed at another staff member's discomfort. The CNA also sternly reprimanded another resident in a public setting, causing visible distress. Additionally, the CNA was observed ranting and cussing in front of residents and expressing frustration about work assignments. Further incidents included the CNA attempting to physically force a resident out of bed against their will, despite the resident's resistance and verbal refusal. The CNA was also described as rushing through care routines, neglecting basic hygiene tasks such as brushing hair, wiping hands or faces, and changing soiled clothing. Another resident was subjected to unprofessional and hurtful comments about their cleanliness. Staff members who witnessed these actions did not immediately report the incidents to administration, with some expressing uncertainty or reluctance to escalate the situation. Licensed and certified staff interviewed after the incidents acknowledged they were trained on abuse, neglect, and exploitation (ANE) policies but failed to recognize or report the abuse at the time. Some staff rationalized their inaction by believing the incidents were isolated or that the affected residents were not alert and oriented enough to understand the abuse. The facility's policy required immediate reporting and intervention for any suspected abuse, but this protocol was not followed during the events described.
Failure to Timely Report Suspected Abuse and Aggressive Staff Behavior
Penalty
Summary
The facility failed to report suspected and observed abuse of six residents by a Certified Nurse's Aide (CNA). Multiple staff members witnessed or were aware of aggressive, verbally abusive, and unprofessional behavior by the CNA toward residents, including making derogatory comments about a resident's hygiene, speaking harshly to residents, and attempting to physically force a resident out of bed against his will. Witness statements documented that the CNA made repeated negative remarks about a resident's smell, yelled at another resident, and was generally snappy and cold toward residents during care routines. Other staff, including a Certified Medication Aide (CMA), another CNA, and a Licensed Nurse (LN), observed or were informed of these incidents but did not immediately report them to administration as required by facility policy and their training on abuse, neglect, and exploitation (ANE). Some staff expressed uncertainty or minimized the incidents, with one stating she thought it was an isolated event and another not wanting to create conflict with a coworker. The lack of timely reporting delayed the facility's awareness and response to the suspected abuse. The residents involved included individuals who were not alert and oriented, and some were visibly upset or verbally expressed distress during or after the incidents. Staff statements and facility documentation confirmed that the required immediate reporting of suspected abuse to administration and authorities did not occur as mandated by policy, resulting in a deficiency related to the timely reporting of suspected abuse, neglect, or theft.
Failure to Prevent Elopement and Ensure Door Security for Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with diagnoses including Alzheimer's disease, dementia, anxiety, unsteadiness, and muscle weakness, was identified as high risk for elopement and falls. The resident's care plan and assessments documented severe cognitive impairment, wandering behaviors, poor safety awareness, and a need for close monitoring and staff assistance with mobility and activities of daily living. Despite these risks, the resident was able to exit the facility through an unlocked and unalarmed door in the 200 hall, which failed to secure properly due to the alarm being unhooked, reportedly by contractors. The mag-lock on the door did not engage, allowing the resident to leave the premises unsupervised. After exiting, the resident traversed a hazardous environment, including cracked sidewalks, uneven grassy areas, a parking lot with large potholes, and several curbs. The resident ultimately fell between two apartment buildings behind the facility. The incident was discovered when a community member called 911, and facility staff identified the resident on an ambulance stretcher. The resident sustained facial abrasions and a urinary tract infection, requiring hospital evaluation and treatment. Staff statements confirmed that the resident was last seen at the nurse's station and that there was a delay in realizing the resident was missing, leading to a search and eventual discovery of the incident by observing the ambulance outside. Facility records and staff interviews revealed that the door alarm was not functioning at the time of the incident, and the required supervision and monitoring for a high-risk resident were not adequately provided. The facility's elopement policy required individualized care planning and routine security monitoring, but these measures were not effectively implemented, resulting in the resident's unsupervised exit and subsequent injury.
Removal Plan
- 1200-pound mag-locks were installed on all doors.
- The door at the end of 200 hall was secured, and the mag-lock was functioning.
- The alarm was rewired and in working order.
- All staff were re-educated on the facility's elopement policy.
- Stop signs were placed on each exit door, and the signs also requested contractors to alert staff before using the exit doors so staff could stay at the exit doors until the contractors were done.
- The facility's Elopement Book was reviewed for accuracy.
- R1 was put on one-to-one.
- The findings of the incident were taken to an emergency QAPI.
Deficiency in CNA In-Service Education
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) completed the required 12-hour in-service education, which is necessary for maintaining the quality of care for residents. Specifically, CNA N had only completed three of the required 12 in-service hours, and CMA T lacked dementia care training. This deficiency was identified during a review of the facility's 12-hour annual in-service documentation for five certified staff members who had been employed at the facility for at least one year. The Administrative Nurse confirmed that the staff did not meet the required education topics and/or hours. Additionally, the facility was unable to provide a policy for the required services, which contributed to the deficiency and placed residents at risk for decreased quality of care.
Deficiencies in Safety and Fall Prevention
Penalty
Summary
The facility failed to maintain a secure environment free from accident hazards by not ensuring that the oxygen storage room was consistently locked. During a walkthrough, it was observed that the room containing 38 fully pressurized supplemental oxygen cylinders was unsecured, despite having a numerical keypad lock that should auto-lock when closed. Staff interviews revealed that the room should always be locked to prevent wandering residents from accessing it, but a staff member had inadvertently left it open after retrieving an oxygen bottle for a resident. Additionally, the facility did not adequately address the fall risks for a resident identified as R33, who had a history of multiple falls. R33's medical record documented several conditions, including diabetes, chronic pain, anxiety disorder, and insomnia, and noted that the resident had experienced 41 falls since admission. Despite having a care plan in place, the facility failed to update it with new interventions for 22 of these falls, as required by their risk management policy. This lack of intervention left R33 at continued risk for falls and injury. The facility's failure to secure the oxygen storage room and to implement effective fall prevention strategies for R33 highlights deficiencies in maintaining a safe environment and in managing individual resident care plans. These oversights placed residents, particularly those who are cognitively impaired and independently mobile, at risk for preventable accidents and injuries.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 7.69% error rate. This deficiency was identified during a survey involving a sample of 12 residents from a total census of 37. The specific incident involved a Certified Medication Aide (CMA) administering amlodipine and benazepril to a resident, despite the physician's orders to hold these medications if the resident's blood pressure was below 100/65 mmHg. On the day of the incident, the resident's blood pressure was recorded at 128/60 mmHg, indicating that the medications should not have been administered according to the physician's parameters. The CMA later verified the physician's orders and acknowledged the error in administering the medications. A Licensed Nurse also confirmed that the medications should not have been given due to the resident's blood pressure being out of the specified parameters. The facility was unable to provide a policy related to medication errors upon request, which contributed to the deficiency. This oversight placed the resident at risk for significant medication errors and potentially affected all residents receiving medications at the facility.
Failure to Identify and Report Medication Administration Errors
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and notified the facility and physician about the repeated administration of two blood pressure medications, amlodipine and benazepril, to Resident 21 when the resident's blood pressure was below the physician-ordered parameters. This occurred multiple times in April, May, June, and July 2024. The resident, who had a diagnosis of hypertension and severely impaired cognition, was dependent on staff for all activities of daily living. The physician's orders specified that the medications should be held if the blood pressure was less than 100/65 mm/Hg, but staff administered the medications despite these parameters being exceeded. The Medication Administration Record (MAR) showed that the medications were given 11 times in April, 16 times in May, 10 times in June, and 8 times in July when the blood pressure was below the specified limits. The CP's Medication Regimen Reviews for these months did not include notes on these irregularities. Observations and interviews confirmed that the medications were administered incorrectly, and the facility's policy required such findings to be communicated to the director of nursing and the medical director. However, the CP did not inform the facility of these ongoing medication errors, placing the resident at risk for unintended results from the medications.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to physician-ordered blood pressure parameters for a resident diagnosed with hypertension, leading to the administration of unnecessary medications. The resident, who had severely impaired cognition and required assistance for daily activities, was prescribed amlodipine and benazepril with specific instructions to hold the medications if blood pressure readings were below 100/65 mm/Hg. Despite these orders, the medications were administered multiple times over several months when the resident's blood pressure was below the specified threshold. Observations and interviews confirmed that staff repeatedly administered the medications outside the prescribed parameters. On one occasion, a Certified Medication Aide was observed administering the medications after obtaining a blood pressure reading that should have prompted withholding the drugs. Both a Licensed Nurse and an Administrative Nurse verified the ongoing medication errors, and the facility was unable to provide a medication administration policy upon request. This practice placed the resident at risk for unnecessary medications and related complications.
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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) |
|---|---|---|---|---|
| Azria Health Great Bend | 2.1 mi | ★★★★★ | 9 | 0 |
| Diversicare Of Larned | 20.4 mi | ★★★★★ | 11 | 0 |
| Locust Grove Village | 28.7 mi | ★★★★★ | 1 | 1 |
| Leisure Homestead At Stafford | 30.6 mi | ★★★★★ | 32 | 0 |
| Sterling Village | 34.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.