Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 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.
Insufficient nursing staff and administrative coverage: The facility failed to ensure staffing matched its Facility Assessment when the DON was also performing ADON, MDS, and Infection Preventionist duties for several months. The assessment called for separate administrative nursing roles, but the DON reported significant staff turnover and difficulty keeping up with responsibilities while covering multiple positions.
A facility failed to maintain a safe, clean, comfortable, and homelike environment when surveyors observed multiple stained carpet areas throughout the halls, including near the 100 hall entrance, the 100/200 hall junction, the oxygen storage room, and across the 100, 200, 300, and 400 halls. Surveyors also found frayed carpet squares and one square with a missing piece near the 300-400 nurse's station. Admin staff verified the conditions and said the carpet needed replacement, but no bids had yet been obtained.
Missing Criminal Background Check for Social Service Staff: The facility could not provide evidence that a criminal background check had been completed for a Social Service staff member who had worked at the facility since 01/10/2022 and had access to residents. Administrative staff stated background and record checks were to be completed before employment, but no criminal record check could be found in the employee’s file.
Expired Famotidine 10 mg was found on the 300 and 400 Hall med cart during observation. A CMA verified the medication was expired, and an Administrative Nurse stated that med aides or nurses were responsible for checking the cart and discarding expired meds. The facility policy required outdated medications to be immediately removed from stock and disposed of according to procedure.
A resident’s paid local TV channels were glitchy and unusable, with flickering, frozen images, and strange colors. He reported the problem to the maintenance supervisor, but staff had not promptly resolved it, and administrative staff were unaware of the issue. The facility policy stated resident complaints must be addressed promptly.
A resident with epilepsy, anxiety, HTN, and moderately impaired cognition received PRN Ativan under an order that lacked a stop date. The EMR did not show a specified duration or physician rationale for the ongoing PRN use, and an RN verified the medication had been given under that order.
Infection control failures occurred when CNAs did not dispose of soiled PPE in the resident room and when catheter care was performed without proper sanitation steps. After a Hoyer lift transfer, one CNA carried used gown and gloves out of the room to the dirty utility room before discarding them, while another CNA discarded gloves in the bathroom trash. Later, a CNA emptied a resident’s urinary catheter by placing a graduated cylinder directly on the floor and reattaching the catheter bag port without sanitizing it.
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.
Insufficient Nursing Staff and Administrative Coverage
Penalty
Summary
The facility failed to ensure there was a sufficient number of nursing staff as outlined in its Facility Assessment. The assessment, last updated on 12/02/2025, documented that the facility was licensed for 51 residents and had a current census of 46. It also stated the staffing plan was based on resident population and needs, and that administrative nursing staff would include one DON, one ADON, and one MDS RN. On 07/15/2026, Administrative Nurse D stated she had been performing the duties of the DON, ADON, MDS, and Infection Preventionist for the past six or seven months. She stated the facility had experienced significant staff turnover, including in administration, and that it had been difficult to keep up with responsibilities. She also stated the facility had recently hired an MDS person and an ADON, which would allow her to focus more on DON duties. The facility’s Facility Assessment policy, dated August 2024, stated the assessment was intended to identify the resources needed to provide necessary person-centered care and services during day-to-day operations and emergencies.
Unsafe and Poorly Maintained Hallway Carpet
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment based on multiple observations of the hallway carpet. Surveyors observed three pink stains near the entrance to the 100 halls, numerous grayish stains at the entrance where the 100 and 200 halls meet, numerous white stains in front of the oxygen storage room by the conference room, and numerous gray and pink stains throughout the 100, 200, 300, and 400 halls. They also observed six carpet squares by the 300-400 nurse's station with frayed carpet, including one square with a missing piece of carpet in the left-hand corner. Administrative staff later verified these conditions and stated the areas needed new carpet, but had not yet contacted carpet installation businesses for bids. The facility did not provide a policy regarding the environment when requested.
Missing Criminal Background Check for Social Service Staff
Penalty
Summary
The facility failed to conduct a criminal background check for one employee, a Social Service Staff member who had worked at the facility since 01/10/2022. During review of staffing and background check records on 07/13/2026, the facility was unable to provide evidence that a criminal background check had been completed for this employee, even though the employee had access to residents. Administrative Staff A stated that the business manager was responsible for obtaining criminal background and record checks on all employees before they began working at the facility. Administrative Staff A verified that no criminal record check could be found for Social Service Staff X, and the business office manager who had been at the facility when the employee was initially hired no longer worked there. The facility’s Background Screening Investigation dated October 2022 stated that all new employees would be investigated before employment for any previous history of abuse, neglect, or exploitation, that non-licensed employees would have a criminal background check as required by law, and that results would be maintained in the employee’s personnel file.
Expired Medication Left on Medication Cart
Penalty
Summary
The facility failed to discard expired stock medication from the 300 and 400 Hall medication cart. During observation on 07/13/2026 at 08:30 AM, Famotidine 10 mg, 60 count, with an expiration date of 4/2026 was found on the medication cart. At 08:35 AM, a CMA verified the medication was expired and stated that medication aides or nurses were to discard expired medications. At 2:45 PM, an Administrative Nurse verified that the pharmacy consultant checked the medication carts monthly and that medication aides or nurses were responsible for checking the medication cart and discarding expired medications. The facility's Storage of Medication policy, dated 01/2024, stated that outdated, contaminated, discontinued, or deteriorated medications are to be immediately removed from stock and disposed of according to medication disposal procedures.
Failure to Promptly Restore Paid TV Channels
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident 35 when staff did not promptly provide access to the local TV channels he paid for. During observation, the resident’s TV showed glitchy local stations with flickering, weird lines, frozen pictures, and strange colors, and he said he could not tell what was on the channels. He reported the problem to the maintenance supervisor, but the issue had not been fixed at the time of observation, and he stated he was unhappy that he was not receiving the stations he paid for. Administrative staff said they were unaware of the issue, while the maintenance supervisor stated the resident had reported it about two weeks earlier and that the cable company had said the facility would need to rewire the cable to the toner, with work planned to begin the next day. The facility policy stated residents had the right to make complaints without fear of punishment and that the nursing home must address the issue promptly.
PRN Ativan Order Lacked Stop Date and Rationale
Penalty
Summary
The facility failed to ensure a 14-day stop date or a specified duration with rationale for a resident’s ongoing PRN Ativan order. The resident had diagnoses of epilepsy, anxiety, and hypertension, and the Quarterly MDS documented moderately impaired cognition, independence with bed mobility and transfers, and receipt of an antianxiety medication during the observation period. The resident’s care plan noted Ativan use for seizures lasting more than 15 minutes and identified the medication as a Black Box medication, with monthly pharmacy review documented. The physician’s order dated 06/20/2026 directed staff to administer Ativan 0.5 mg every six hours as needed for seizure activity lasting 1-2 minutes related to convulsions, but the order lacked a stop date. The EMR also lacked evidence of a specified duration and physician rationale for the extended PRN use. On 07/13/2026, observation showed the resident sitting in the dining room eating lunch independently, and an Administrative Nurse verified the resident had received PRN Ativan under the order without a definitive stop date or documented rationale for continued use.
Infection Control Failures During PPE Disposal and Catheter Care
Penalty
Summary
The facility failed to ensure nursing staff followed appropriate infection control procedures related to disposal of soiled PPE, hand hygiene, and catheter care. On 07/14/2026 at 10:00 AM, two CNAs used a Hoyer lift to transfer Resident 9 from a wheelchair to the bed and repositioned him on his left side. After the transfer, one CNA removed her gloves and gown, wadded them up in her hand, and left the room carrying the soiled PPE down the hallway to the dirty utility room before discarding it. The other CNA discarded her gloves in the bathroom trash can. On 07/14/2026 at 10:05 AM, the CNA stated she should have discarded the gown and gloves in Resident 9's room and not carried them out of the room and down the hallway. On 07/14/2026 at 02:30 PM, Resident 5 was in bed playing a handheld game while a CNA emptied his urinary catheter. The CNA donned a gown and gloves, gathered a graduated cylinder from the bathroom, and placed it directly on the floor without a barrier. The CNA then opened the catheter bag port and allowed urine to flow into the cylinder without sanitizing the port, then closed the port and reattached it to the bag without sanitizing it. At 02:35 PM, the CNA stated he had not placed a barrier on the floor under the graduated cylinder or used anything to sanitize the catheter bag port before closing it and placing it back on the bag. The Infection Preventionist stated staff should remove gloves and gowns in the resident's room and discard them in the room, and that it was infection standard of care to place a barrier on the floor while emptying a catheter bag so the cylinder or bag did not contact the floor.
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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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 1 | 0 |
| Diversicare Of Larned | 20.4 mi | ★★★★★ | 11 | 0 |
| Locust Grove Village | 28.7 mi | ★★★★★ | 9 | 0 |
| Leisure Homestead At Stafford | 30.6 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.