Azria Health Great Bend

Inspectors wroteThe facility had a census of 61 residents. The sample included 17 residents, with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure staff provided adequate supervision to prevent the elopement of Cognitively Impaired Resident (R) 37, who was at risk for wandering/elopement, falls, and used a walker for mobility. The facility also failed to conduct a complete investigation when R48 obtained skin tears of unknown origin. This placed the resident at risk for abuse. On 07/15/25 at approximately 07:35 PM, facility staff could not find R37 in the building and reported seeing R37 in the lobby approximately 5-10 minutes prior. The staff found R37's walker in the lobby, but not R37. The staff located R37 outside in the facility van, seated in the front seat, in approximately 95-degree Fahrenheit (F) weather. [...]

Inspectors wroteThe facility had a census of 62 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 61 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 61 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to ensure staff used Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact cares) when providing care with close contact to residents with an open wound or an indwelling device and failed to properly disinfect a blood glucose meter used for more than one resident. This deficient practice placed all residents at risk for infection.

Inspectors wroteThe facility had a census of 61 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)5 and R69s' insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when expired. This deficient practice placed the affected residents at risk for ineffective medications. The facility failed to ensure medications were only accessible to licensed staff when the treatment cart was left unlocked without licensed staff supervision.

Inspectors wroteThe facility had a census of 61 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure a 14-day stop date or a specified duration with a rationale for Resident (R) 61's ongoing as-needed (PRN) antianxiety (class of medications that calm and relax people) medication. This placed R61 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications.

Inspectors wroteThe facility had a census of 61 residents. The sample included 17 residents, with two reviewed for abuse, neglect, or exploitation. Based on observation, interview, and record review, the facility failed to thoroughly investigate in a timely manner the injury of unknown origin to Resident (R) 48, who stated it happened when staff were transferring her.

Inspectors wroteThe facility had a census of 61 residents. The sample included 17 residents, with three reviewed for hospitalization. Based on observation, record review, and interview, the facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO - a public official who works to resolve resident issues in nursing facilities) for two sampled residents, Resident (R) 42 and R6. This placed the residents at risk for uninformed care choices.

Inspectors wroteThe facility had a census of 61 residents. The sample included 17 residents, with three reviewed for bathing. Based on observation, record review, and interview, the facility failed to provide consistent bathing services for two residents, Resident (R) 27 and R42. This placed the residents at risk for complications related to poor hygiene.

Inspectors wroteThe facility had a census of 61 residents. The sample included 17 residents, with one reviewed for range of motion (ROM). Based on observation, interview, and record review, the facility failed to provide ROM services to improve or maintain Resident (R) 56's ROM in his partially contracted (abnormal permanent fixation of a joint or muscle) right hand.

Inspectors wroteThe facility had a census of 61 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to provide interventions for bowel management for one resident, Resident (R) 9. This placed R9 at risk for physical decline and fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move).- The Electronic Medical Record for R9 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) without behavioral disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and constipation (difficulty passing stool). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had moderately impaired cognition. [...]

Inspectors wroteThe facility had a census of 61 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 11's medication administration was free from significant errors when staff crushed one extended-release medication. This placed R11 at risk for the medication being improperly released. Fincings included:- On 07/28/25 at 08:52 AM, Certified Medication Aide (CMA) R crushed medications for R11, including metoprolol (medication used to treat chest pain (angina), heart failure, and high blood pressure) extended release (ER), 25 milligrams (mg). CMA R placed the crushed medications in applesauce and administered them to R11, even after being asked if it was okay to crush metoprolol ER. CMA R stated she would ask the nurse later. [...]

Inspectors wroteThe facility had a census of 61 residents. The sample included 17 residents, with one reviewed for hospice (a type of health care that focused on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 6. This placed the residents at risk for inadequate end-of-life cares.

Inspectors wroteThe facility had a census of 61 residents. The sample included 17 residents. Based on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents a risk for inadequate staffing.

Inspectors wroteThe facility identified a census of 62 residents, with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on record review, observation, and interview, the facility failed to provide necessary care, consistent with professional standards of practice, to prevent pressure ulcers including offloading for Resident (R) 1 who developed a facility-acquired unstageable pressure ulcer (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus) on her left heel. This deficient practice also placed R1 at risk for infection and pain.

Inspectors wroteThe facility identified a census of 58 residents with three residents reviewed for elopement and wandering. Based on record review, observation, and interview, the facility failed to ensure staff provided adequate supervision to prevent cognitively impaired Resident (R)1 from exiting the facility without staff knowledge and supervision. On 06/13/24 at approximately 07:55 AM R1, who was at risk for elopement, propelled his wheelchair from the dining room to the smoker's room on the south hall. R1 went into the smoker's room and said that it was his home. Housekeeping Staff U removed R1 from the smoker's room and told Certified Nurse Aide (CNA) N what R1 was doing. R1 reentered the smoker's room and CNA N went in and tried to convince R1 to leave but R1 again stated it was his home. Since R1 was not attempting to exit, CNA N left him to go answer call lights. [...]

Inspectors wroteThe facility identified a census of 65 residents with three residents reviewed for medication errors. Based on record review, observation, and interview, the facility failed to follow the physician's orders for Resident (R)1's insulin (a hormone that lowers the level of glucose in the blood) administration which resulted in R1's blood sugar decreased to 44 milligrams per deciliter (mg/dl) and had to be transferred to a higher level of care. On 12/17/23 Licensed Nurse (LN) G administered eight units of insulin aspart (short-acting insulin) to R1 right as R1 started to eat supper, despite the physician's order which directed staff to only give insulin aspart if the resident ate greater than 50% of the meal. R1 only ate three to four bites of her supper. [...]

Inspectors wroteThe facility had a census of 64 residents. Based on observation, interview, and record review the facility failed to provide adequate nutritional servings during a meal, as specified in the recipe. This deficient practice placed residents who received their meals from the facility kitchen at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 64 residents. The sample included 19 residents. Based on observation, interview, and record review, the facility failed to discard expired stock medication. These deficient practices placed the affected resident at risk for ineffective medications.

Inspectors wroteThe facility had a census of 64 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to honor resident rights when the facility revoked Resident (R) 31's smoking privilege as a form of reprisal for the facility's inadequate supervision which allowed R31 to obtain cigarettes and a lighter from another resident's room; R31 lit a cigarette in the hall outside of the smoking room. (See F689). This deficient practice placed R31 at risk for impaired self-determination about things that were important to her, including smoking.

Inspectors wroteThe facility had a census of 64 residents. The sample included 19 residents with nine reviewed for accidents. Based on observation, record review, and interview, the facility failed to provide the care planned amount of staff assistance for Resident (R) 29 to prevent falls, and failed to provide supervision for R31, who entered another resident's room and engaged in unsafe activity. These deficient practices placed the affected residents at risk for further falls and preventable injury.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 19 residents, with three reviewed for abuse. Based on record reviews and interviews, the facility failed to establish and implement an admissions agreement that explained and protected resident's right to personal property, safeguarded by the facility in a manner which allowed full accessibility to the valuable by the resident.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents with four reviewed for Beneficiary Notices. Based on record review and interview the facility failed to inform Resident (R) 17, R38, R42, and R48 or their representative of the monetary cost to stay in the facility after Medicare Part A services ended. This deficient practice placed the four residents at risk to make an uninformed decision regarding the cost of their continued stay.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents. Based on observation, interview, and record review the facility failed to revise Resident (R) 36's care plan to include the amount of fluids to be given each shift and from each source. This placed R36 at risk to not receive interventions designed to limit his fluid intake.

Inspectors wroteThe facility had a census of 56. The sample included 15 residents. Based on observation, record review and interview the facility failed to ensure blood sugar parameters were provided to direct assessment, treatment and physician notification for one sampled resident, Resident (R) 32. This placed the resident at risk for adverse side effects from abnormal blood sugars and lack of physician oversight.

Inspectors wroteThe facility had a census of 56 residents. The sample included 15 residents, with seven reviewed for pressure ulcers. Based on observation, record review, and interview, the facility failed to prevent the development of a suspected deep tissue injury (an injury to the soft tissue under the skin due to pressure and is usually over a bony prominence) for one sampled resident, Resident (R) 44. This placed the resident at risk for further skin breakdown.

Inspectors wroteThe facility had a census of 56 residents. The sample included 15 residents, with one reviewed for bladder and bowel incontinence. Based on observation, record review, and interview, the facility failed to develop a personalized toileting plan for R42 who had urinary incontinence (loss of bladder control), history of skin breakdown due to recently healed moisture associated skin damage (inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine) on the resident's buttocks, and a history of Urinary Tract Infections (UTI's - bladder infection). This deficient practice placed R42 at risk for UTIs and skin breakdown.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents with two reviewed for hydration. Based on observation, interview, and record review the facility failed to clarify the order for fluid restriction, plan the amount of fluids per shift and meals, and thoroughly document the fluid amounts Resident (R) 36 consumed daily. This placed the resident at risk for consuming greater amounts of fluids than the physician considered safe for his health.

Inspectors wroteThe facility had a census of 56 residents. The sample included 15 residents. Based on observation, record review and interview the facility failed to provide adequate supervision, security and maintain accurate records of narcotic pain medications (medications used to treat moderate to severe pain) for two sampled residents, Resident (R) 106 and R7. This placed the residents at risk for lack of pain control and misappropriation of medications.

Inspectors wroteThe facility had a census of 56 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist identified and reported to the Director of Nursing (DON), medical director, or physician about the lack of physician ordered blood sugar parameters for Resident (R) 32 and R3, and an inappropriate diagnosis for the use of an antipsychotic medication (medication used to treat significant mental health problems) for R54. This placed the residents at risk for adverse side effects related to abnormal blood sugars and antipsychotic medications.

Inspectors wroteThe facility had a census of 56 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to provide physician ordered blood sugar parameters for two sampled residents, Resident (R) 32 and R3. This placed the residents at risk for abnormal blood sugars and lack of physician oversight.

Inspectors wroteThe facility had a census of 56 residents. The sample included 15 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure an appropriate diagnosis for the use of an antipsychotic medication (medications used to treat significant mental health problems) for one sampled resident, Residents (R) 54. This placed R54 at risk to receive unnecessary antipsychotic medications and adverse medication side effects.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents. Based on observation, interview, and record review the facility failed to dispose of one expired insulin (medication used to regulate blood sugar levels) pen for Resident (R) 36, in one of four facility medication carts. This deficient practice placed R36 at risk to receive expired, ineffective insulin.

Inspectors wroteThe facility had a census of 57 residents. The sample included 15 residents with seven reviewed for pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Based on observation, interview, and record review the facility failed to perform proper infection control during an open wound dressing change for Resident (R) 36. This placed R36 at risk for infection.