Starfile / Kansas

ACCESS MENTAL HEALTH

500 PEABODY, PEABODY, KS 66866 · CCN 17E210

SFF

Inspection history vs Kansas & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$100,231

Number of fines

2

Number of penalties

4

Payment denials

2

Inspection citations (45)9 immediate jeopardy2 actual harm

1. EF0584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.2025-12-10 · Health · corrected 2026-01-23

   Potential for more than minimal harm

2. DF0641Ensure each resident receives an accurate assessment.2025-12-10 · Health · corrected 2026-01-23

   Potential for more than minimal harm

3. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-12-10 · Health · corrected 2026-01-23

   Potential for more than minimal harm

4. DF0658Ensure services provided by the nursing facility meet professional standards of quality.2025-12-10 · Health · corrected 2026-01-23

   Potential for more than minimal harm

5. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2025-12-10 · Health · corrected 2026-01-23

   Potential for more than minimal harm

6. JF0740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.2025-12-10 · Health · corrected 2025-11-05

   Immediate jeopardy

7. DF0880Provide and implement an infection prevention and control program.2025-12-10 · Health · corrected 2026-01-23

   Potential for more than minimal harm

8. DF0552Ensure that residents are fully informed and understand their health status, care and treatments.2025-06-23 · Health · corrected 2025-07-25

   Potential for more than minimal harm

9. EF0636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.2025-06-23 · Health · corrected 2025-08-07

   Potential for more than minimal harm

10. EF0641Ensure each resident receives an accurate assessment.2025-06-23 · Health · corrected 2025-07-25

    Potential for more than minimal harm

11. DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2025-06-23 · Health · corrected 2025-07-25

    Potential for more than minimal harm

12. EF0759Ensure medication error rates are not 5 percent or greater.2025-06-23 · Health · corrected 2025-07-25

    Potential for more than minimal harm

13. EF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2025-06-23 · Health · corrected 2025-07-25

    Potential for more than minimal harm

14. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-06-23 · Health · corrected 2025-07-25

    Potential for more than minimal harm

15. FF0880Provide and implement an infection prevention and control program.2025-06-23 · Health · corrected 2025-07-25

    Potential for more than minimal harm

16. DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2025-06-23 · Health · corrected 2025-07-25

    Potential for more than minimal harm

17. DF0622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

18. DF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

19. DF0641Ensure each resident receives an accurate assessment.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

20. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

21. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

22. DF0688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

23. DF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

24. GF0692Provide enough food/fluids to maintain a resident's health.2025-01-15 · Health · corrected 2025-02-12

    Actual harm

25. DF0699Provide care or services that was trauma informed and/or culturally competent.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

26. DF0740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

27. DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

28. DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

29. DF0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

30. FF0801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

31. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

32. EF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

33. DF0887Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.2025-01-15 · Health · corrected 2025-02-12

    Potential for more than minimal harm

34. JF0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.2024-10-10 · Health · corrected 2024-11-11

    Immediate jeopardy

35. JF0742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.2024-10-10 · Health · corrected 2024-11-11

    Immediate jeopardy

36. JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-02-01 · Health · corrected 2024-02-29

    Immediate jeopardy

37. GF0741Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.2024-02-01 · Health · corrected 2024-02-29

    Actual harm

38. FF0835Administer the facility in a manner that enables it to use its resources effectively and efficiently.2024-02-01 · Health · corrected 2024-02-29

    Potential for more than minimal harm

39. FF0867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.2024-02-01 · Health · corrected 2024-02-29

    Potential for more than minimal harm

40. KF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2024-01-16 · Health · corrected 2024-02-20

    Immediate jeopardy

41. LF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-01-16 · Health · corrected 2024-02-20

    Immediate jeopardy

42. LF0610Respond appropriately to all alleged violations.2024-01-16 · Health · corrected 2024-02-20

    Immediate jeopardy

43. JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-01-16 · Health · corrected 2024-02-20

    Immediate jeopardy

44. EF0600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.2023-06-14 · Health · corrected 2023-07-14

    Potential for more than minimal harm

45. JF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-06-14 · Health · corrected 2023-01-31

    Immediate jeopardy

Ownership

No ownership records.

Other facilities in PEABODY

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.