Access Mental Health
Peabody, Marion County, Kansas · CCN 17E210 · For-profit (LLC) · not part of a chain
CMS rates Access Mental Health unrated overall as of August 2026. 45 certified beds, 44 residents a day on average. 45 citations on record from the current inspection cycles, 8 at immediate jeopardy; 3 fines totalling $114,739 and 2 payment denials.
On record
- Special Focus Facility. CMS has placed this facility in the program for homes with a history of serious quality issues, which brings more frequent inspection.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | Did not submit staffing data, or submitted data that did not meet the criteria for a staffing rating (CMS footnote 18) |
|---|---|
| Health inspections | Did not submit staffing data, or submitted data that did not meet the criteria for a staffing rating (CMS footnote 18) |
| Staffing | Did not submit staffing data, or submitted data that did not meet the criteria for a staffing rating (CMS footnote 18) |
| Quality measures | Did not submit staffing data, or submitted data that did not meet the criteria for a staffing rating (CMS footnote 18) |
Staffing
| Total nurse staffing | Did not submit staffing data, or submitted data that did not meet the criteria for a staffing rating (CMS footnote 18) |
|---|---|
| Nursing staff turnover | 25.9% (registered nurses 0%) |
| Administrators who left | 1 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-06-03 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has no plan of correction |
| 2026-06-03 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · tag F0814 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has no plan of correction |
| 2025-12-10 complaint survey |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · tag F0740 |
J Immediate jeopardy to resident health or safety; isolated | Past Non-Compliance 2025-11-05 |
| 2025-12-10 complaint survey |
Honor 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. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-01-23 |
| 2025-12-10 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-23 |
| 2025-12-10 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-23 |
| 2025-12-10 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-23 |
| 2025-12-10 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-23 |
| 2025-12-10 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-01-23 |
| 2025-06-23 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-07-25 |
| 2025-06-23 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-07-25 |
| 2025-06-23 complaint survey |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · tag F0636 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-08-07 |
| 2025-06-23 complaint survey |
Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-07-25 |
| 2025-06-23 complaint survey |
Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-07-25 |
| 2025-06-23 complaint survey |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-07-25 |
| 2025-06-23 complaint survey |
Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · tag F0552 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-25 |
| 2025-06-23 complaint survey |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · tag F0655 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-25 |
| 2025-06-23 complaint survey |
Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-25 |
| 2025-01-15 complaint survey |
Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Nutrition and Dietary Deficiencies · tag F0801 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · tag F0883 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Resident Rights Deficiencies · tag F0622 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · tag F0623 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Provide 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. Quality of Life and Care Deficiencies · tag F0688 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · tag F0699 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Quality of Life and Care Deficiencies · tag F0740 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · tag F0756 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · tag F0757 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Implement 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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2025-01-15 complaint survey |
Educate 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. Infection Control Deficiencies · tag F0887 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-12 |
| 2024-10-10 complaint survey |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-11-11 |
| 2024-10-10 complaint survey |
Provide 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. Quality of Life and Care Deficiencies · tag F0742 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-11-11 |
| 2024-02-01 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-02-29 |
| 2024-02-01 complaint survey |
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Quality of Life and Care Deficiencies · tag F0741 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-02-29 |
| 2024-02-01 complaint survey |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · tag F0835 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-02-29 |
| 2024-02-01 complaint survey |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · tag F0867 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-02-29 |
| 2024-01-16 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
L Immediate jeopardy to resident health or safety; widespread | Deficient, Provider has date of correction 2024-02-20 |
| 2024-01-16 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
L Immediate jeopardy to resident health or safety; widespread | Deficient, Provider has date of correction 2024-02-20 |
| 2024-01-16 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
K Immediate jeopardy to resident health or safety; pattern | Deficient, Provider has date of correction 2024-02-20 |
| 2024-01-16 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-02-20 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2025-12-10 | Fine | $14,508 |
| 2025-06-23 | Payment denial for 12 days from 2025-07-26 | — |
| 2025-06-23 | Fine | $64,643 |
| 2025-01-15 | Fine | $35,588 |
| 2024-01-16 | Payment denial for 16 days from 2024-02-13 | — |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
CMS lists no ownership for this facility.
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Access Mental Health.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Marion County.