Azria Health Great Bend

In the surveyor’s words

From the most serious findings on record at Azria Health Great Bend, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 29, 2025

  The 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. […]

• Immediate jeopardy, isolatedF689Jun 17, 2024

  The 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. […]

• Actual harm, isolatedF686May 7, 2025

  The 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. […]

• Actual harm, isolatedF760Jan 11, 2024

  The 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. […]

• No harm, potential for more than minimal, widespreadF801Jul 29, 2025

  The 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.Findings included:- On 07/27/25 at 08:45 AM, observation revealed that dietary staff in the kitchen prepared the breakfast meal. On 07/27/25 at 12:00 PM, Dietary Staff BB verified she was not a certified dietary manager. Dietary Staff BB stated the facility had three residents with a pureed diet and 15 with a mechanical soft diet. […]