Map showing the location of ACCESS MENTAL HEALTH in PEABODY, Kansas
500 PEABODY, PEABODY, KS, 66866

Overall Score

CMS Five-Star Quality Rating
Not ratedCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

CMS has not published a rating for this facility, so there is no peer position to show.

How the rating is built

  • Health inspectionsStarting point
  • StaffingCan add or remove a star
  • Quality measuresCan add or remove a star

CMS withholds a rating when a facility is new, has too little inspection history, or is under review.

  • Special Focus FacilityCMS has placed this facility in the Special Focus Facility program for a history of serious quality problems. It is inspected twice as often and can lose Medicare certification if it does not improve.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cyclesNo dataKS avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnoverNo dataKS avg3.4★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessmentsNo dataKS avg3.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff2.58hrsAbove only 4% of peersKS avg4.07Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.62hrsAbove only 44% of peersKS avg0.71Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better35%Above 84% of peersKS avg50%RN turnover29%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$100,231Above only 4% of peersKS avg$21,017Fines · denials2 · 2
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
45citations
7inspection dates
2actual harm (G–I)
9immediate jeopardy (J–L)
Dec 10, 2025most recent

Citations by monthJun 2023 – Dec 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Dec 10, 20257 citationsCycle 1worst J · immediate jeopardy
  1. F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareJ · isolatedCorrected Nov 5, 2025
  2. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jan 23, 2026
  3. F656Develop 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 PlanningD · isolatedCorrected Jan 23, 2026
  4. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jan 23, 2026
  5. F690Provide 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 CareD · isolatedCorrected Jan 23, 2026
  6. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jan 23, 2026
  7. F584Honor 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 RightsE · patternCorrected Jan 23, 2026
Jun 23, 20259 citationsCycle 2worst F · no actual harm$64,643, payment denial
  1. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Jul 25, 2025
  2. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Jul 25, 2025
  3. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Jul 25, 2025
  4. F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningE · patternCorrected Aug 7, 2025
  5. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningE · patternCorrected Jul 25, 2025
  6. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Jul 25, 2025
  7. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Jul 25, 2025
  8. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jul 25, 2025
  9. F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Jul 25, 2025
Jan 15, 202517 citationsCycle 3worst G · actual harm$35,588
  1. F887Educate 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 ControlD · isolatedCorrected Feb 12, 2025
  2. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected Feb 12, 2025
  3. F656Develop 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 PlanningD · isolatedCorrected Feb 12, 2025
  4. F657Develop 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 PlanningD · isolatedCorrected Feb 12, 2025
  5. F688Provide 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 CareD · isolatedCorrected Feb 12, 2025
  6. F690Provide 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 CareD · isolatedCorrected Feb 12, 2025
  7. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Feb 12, 2025
  8. F699Provide care or services that was trauma informed and/or culturally competent.Quality of Life and CareD · isolatedCorrected Feb 12, 2025
  9. F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Feb 12, 2025
  10. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Feb 12, 2025
  11. F758Implement 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 ServiceD · isolatedCorrected Feb 12, 2025
  12. F801Employ 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 DietaryF · widespreadCorrected Feb 12, 2025
  13. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Feb 12, 2025
  14. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Feb 12, 2025
  15. F622Not 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 RightsD · isolatedCorrected Feb 12, 2025
  16. F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Feb 12, 2025
  17. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Feb 12, 2025
Oct 10, 20242 citationsCycle 2worst J · immediate jeopardy
  1. F742Provide 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 CareJ · isolatedCorrected Nov 11, 2024
  2. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Nov 11, 2024
Feb 1, 20244 citationsCycle 2worst J · immediate jeopardy
  1. F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Feb 29, 2024
  2. F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationF · widespreadCorrected Feb 29, 2024
  3. F741Ensure 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 CareG · isolatedCorrected Feb 29, 2024
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Feb 29, 2024
Jan 16, 20244 citationsCycle 3worst L · immediate jeopardypayment denial
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationK · patternCorrected Feb 20, 2024
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationL · widespreadCorrected Feb 20, 2024
  3. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationL · widespreadCorrected Feb 20, 2024
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Feb 20, 2024
Jun 14, 20232 citationsCycle 3worst J · immediate jeopardy
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Jul 14, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Jan 31, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined2.58hrsAbove only 4% of peers−1.49 vs KS avg
  • Registered nursesRN hours only0.62hrsAbove only 44% of peers−0.09 vs KS avg
  • Licensed practical nursesLPN hours0.37hrs
  • Nurse aidesCNA hours1.59hrs
  • Weekend nursingAll staff on Saturdays and Sundays2.48hrs
  • Kansas average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better35%Above 84% of peersKS avg 50%
  • RN turnoverRegistered nurses only29%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy45 certified beds · ~44 residents a day97%Top 7%KS avg 82%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $100,231In fines
  • 2Fines
  • 2Payment denials
  • $21,017KS avg in fines
Above only 4% of peersFewer fines than 4% of rated homes in Kansas

Actions on record

  1. Jun 23, 2025Civil money penalty$64,643
  2. Jun 23, 2025Denial of payment for new admissionsfrom Jul 26, 2025
  3. Jan 15, 2025Civil money penalty$35,588
  4. Jan 16, 2024Denial of payment for new admissionsfrom Feb 13, 2024

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Independent
Certification
Medicaid
Location type
Rural
Ownership change
None in the last 12 months

People and entities on file

Ownership Data Not Available

    Person Organization

    Sources & notes

    Public data, updated quarterly

    Data sources

    • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
    • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
    • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

    Notes

    • CMS Certification Number 17E210 · 500 PEABODY, PEABODY, KS, 66866.
    • Percentiles compare this facility with every rated nursing home in Kansas and Marion County. Turnover and fines are inverted so a high percentile is always good.
    • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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