Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethany Home Association during CMS and state inspections, most recent first.
A resident with a history of stroke and blood clotting disorder experienced vomiting and diarrhea, and staff administered medication but did not notify the resident's representative of the change in condition until three days later. Documentation confirming timely notification was lacking, and the facility could not provide a policy on change in condition notification.
A resident with a history of urinary retention and chronic kidney disease experienced pain, red drainage, and no urine output from an indwelling catheter. Despite multiple catheter changes and ongoing symptoms, nursing staff did not notify the physician as required by policy and the resident's care plan. The issue was only reported after the resident became increasingly drowsy and was sent to the emergency room, where a UTI was diagnosed.
The facility did not maintain consistent RN coverage for eight consecutive hours daily, as required, with multiple days lacking documented RN presence and no policy in place to ensure compliance.
The facility failed to implement a water management program for Legionella and did not adhere to Enhanced Barrier Precautions for a resident with a urinary catheter. Maintenance staff were unaware of water management checks, and a CNA did not use proper PPE during catheter care, increasing infection risk.
A resident with a urinary catheter experienced inadequate care, as staff failed to consistently follow infection control protocols, including wearing PPE while emptying the catheter bag. The resident, with a history of rapid UTI progression to sepsis, was at increased risk due to these lapses. Observations showed improper handling of catheter equipment, and the facility's policy lacked specific guidance for emptying drainage bags.
A facility failed to provide trauma-informed care for a resident with PTSD, generalized anxiety disorder, and major depressive disorder. The resident's care plan lacked information on trauma triggers, and staff were unaware of the resident's PTSD diagnosis and specific triggers. This oversight placed the resident at risk for unmet mental healthcare needs.
A facility failed to ensure appropriate use and documentation for psychotropic medications for two residents. One resident received quetiapine and sertraline without an approved indication or monitoring for effectiveness, while another received PRN lorazepam without a stop date. These deficiencies placed residents at risk for unnecessary medication use and side effects.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to notify a resident's representative of a significant change in the resident's condition. The resident, who had a history of cerebral infarction and thrombophilia and was assessed as having moderately impaired cognition, experienced vomiting and diarrhea throughout the day. Staff administered Maalox and Imodium to address these symptoms. However, there was no documentation that the resident's representative was informed of this change in condition at the time it occurred. Further review of the clinical record showed that the representative and physician were not notified until three days after the initial onset of symptoms. Administrative staff confirmed the lack of timely notification and documentation. Additionally, the facility was unable to provide a policy regarding change in condition notification when requested.
Failure to Notify Physician of Catheter Complications and Lack of Urine Output
Penalty
Summary
The facility failed to notify the physician regarding significant changes in a resident's urinary catheter status, specifically the presence of red drainage and the absence of urine output during the night shift. The resident in question had a history of urinary retention, benign prostatic hyperplasia, and chronic kidney disease, and was dependent on staff for toileting and other activities of daily living. The care plan and facility policy required staff to monitor for signs and symptoms of urinary tract infection (UTI), pain or discomfort related to the catheter, and to notify the physician of any changes such as no urine output or abnormal drainage. Documentation in the electronic medical record showed that the resident experienced pain, little urine output, and red drainage from the catheter on multiple occasions. Nursing staff changed the catheter several times, noted continued red drainage, and observed a period with no urine output overnight. Despite these findings, there was no documentation that the physician or responsible party was notified about the lack of urine output or the red drainage until later, when the resident exhibited increased drowsiness and was subsequently sent to the emergency room for evaluation. Interviews with staff confirmed that they were aware of the need to notify the physician in such situations, and the facility's policy also directed immediate notification for excessive bleeding or lack of urine output. The failure to promptly notify the physician as required by policy and care plan placed the resident at risk for further complications, as evidenced by the subsequent hospital admission for a UTI.
Failure to Provide Consistent RN Coverage
Penalty
Summary
The facility, with a census of 73 residents, failed to provide consistent Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week, as required. Review of the facility's Payroll Based Journal (PBJ) for the specified fiscal quarter revealed that there were four or more days within the quarter without the required RN coverage. Further examination of the facility's working schedule and daily posted staffing showed that no RN hours were posted for two specific days, and the facility was unable to provide documentation for RN coverage on those days when requested. Additionally, the facility did not have a policy in place to ensure consistent RN coverage for the required hours each day.
Inadequate Water Management and Infection Control Practices
Penalty
Summary
The facility failed to implement a comprehensive water management program to address the risk of Legionella and other waterborne pathogens. Maintenance staff were unaware of any routine water management checks, and there was no system in place to manage standing water in unoccupied rooms. The facility's policy, dated May 2024, outlined the need for Legionella risk assessments, action plans, and regular monitoring, but these measures were not implemented. This oversight placed residents at risk of contracting Legionella disease. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for a resident with a urinary catheter colonized with proteus mirabilis. The resident's care plan required staff to use gowns and gloves during high-contact care, but observations revealed that a CNA did not wear a gown while emptying the catheter bag. The catheter drainage bag was also improperly placed inside a trash can with used tissues, which was not in line with best practices. Administrative staff confirmed that PPE, including gowns, should have been used during catheter care. The facility's failure to implement EBP and proper infection control measures for the resident's urinary catheter care increased the risk of infection. The facility's policy required clear signage and education on PPE use, but these were not effectively communicated or followed by staff, leading to inadequate infection prevention during the resident's care.
Inadequate Catheter Care Leads to UTI Risk
Penalty
Summary
The facility failed to provide adequate catheter care for a resident, identified as R36, who had a urinary catheter due to bladder-neck obstruction and urine retention. The resident's care plan required staff to change the catheter every two weeks, monitor for signs of urinary tract infections (UTIs), and implement enhanced barrier precautions due to colonization with proteus mirabilis. However, observations revealed that staff did not consistently follow these protocols, placing the resident at risk for UTIs and other complications. During an observation, a Certified Nurse Aide (CNA) was seen emptying the resident's catheter drainage bag without wearing a protective gown, contrary to the facility's policy requiring personal protective equipment (PPE) for such tasks. The CNA placed the urinal canister inside a trash can with used tissues, which is not a best practice for infection control. The facility's policy on indwelling urinary catheter care lacked specific guidance for emptying the drainage bag, contributing to inconsistent practices among staff. The resident experienced symptoms consistent with a UTI, including chills, increased temperature, and confusion, leading to an unplanned discharge to an acute hospital. The resident's medical records documented a history of rapid progression from UTI to sepsis, underscoring the importance of proper catheter care. Despite the resident's ability to manage his catheter, staff were responsible for providing support and ensuring adherence to infection control measures, which was not consistently done.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD), generalized anxiety disorder, and major depressive disorder. The resident's care plan, which should have included information on trauma triggers to prevent re-traumatization, lacked this critical information. Despite the resident being seen routinely by a mental health practitioner and receiving medications for their conditions, staff members, including a Certified Nurse Aide and a Licensed Nurse, were unaware of the resident's PTSD diagnosis and specific triggers. The facility's policy on trauma-informed care mandates that residents who are trauma survivors receive care that accounts for their experiences and preferences to eliminate or mitigate triggers. However, the facility did not adhere to this policy, as evidenced by the absence of trauma triggers in the resident's care plan. This oversight placed the resident at risk for unmet mental healthcare needs and impaired psychosocial well-being.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure appropriate use and documentation for psychotropic medications for two residents, R121 and R41. For R121, the facility did not have an approved indication for the use of quetiapine and sertraline, as required by CMS guidelines. The resident's electronic medical record showed diagnoses of vascular dementia without psychosis, and there was no documentation of specific targeted behaviors for the use of these medications. Despite the resident's anxiety and depression, there was no physician documentation or monitoring for the effectiveness and ongoing necessity of the medications. The facility's policy required a diagnosis and targeted symptoms for psychotropic medication use, which was not adhered to in this case. For R41, the facility failed to include a stop date for the PRN use of lorazepam, an antianxiety medication. The resident's electronic medical record showed diagnoses of anxiety and dementia, with severely impaired cognition and dependence on staff for most activities of daily living. The physician's order for lorazepam lacked a specified duration or rationale for extended use, and the consultant pharmacist's recommendation to address the missing stop date was not acted upon. Observations showed the resident receiving lorazepam without a stop date, contrary to the facility's policy on psychotropic drug use. These deficiencies placed both residents at risk for unnecessary use of antipsychotic and psychotropic drugs and their related side effects. The facility's failure to comply with its own policies and CMS guidelines regarding psychotropic medication use and monitoring contributed to these deficiencies, highlighting a lack of appropriate documentation and oversight in medication management for residents with dementia and anxiety.
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What surveyors actually found near you
We read the 66 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lindsborg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverview Estates | 8.4 mi | ★★★★★ | 0 | 0 |
| Mcpherson Operator, Llc | 12.8 mi | ★★★★★ | 0 | 0 |
| The Cedars | 13.8 mi | ★★★★★ | 9 | 0 |
| Pinnacle Park Nursing & Rehab Center | 14.7 mi | ★★★★★ | 0 | 0 |
| Legacy At Salina | 17.9 mi | ★★★★★ | 27 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.