Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
The facility failed to maintain required CNA in-service education for a CNA specific to the resident population. Record review and an interview with the Administrative Nurse confirmed the CNA had not completed mandatory training in psychosocial needs of the older adult, abuse prevention in persons with dementia, and challenging behaviors/care interventions for individuals experiencing dementia. The facility did not provide a CNA education policy.
Failure to protect a hospice resident with severe cognitive impairment from staff abuse. A CNA was observed force-feeding the resident, continuing to feed her when she was not chewing, and handling her roughly by pulling on her arms and grabbing her forcefully to get her up. Witnesses reported the resident gagged and was not given enough time to chew or breathe, while a later survey observation found the resident in bed with blank eyes and weakly saying, "Help."
Failure to immediately report alleged abuse: Staff observed a CNA forcefully feed a resident, continue feeding when the resident was not chewing, grab the resident by the arm, and handle residents roughly. A CNA student and another witness reported the behavior, and the DON stated she did not learn of the allegation until notified by the CNA instructor. Another resident also reported the CNA pushed him down into his chair during care.
The facility failed to ensure agency CNA staff had documented infection control training. Record review showed no proof that four agency CNAs had completed the required training, and an Administrative Nurse stated the facility relied on the agency providers to ensure staff education. The facility also could not provide a policy for verifying that all staff had received the required education.
Infection Control Failures With Catheter Care and Respiratory Equipment Storage: A resident’s catheter bag was repeatedly observed on or near a trash can and later on the floor without a privacy bag, while two residents’ nasal cannulas were found laid on their beds instead of being stored in a sanitary container. Staff interviews showed inconsistent practices for catheter bag placement and hand hygiene expectations.
A resident with PTSD, vascular dementia, and DM had a BIMS score of 3 and required assistance with ADLs. He was observed sitting in his chair with his bedside table in front of him and was unable to find his call light, stating he did not know where it was. Staff stated the call light should be clipped to the chair or otherwise kept within reach, and the care plan directed staff to ensure the call light was within reach and respond promptly to requests for assistance.
A resident with Alzheimer’s disease, depression, and moderately impaired cognition received Seroquel and Xanax, but the EMR lacked a documented physician rationale for the antipsychotic, including risk-versus-benefit review and unsuccessful nonpharmacological attempts. The care plan and psychotropic CAA documented the medications and related diagnoses, while staff interviews confirmed the antipsychotic indication was not questioned and was known to be incorrect.
Improper Hoyer Lift Transfer Staffing: A resident with severe cognitive impairment and total dependence for transfers was moved from bed to a Broda chair by a CNA using a Hoyer lift without a second staff member, despite the care plan directing a sling lift with one to two assist. The CNA said she had done the transfer alone before, while an LN and an administrative nurse stated that two staff members are required for Hoyer transfers and the facility policy requires safe handling during transfers.
Failure to address significant weight loss for a resident with Parkinson's disease, ataxia, dementia, dysphagia, and limited ROM. The resident lost 40 lbs in 90 days, was on a regular diet with thin liquids, refused altered consistency foods, and reported decreased appetite and a desire to lose weight. The RD noted aspiration risk and recent hospitalization, but the facility could not provide a physician order for prescribed weight loss or safe weight loss parameters.
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.
CNA In-Service Training Not Completed
Penalty
Summary
The facility failed to maintain an in-service training program for Certified Nurse Aide (CNA) M that was specific to the needs of the resident population. Record review showed CNA M did not complete required education in Psychosocial Needs of the Older Adult, Abuse Prevention in Persons with Dementia, and Challenging Behaviors: Care and Interventions for Individuals Experiencing Dementia by the scheduled completion dates. On 07/14/2026 at 11:30 AM, Administrative Nurse D verified that CNA M had not completed these mandatory CNA trainings. Administrative Nurse D stated the education was due at the end of the month they were assigned. Upon request, the facility did not provide a CNA Education Policy.
Failure to Protect a Hospice Resident from Staff Abuse
Penalty
Summary
The facility failed to ensure a severely cognitively impaired resident on hospice remained free from staff-to-resident abuse. The resident had diagnoses including malignant melanoma, hyperlipidemia, hypothyroidism, depression, and a traumatic subdural hematoma. Her MDS documented a BIMS score of 7, indicating severely impaired cognition, and she required assistance with most ADLs, including setup/cleanup for eating and moderate to substantial staff assistance for other care needs. Her care plan and CAA documentation noted she needed help with mobility, dressing, grooming, toileting, and transfers, and that she was on hospice for malignant melanoma. The incident report and witness statements documented that a CNA forcefully fed the resident mandarin oranges in her room, continued feeding her when she was not chewing, and rapidly fed her without allowing enough time to breathe or chew. A CNA instructor reported that the resident was force-fed and that the CNA grabbed the resident by the arm forcefully when helping her up to use the bathroom. Another CNA witness stated the resident was fed quickly without pauses and that the CNA did not handle the resident with care, instead pulling on her arms. A survey observation later found the resident lying in bed with the lights off and oxygen on, and when the surveyor entered the room, the resident had cloudy, blank eyes and weakly whispered, "Help." Administrative Nurse D stated she was not notified until the day after the incident and that the CNA had been suspended pending investigation. She also stated the CNA said she did not think she had been too rough and that the resident needed to eat. Administrative Nurse D verified the CNA had not completed mandatory trainings related to abuse prevention with persons with dementia, challenging behaviors, and psychosocial needs of an older adult. The facility policy stated it would prevent and prohibit abuse, neglect, misappropriation, and exploitation by identifying and intervening in situations where abuse or neglect was more likely to occur.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
The facility failed to ensure staff reported an allegation of staff-to-resident abuse immediately to the administrator. A Facility Incident Report documented that Administrative Nurse D was notified on 07/01/2026 by the CNA instructor that a student, NA N, had observed CNA M forcefully feeding mandarin oranges to R1 in her room on 06/30/2026. NA N stated R1 was not chewing the oranges and CNA M continued to feed her, and also reported that when CNA M got R1 up to use the bathroom, CNA M grabbed R1 by the arm forcefully to get her up. CNA O’s notarized witness statement documented that CNA M fed R1 quickly without pause and did not allow enough time for R1 to chew and swallow her food. NA N’s notarized witness statement documented that CNA M rapidly fed R1 without allowing breaks to breathe or chew, causing R1 to vomit because too much food was in her mouth. Additional statements and observations described CNA M handling residents roughly. NA N stated she observed CNA M throughout the day not handle the resident with care and pull on the resident’s arms. On 07/14/2026, R3 stated CNA M had pushed him down into his chair several times when she provided care. During interview, Administrative Nurse D stated she did not find out about the incident until 07/01/2026 when the CNA instructor notified her, and that CNA M had been suspended pending investigation. The facility’s Abuse, Neglect, and Exploitation Policy dated 04/22/26 stated the facility would implement policies and procedures to prevent and prohibit abuse, neglect, misappropriation of property, and exploitation.
Failure to Document Infection Control Training for Agency CNAs
Penalty
Summary
The facility failed to ensure agency staff received the required infection control training as part of its infection prevention and control program. During record review on 06/09/26, documentation could not be provided showing that agency CNA M, CNA N, CNA O, and CMA P had completed infection control training. During an interview later that day, Administrative Nurse D stated the two agency providers used by the facility for staffing had said they ensured their staff had the required education. On 06/10/26, the facility also failed to provide a policy related to ensuring all staff had received the required staff education when requested.
Infection Control Failures With Catheter Care and Respiratory Equipment Storage
Penalty
Summary
The facility failed to ensure adequate infection control practices related to urinary catheter care, hand hygiene, and the sanitary storage of respiratory equipment. On 06/08/26, R38’s nasal oxygen cannula was observed coiled on his bed and not stored in a sanitary container. On 06/08/26, R18’s catheter bag was observed located on the trash can next to his recliner without a privacy bag. On 06/09/26, R18’s catheter bag was again observed hanging on the trash can beside his recliner without a privacy bag, and later that day his catheter bag was observed on the floor without a privacy bag while he sat in his recliner with his feet up. Also on 06/09/26, R21’s nasal oxygen cannula was observed laid on his bed and not contained in a sanitary manner. During interview on 06/10/26, a CMA stated staff usually place the catheter bag in the trash can after placing a trash bag, while an LN stated the catheter bag should be inside the trash can and never on the floor, and that R18’s preferences should be on the care plan. An Administrative Nurse stated staff were expected to ensure catheter bags were not on the floor and to wash their hands between the dirty and the clean. The facility policy stated it facilitates safe care by establishing and maintaining an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable disease and infection.
Call light not within resident's reach
Penalty
Summary
The facility failed to ensure Resident 47's call light was within reach so he could call for staff assistance. Resident 47 had diagnoses of PTSD, vascular dementia, and DM. His Significant Change MDS documented a BIMS score of 3, indicating severely impaired cognition, and noted he needed setup or cleanup assistance with eating and supervision or touching assistance with oral hygiene and toileting. His Falls CAA documented that he was alert to self, had clear speech, was able to verbalize his needs, and usually understood others. His care plan identified him as high risk for falls related to confusion, deconditioning, gait, and balance problems, and directed staff to anticipate and meet his needs, ensure his call light was within reach, and respond promptly to requests for assistance. During observation, Resident 47 was seen sitting in his recliner and later in his blue chair with his bedside table in front of him, and he was unable to find his call light. He stated he did not know where his call light was. A CNA stated call lights should be placed on the person or clipped to the chair and said she would clip his call light on his blue chair because he was unable to reach it. An LN stated call lights should always be within the resident's reach and should be clipped to the chair or placed across his lap. An Administrative Nurse stated call lights should be within the resident's reach if the resident was in their room. The facility's policy stated call lights should be available at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure Resident 66 had an appropriate indication, or a documented physician rationale that included multiple unsuccessful attempts at nonpharmacological symptom management and a risk-versus-benefit review, for continued use of the antipsychotic Seroquel. The resident’s EMR documented diagnoses of Alzheimer’s disease and major depressive disorder, and the Quarterly MDS showed a BIMS score of 8, indicating moderately impaired cognition. The MDS also documented that the resident needed assistance with eating, oral hygiene, bathing, and toileting, and that the resident received both an antianxiety medication and an antipsychotic medication. The resident’s psychotropic use CAA documented diagnoses of Alzheimer’s, dementia, depression, and anxiety, and noted daily use of Seroquel and Xanax. The care plan listed Seroquel for major depressive disorder and Xanax for anxiety, with directions to monitor for side effects and effectiveness. The physician order for Seroquel was 100 mg twice daily related to major depressive disorder, but the EMR lacked documentation of a physician rationale for the antipsychotic, including risk versus benefits. During interviews, an LN stated she had not questioned the physician’s diagnoses for psychotropic medication, and an administrative nurse stated she was aware the resident did not have the correct indication for the antipsychotic medication.
Improper Hoyer Lift Transfer Staffing
Penalty
Summary
The facility failed to ensure an environment free of potential accident hazards when staff did not use two staff members during a Hoyer lift transfer for a resident who was totally dependent on staff for transfers. The resident had diagnoses of vascular dementia and anxiety, with a BIMS score of 3 on the Significant MDS and 5 on the Quarterly MDS, indicating severe cognitive impairment. The care plan dated 01/17/25 and revised on 06/04/25 directed that transfers be completed with a sling lift and one to two assist. On 06/08/26 at 08:35 AM, a CNA obtained the Hoyer lift and transferred the resident from bed to a Broda chair without assistance from a second staff member. During interview, the CNA stated the care plan listed the transfer as a one to two person assist and said she had done the transfer by herself in the past. Later interviews documented that an LN stated two staff members are needed during Hoyer lift transfers, and an Administrative Nurse stated that although she had learned in CNA class that one to two staff may transfer a resident using a Hoyer lift, state regulation required two staff members for a Hoyer transfer. The facility policy on Safe Resident Handling/Transfers stated that residents are to be handled and transferred safely to prevent or minimize risk for injury.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to address a significant weight loss for a resident with Parkinson's disease, ataxia, dementia, dysphagia, limited range of motion, and a history of needing staff assistance with meals. The resident's record documented a 40-pound weight loss in 90 days. The dietitian noted the resident had recent hospitalization, was alert with slurred speech, could state food preferences, was on a regular diet, was at risk of aspiration, refused altered consistency foods, reported wanting to lose weight, and said his appetite had decreased. The resident also remained on a diuretic medication. The resident's care plan included weekly weights, a regular diet with thin liquids, and assistance with meals after setup, but the facility was unable to provide a physician order for prescribed weight loss, including safe weight loss parameters. Staff interviews indicated that weight loss would normally be verified by reweighing the resident, checking for edema, asking about dental problems, and notifying the physician, but the record did not show that a physician-directed weight loss plan had been ordered. The facility's weight monitoring policy stated residents should maintain acceptable nutritional status unless their clinical condition or preferences made that impossible.
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.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 41 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
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 | ★★★★★ | 10 | 0 |
| The Cedars | 13.8 mi | ★★★★★ | 9 | 0 |
| Pinnacle Park Nursing & Rehab Center | 14.7 mi | ★★★★★ | 8 | 0 |
| Legacy At Salina | 17.9 mi | ★★★★★ | 2 | 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 October 2026) and official state health department websites.