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 Bethel Home during CMS and state inspections, most recent first.
The facility failed to update care plans for four residents, resulting in deficiencies related to falls, pressure ulcers, and medication changes. Two residents experienced falls without appropriate interventions being added to their care plans. Another resident's care plan was not updated for a facility-acquired pressure ulcer, and a fourth resident's care plan did not reflect changes in psychotropic medication. Staff interviews indicated a lack of clarity in updating care plans.
A facility failed to ensure a safe environment, leading to deficiencies in medication security and fall prevention. A resident had unsecured medications in her room, and staff were unaware of secure storage options. Additionally, three residents experienced repeated falls without timely interventions in their care plans. Staff interviews revealed communication gaps and procedural lapses in updating care plans and implementing interventions post-fall.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in care. A resident's care plan lacked interventions for psychotropic medication use and dementia care. Another resident's care plan was missing interventions for PRN oxygen use, nebulized medication, and timely pressure ulcer care. A third resident's care plan did not include necessary wound care interventions for a leg stump wound.
A facility failed to perform ongoing assessments of a stage three pressure ulcer for a resident with diabetes and quadriplegia. Despite having a care plan that included repositioning and preventative measures, the facility did not consistently document weekly assessments as required. The ulcer worsened over time, and staff interviews revealed inconsistencies in following the facility's skin protocol for monitoring and documenting pressure ulcers.
A facility failed to ensure a resident's PRN Xanax had a 14-day stop date or clinical rationale for continued use. The resident, with anxiety disorder and insomnia, received Xanax without an ordered stop date, contrary to facility policy requiring a 14-day limit unless evaluated by a physician.
Staff failed to follow proper hand hygiene protocols during wound care for two residents. A nurse and a CNA were observed not washing hands between glove changes while treating wounds and assisting with dressing. Interviews confirmed staff awareness of the protocols, but the facility did not ensure consistent adherence, risking infection spread.
The facility failed to maintain an effective antibiotic stewardship program, leading to inadequate monitoring of antibiotic use and infection control. A resident with potential clostridium difficile infection was not properly tracked, and several antibiotics prescribed were not recorded or lacked necessary tests. Communication issues further exacerbated the deficiency, as staff were unaware of the resident's condition and failed to complete the infection monitoring system.
Failure to Revise Care Plans for Falls, Pressure Ulcers, and Medication Changes
Penalty
Summary
The facility failed to revise care plans for four residents, leading to deficiencies in addressing falls, pressure ulcers, and medication changes. Two residents experienced falls without appropriate interventions being added to their care plans. One resident had multiple falls over several months, yet their care plan lacked any fall prevention strategies. Another resident's care plan was not updated following a fall, leaving them without necessary interventions to prevent future incidents. Additionally, the facility did not update the care plan for a resident who developed a facility-acquired pressure ulcer, failing to include necessary interventions for skin care. Another resident's care plan was not revised to reflect changes in psychotropic medication, specifically the addition of Buspirone for anxiety. Interviews with staff revealed a lack of clarity and communication regarding the responsibility for updating care plans, contributing to these deficiencies.
Deficiencies in Medication Security and Fall Prevention
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for several residents, leading to deficiencies in care. One resident, identified as R37, had unsecured medications in her room, including over-the-counter creams and lotions with warnings to keep out of reach of children. The resident reported she was not educated on securing medications, and staff interviews revealed a lack of secure storage options in resident rooms. Additionally, there was no completed assessment for self-medication in the electronic health record (EHR) for R37, despite facility policy requiring such an assessment. Three other residents, R21, R33, and R36, experienced repeated falls without appropriate or timely interventions being implemented in their care plans. R36, with moderately impaired cognition, had several falls documented, but interventions were either delayed or absent. Similarly, R21, with intact cognition, had falls related to dizziness from diuretic use, yet immediate interventions were not noted, and care plan updates were limited to therapy evaluations. R33, with severely impaired cognition, also had multiple falls, with care plan interventions either missing or not updated promptly. Interviews with facility staff, including certified medication aides, licensed nurses, and administrative nurses, highlighted communication gaps and procedural lapses in updating care plans and implementing interventions post-fall. The facility's policies on self-administration of medications and fall prevention were not adequately followed, contributing to the unsafe environment and increased risk of preventable accidents and injuries for the residents involved.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for three residents, leading to deficiencies in their care. Resident 33's care plan was inadequate concerning psychotropic medication use and dementia care. Resident 21's care plan lacked interventions related to PRN oxygen use, scheduled nebulized medication use, and timely intervention for pressure ulcer care. Resident 3's care plan was missing documentation related to wound care on the left leg stump. Resident 21 had a history of asthma and was documented to have intact cognition. Despite having an open sore on the right buttock, the care plan was not updated in a timely manner to address this issue. Additionally, the care plan did not include interventions for oxygen or nebulized medication use, even though physician orders and observations indicated the need for such interventions. The lack of timely updates and comprehensive care planning had the potential to negatively impact Resident 21's physical and psychosocial well-being. Resident 3, who had a history of diabetes mellitus type 2 and a left leg amputation, also experienced deficiencies in care planning. The care plan did not include necessary interventions for a wound on the left leg stump, despite physician orders and evaluations indicating the need for wound care. The absence of appropriate care plan documentation for wound care had the potential to lead to uncommunicated needs and negatively affect Resident 3's well-being.
Failure to Monitor and Document Stage Three Pressure Ulcer
Penalty
Summary
The facility failed to perform an ongoing assessment of a stage three pressure ulcer for Resident 2, who had a history of diabetes mellitus type two and quadriplegia. Despite having a preventative mattress and cushion in place, Resident 2 developed a facility-acquired stage three pressure ulcer on the right buttock. The resident required maximal to total assistance with activities of daily living and had a history of pressure ulcers, but no skin breakdown was initially documented. The care plan for Resident 2 included interventions such as repositioning every two hours, using a personal air mattress and cushion, and educating the resident on preventative measures. However, the facility did not consistently document weekly assessments of the pressure ulcer as per physician orders. Progress notes indicated that the ulcer worsened over time, with measurements showing an increase in size and skin peeling around the peri wound. Despite some documentation in the wound clinic notes, there were gaps in the ongoing weekly assessments required for monitoring the ulcer's progression. Interviews with staff revealed that the charge nurse was responsible for measuring and documenting skin conditions weekly, but this was not consistently done for Resident 2. The facility's policy required detailed documentation of pressure ulcers, including location, size, and other characteristics, at each dressing change. However, the facility failed to adhere to this protocol, resulting in inadequate monitoring and documentation of the resident's pressure ulcer.
Failure to Ensure 14-Day Stop Date for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's PRN psychotropic medication, Xanax, had the required 14-day stop date or a documented clinical rationale for continued use beyond the initial 14 days. The resident, who had diagnoses of anxiety disorder, insomnia, and hypertension, received doses of Xanax on two occasions without evidence of an ordered stop date. The resident's electronic health record showed a telephone order for Xanax with an indefinite end date, which was confirmed by an administrative nurse who was unaware of the regulatory requirement for a 14-day stop date or physician evaluation for continued use. The resident's admission data indicated intact cognition, and the resident was observed to be calm and relaxed while working on a puzzle. However, the facility's policy on psychotropic medications, which requires PRN orders for such drugs to be limited to 14 days unless evaluated by the attending physician, was not followed. This oversight had the potential to lead to the resident receiving unnecessary psychotropic medication.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
Staff at the facility failed to adhere to proper hand hygiene protocols during wound care for two residents, R2 and R21. Observations revealed that a Licensed Nurse (LN) removed a dressing from a skin tear on R21 without performing hand hygiene, cleaned the wound, and applied a new dressing without changing gloves or washing hands. Similarly, a Certified Nursing Assistant (CNA) assisted R2 with dressing, removed gloves, and applied new gloves without washing hands before applying Foley tubing to R2's leg. Another LN was observed cleansing a wound on a resident's buttock, using a dirty glove to handle a sterile dressing, and failing to wash hands between glove changes. Interviews with the involved staff confirmed their awareness of the hand hygiene protocols they neglected to follow. LN J admitted to not performing appropriate glove changes and hand hygiene between dirty and clean phases. LN H acknowledged the need to wash hands after removing gloves and before applying new ones. CNA O also verified the omission of hand washing between glove changes. Administrative Nurses C and B expressed their expectations for staff to follow infection control practices, including hand washing, but the facility failed to ensure these practices were consistently followed, posing a potential risk of spreading infections among residents.
Deficiency in Antibiotic Stewardship and Infection Control
Penalty
Summary
The facility failed to maintain an effective and ongoing antibiotic stewardship program, which is crucial for preventing antibiotic resistance and the spread of multi-drug resistant organisms. The Infection Preventionist, Administrative Nurse C, reported that she was responsible for tracking antibiotic use and ensuring that nurses followed McGeer's Criteria. However, she was not notified about a resident being tested for clostridium difficile, which is a significant oversight as precautions should have been initiated. The surveyor discovered that the resident had 56 loose stools out of 75 in the past 30 days, indicating a potential infection that was not properly monitored. Additionally, several antibiotics prescribed to residents were not recorded on the tracking form, and some lacked culture and sensitivity tests or appropriate diagnoses. Communication issues were evident, as Administrative Nurse B was unaware of the resident's condition and confirmed the lack of completion of the computerized infection monitoring system. The facility's policy required staff to monitor antibiotic use with support from the Medical Director, Pharmacist, and Director of Nursing, but this was not effectively implemented. The failure to adhere to the facility's Antibiotic Stewardship policy and the lack of proper documentation and communication contributed to the deficiency in managing antibiotic use and infection control.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 47 citations issued within 25 miles in the last 12 months — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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How nearby facilities compare on the same public inspection record.
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|---|---|---|---|---|
| The Shepherd's Center | 16.3 mi | ★★★★★ | 24 | 0 |
| Fowler Residential Care | 20 mi | ★★★★★ | 0 | 0 |
| Meade District Hosp Ltcu Dba Lone Tree Retirement | 22 mi | ★★★★★ | 22 | 0 |
| Sunporch Of Dodge City | 24.5 mi | ★★★★★ | 1 | 0 |
| Kansas Soldiers Home | 25.6 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.