Inspection Reports for Bethany Home Association of Lindsborg, Kansas
821 E. SWENSSON DRIVE, KS, 67456
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 10, 2024, found no deficiencies and confirmed that all previous issues had been corrected. Earlier inspections showed recurring deficiencies related mainly to negotiated service agreements, emergency management plan reviews, tuberculosis testing compliance, and posting of electronic monitoring notices. Complaint investigations generally identified these documentation and procedural issues, with no enforcement actions or fines listed in the available reports. Most complaints were substantiated and addressed through plans of correction, with follow-up surveys confirming resolution. The facility’s inspection history indicates improvement over time, with recent surveys showing compliance after prior citations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
35 residents
Based on a June 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Jul 10, 2024
Visit Reason
An offsite revisit survey was conducted on 07/10/24 to verify correction of all previous deficiencies cited on 06/18/24.
Findings
All deficiencies cited in the previous survey have been corrected as of the compliance date of 06/29/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 18, 2024
Visit Reason
This document is a plan of correction submitted in response to a resurvey with a complaint (#179080) conducted at the facility on 06/18/24.
Findings
The plan of correction addresses citations found during the resurvey related to the complaint investigation conducted on 06/18/24.
Complaint Details
The visit was complaint-related, referencing complaint number #179080.
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 4
Jun 18, 2024
Visit Reason
The inspection was a resurvey with a complaint (#179080) conducted to evaluate compliance with health care service agreements, disaster and emergency preparedness, infection control policies, and electronic monitoring notices.
Findings
The facility failed to ensure negotiated service agreements contained the name of the licensed nurse responsible for health service plans, did not perform quarterly reviews of the emergency management plan with residents and staff, failed to comply with tuberculosis testing guidelines for residents and staff, and did not post required electronic monitoring notices at the facility entrance and resident rooms.
Complaint Details
The visit was a resurvey with a complaint (#179080) focused on compliance with negotiated service agreements and other regulatory requirements.
Severity Breakdown
SS=F: 3
Scope and Severity of E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Negotiated service agreements lacked the name of the licensed nurse responsible for implementation and supervision of the health service plan. | SS=F |
| Failure to ensure quarterly review of the facility's emergency management plan with residents and staff. | SS=F |
| Failure to comply with tuberculosis testing and questionnaire requirements for residents and newly hired staff. | SS=F |
| Failure to post conspicuous notice at the entrance and resident rooms regarding authorized electronic monitoring. | Scope and Severity of E |
Report Facts
Census: 35
Sample size: 3
Sample size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Operator Licensed Nurse A | Operator/ Licensed Nurse | Named in findings related to failure to ensure negotiated service agreements contained licensed nurse name, failure to ensure emergency plan reviews, and failure to ensure TB testing compliance |
| Dietary Staff D | Dietary Staff | Named in finding related to lack of TB testing and questionnaire upon hire |
Inspection Report
Follow-Up
Deficiencies: 0
Nov 28, 2022
Visit Reason
An offsite revisit survey was conducted on 11/28/22 to verify correction of all previous deficiencies cited on 10/31/22.
Findings
All deficiencies have been corrected as of the compliance date of 11/24/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 7
Deficiencies: 10
Oct 31, 2022
Visit Reason
The inspection was a resurvey with a complaint #KS00171580 conducted on 10/27/22 and 10/31/22 at Joy Home, a home plus facility in Oxford, KS.
Findings
The facility was found deficient in multiple areas including failure to post notice of policies and procedures, incomplete negotiated service agreements (NSA) for residents, lack of timely NSA reviews and signatures, inadequate disaster and emergency preparedness education and plan availability, non-compliance with tuberculosis screening guidelines for staff, incomplete employee records for licensure and background checks, delayed signing of verbal physician orders, and improper labeling of over-the-counter medications.
Complaint Details
The inspection was a resurvey with complaint #KS00171580 conducted on 10/27/22 and 10/31/22.
Severity Breakdown
SS=F: 9
SS=D: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to post notice of availability of policies and procedures related to resident services in a place readily accessible to residents. | SS=F |
| Negotiated Service Agreements (NSA) for residents R127, R129, and R131 did not describe services based on their Functional Capacity Screens (FCS) and failed to identify hospice providers and payment responsibilities. | SS=F |
| Failed to review and revise NSAs following significant changes in condition and at least once every 365 days for residents R127, R129, and R131. | SS=F |
| Failed to obtain signatures of all individuals involved in the development of the NSA for Resident R127. | SS=D |
| Failed to ensure quarterly review of the emergency management plan with employees and residents. | SS=F |
| Failed to make the emergency management plan available to staff, residents, and visitors. | SS=F |
| Failed to comply with tuberculosis screening and testing guidelines for five sampled staff members. | SS=F |
| Failed to ensure evidence of licensure, certification, and criminal background checks were completed upon hire for several staff members. | SS=F |
| Failed to ensure all verbal physician orders were signed by the medical care provider within seven working days for residents R127, R129, and R131. | SS=F |
| Failed to ensure over-the-counter medications were labeled with the full name of the resident on both the original package and the medication container. | SS=F |
Report Facts
Census: 7
Days late for NSA completion: 373
Days late for NSA completion: 102
Days late for NSA completion: 522
Days RN worked without valid registration: 27
Days CNA worked without valid certification: 144
Days CNA worked before background check completed: 14
Days delay in signing physician order: 37
Days delay in signing physician order: 64
Days delay in signing physician order: 65
Days delay in signing physician order: 39
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Confirmed lack of policy notice posting, emergency plan availability, TB screening non-compliance, and verbal order signing delays |
| Administrative Staff A | Administrative Staff | Confirmed deficiencies in negotiated service agreements and labeling of OTC medications |
| Administrative Staff B | Administrative Staff | Confirmed lack of NSA signatures for Resident R127 |
| Medical Provider C | Medical Provider | Signed delayed physician orders for residents R127, R129, and R131 |
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 27, 2022
Visit Reason
This document is a Plan of Correction addressing findings from a resurvey conducted with a complaint #KS00171580 at the facility on 10/27/22 and 10/31/22.
Findings
The Plan of Correction references citations from a resurvey combined with a complaint investigation conducted on the specified dates.
Complaint Details
Complaint #KS00171580 was part of the resurvey that generated the findings addressed in this Plan of Correction.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 13, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 7/13/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Census: 17
Deficiencies: 2
Sep 27, 2018
Visit Reason
The inspection was a resurvey conducted at an assisted living facility to assess compliance with negotiated service agreement requirements.
Findings
The facility failed to ensure that negotiated service agreements were properly developed and revised for residents, lacking descriptions of services, providers, and payment responsibilities. Specifically, agreements did not address services related to falls, unsteadiness, hearing/vision impairments, and therapy services for multiple residents.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to develop negotiated service agreements including service descriptions, providers, and payment responsibilities for 2 of 3 residents. | SS=E |
| Failed to review and revise negotiated service agreements at least annually or following significant changes for 2 of 3 residents. | SS=E |
Report Facts
Census: 17
Residents sampled: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nursing Staff A | Interviewed regarding requirements for negotiated service agreements and acute care service plans |
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 19, 2016
Visit Reason
This document is a Plan of Correction submitted in response to a prior inspection report for Bethany AL dated 12/19/2016.
Findings
No deficiencies were cited in the related inspection report, so no corrective actions were required.
Deficiencies (1)
| Description |
|---|
| No deficiencies cited |
Inspection Report
Re-Inspection
Deficiencies: 0
Dec 19, 2016
Visit Reason
The visit was a resurvey of the Assisted Living/Residential Healthcare facility to verify compliance following a previous inspection.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 1, 2015
Visit Reason
The document is a Plan of Correction submitted following an Assisted Living/Residential Healthcare resurvey of the facility.
Findings
The resurvey resulted in a finding of no deficiency citations for the facility.
Loading inspection reports...
