Inspection Reports for Bethany Home Association of Lindsborg, Kansas

This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.

All previously reported deficiencies identified by regulation numbers 483.25(b)(1), 483.25(d)(1)(2)(n)(1)-(3), 483.45(d), 483.45(c)(1)(3)-(5), and 483.80(a)(1)(2)(4)(e)(f) were corrected as of the revisit date.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be an "E" level deficiency, pattern, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective January 18, 2017.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a survey conducted on December 19, 2016.

The Plan of Correction addresses multiple deficiencies including pressure ulcer care, electric recliner safety, fall interventions, pharmacy reviews of psychoactive medications, and housekeeping sanitation procedures. The facility outlines corrective actions, staff education, and monitoring plans to ensure compliance and resident safety.

The inspection was conducted as a Health Resurvey and Complaint investigation related to allegations including pressure ulcer care, accident hazards, medication regimen, and infection control.

The facility failed to provide adequate care to prevent and treat pressure ulcers for Resident #5, failed to ensure a safe environment and supervision to prevent accidents for Residents #5 and #92, failed to follow up on pharmacist recommendations for medication dose reductions for Resident #85, failed to evaluate duplicate psychotropic medications for Resident #82, and failed to maintain proper infection control practices during housekeeping.

The visit was triggered by complaints regarding pressure ulcer care, accident hazards, medication management, and infection control.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies at the facility to be at an "F" level, indicating no harm with potential for more than minimal harm but not immediate jeopardy. A plan of correction was required, and enforcement remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The revisit confirmed that the previously cited deficiency with ID Prefix F0323 related to regulation 483.25(h) was corrected as of 08/18/2016. No other deficiencies were noted.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiency to be a 'D' level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The inspection was conducted as a complaint investigation (#103338) regarding the facility's failure to provide adequate supervision to prevent accidents.

The facility failed to provide adequate supervision for one resident who received a hot pack left on longer than recommended, resulting in a reddened area on the resident's back. Staff did not monitor the resident's skin properly, placing the resident at risk for injury and burns.

The complaint investigation found that the facility failed to supervise Resident #1 adequately, resulting in a hot pack being left on the resident's back longer than the recommended 15-30 minutes, causing skin redness but no blistering. The resident had intact cognition and required extensive assistance. Therapy staff and nursing aides failed to monitor the skin condition properly.

This is a post-certification revisit to verify that previously reported deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.

The report confirms that all previously cited deficiencies identified by regulation numbers 483.20(g)-(j), 483.20(d), 483.20(k)(1), 483.20(d)(3), 483.10(k)(2), and 483.65 have been corrected as of the revisit date.

This document is a Plan of Correction submitted by the facility to address deficiencies cited during a prior survey.

The facility identified multiple deficiencies related to resident assessments, care plan updates, coordination with Hospice services, and infection control practices. Corrective actions include reassessments, staff education, audits, and ongoing monitoring to ensure compliance.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found isolated 'D' level deficiencies that constitute no actual harm but have the potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective October 30, 2015.

The inspection was conducted as a Health Resurvey and Complaint Investigations #90777 and #91271 to evaluate compliance with regulatory requirements.

The facility failed to provide accurate resident assessments, develop comprehensive care plans, coordinate hospice care, and maintain infection control standards. Specific deficiencies were noted in assessment accuracy for residents #32 and #51, care planning for residents #20 and #22, hospice care coordination for resident #20, and infection control during wound care for resident #22.

The inspection included complaint investigations #90777 and #91271. The facility was found noncompliant in multiple areas related to resident assessments, care planning, hospice coordination, and infection control.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The report shows that the previously cited deficiencies under regulations 483.13(c) and 483.25(h) were corrected as of 12/03/2014.

This Plan of Correction document addresses deficiencies cited during a complaint investigation survey at Bethany Home.

The plan outlines corrective actions for deficiencies related to abuse, neglect, exploitation reporting, and resident lifting and transfer procedures, with education and monitoring measures to ensure compliance.

The visit was complaint-related, with investigations into allegations of abuse, neglect, and exploitation. The investigation was completed and provided to the state surveyor immediately upon request. All allegations, substantiated or unsubstantiated, are to be reported and monitored.

An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be 'D' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The inspection was conducted as a complaint investigation (#80325) regarding allegations of abuse and failure to report, as well as concerns about resident safety and supervision related to the use of mechanical lifts.

The facility failed to report an allegation of potential abuse by staff involving Resident #3 to the state agency. Additionally, the facility failed to identify physical declines in Residents #1 and #2 that resulted in injuries due to improper use of sit to stand lifts, including significant bruising and pain. Staff training on lift use was limited to initial hire with no ongoing training.

The complaint investigation (#80325) was substantiated in part, finding the facility failed to report an allegation of abuse and failed to ensure adequate supervision and safe use of assistive devices, resulting in resident injuries.

This is a post-certification revisit to verify that previously cited deficiencies have been corrected as of the revisit date.

The report documents that all previously identified deficiencies listed on the CMS-2567 have been corrected by 07/31/2014.

This document is a Plan of Correction submitted by Bethany Home Association in response to deficiencies cited during a prior survey. It outlines corrective actions taken and planned to address various regulatory compliance issues.

The plan details corrective actions for multiple deficiencies including medication refusal protocols, mail delivery, incident reporting, resident preferences, depression and mood disorder management, maintenance repairs, elopement prevention, food safety, and chemical storage. The facility has implemented new policies, staff training, and monitoring systems to ensure compliance.

A Health survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency in the facility to be a 'G' level. As a result, enforcement remedies including denial of payment for new Medicare admissions effective October 2, 2014, were imposed until substantial compliance is achieved or the provider agreement is terminated.

The inspection was conducted as a Health Resurvey and Complaint Investigations #74968, #75410 and #75311.

The facility was found deficient in multiple areas including failure to notify physicians of changes in resident condition, failure to provide privacy in mail handling, failure to report injuries of unknown origin, failure to provide resident choice and preferences, failure to provide medically-related social services, failure to maintain a sanitary environment, failure to develop comprehensive care plans, failure to provide psychosocial and emotional support, failure to prevent accidents and adequately supervise residents, failure to monitor drug regimens and medication refusals, failure to provide evening snacks to all residents, and failure to maintain sanitary food preparation and service.

The inspection included complaint investigations #74968, #75410, and #75311.

The document is a resurvey of an Assisted Living/Residential Healthcare facility to verify compliance and check for deficiencies.

The resurvey resulted in a finding of no deficiency citations.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

The health survey was conducted as a routine annual inspection to assess compliance with applicable regulations under 42 CFR, Part 483, Subpart B for long term care facilities.

The survey resulted in a finding of no deficiency citations with respect to the applicable regulations for long term care facilities.

This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.

The report confirms that deficiencies previously cited under regulations 483.35(i) and 483.60(a),(b) have been corrected as of 06/15/2012.

The inspection was conducted as a health resurvey and complaint investigation #55113 at the facility.

The facility failed to maintain sanitary food preparation and serving practices, including improper hairnet use and handling of residents' glasses. Additionally, the facility failed to monitor expiration dates of stock medications and medications for one resident, potentially exposing residents to outdated medications.

The visit included a complaint investigation #55113. The findings were substantiated as the facility failed to meet sanitary food handling and pharmaceutical service requirements.

This document is a Plan of Correction submitted by Bethany Home addressing deficiencies cited related to food sanitation practices and medication management.

The plan outlines corrective actions including updated policies on food preparation and sanitary practices, implementation of new hair restraints for dietary staff, education and monitoring procedures, and revised medication check practices to ensure expired medications are identified and removed.

This document is a Plan of Correction submitted in response to deficiencies cited during a prior survey related to a complaint investigation at Bethany Home.

The plan addresses deficiencies related to improper use of commercial hot packs/thermal agents by staff, including reeducation, competency checks, and monitoring to ensure compliance with proper procedures.

This Plan of Correction is linked to a complaint investigation at Bethany Home dated 08/04/2016.