Bethany Home Association: Catheter Care Failures - KS
By early afternoon, he was hard to wake up. His vital signs had dropped. His urine output had changed in both volume and color. Only then did staff at Bethany Home Association contact the physician, who told them to send him to the emergency room immediately.
He was transferred from the local hospital to a facility in another city and admitted for a urinary tract infection.
Federal inspectors cited Bethany Home Association following a complaint inspection completed September 2, 2025. The citation, tagged F0690, covered catheter care and the failure to act on signs of resident decline. Inspectors found the harm level minimal or potential, with few residents affected. But the timeline they reconstructed told a more specific story.
A nurse's note from the morning of June 19, 2025, at 10:26 a.m., recorded that the resident, identified in inspection records as R2, had vomited at breakfast. He told staff his medication was making him nauseous. No temperature was taken. Staff noted they would continue to monitor him.
That was the response. Continue to monitor.
Four hours later, at 2:00 p.m., a second nurse's note documented what monitoring had turned up: R2 was increasingly drowsy, difficult to arouse, showing vital signs on the lower end of normal, and producing urine that had changed in output and color. The physician was contacted. The order came back: send him to the emergency room now.
By 5:28 p.m., R2's spouse reported he had already been transferred out of the local hospital entirely, moved to a facility in another city, and admitted for a UTI.
When inspectors visited the facility on September 2, R2 was in his room, in bed, his catheter bag fastened to the bed frame. They interviewed the staff who had been involved in his care.
Certified Nurse Aide M told inspectors she would contact a nurse if a resident did not act right or seemed outside their normal behavior. Licensed Nurse G said that if she had to change R2's catheter more than once in a short period of time, she would reach out to the physician. She added that R2's spouse was closely involved in his care and that she made sure to keep her informed of any health changes. She also told inspectors that nursing staff had recently been reeducated on when to contact the physician and responsible parties when a resident's condition changed.
That reeducation happened after R2 was hospitalized.
Administrative Nurse D told inspectors she would expect the physician to be notified if a catheterized resident had no urine output at all, or showed any other changes.
The facility's own catheter protocol, dated August 27, 2024, required licensed nurses to reassess every catheterized resident every shift, checking for pain or discomfort and tracking any changes. The protocol specifically addressed what to do if bleeding appeared or clots were noted: notify the physician immediately.
It said nothing about waiting until a resident could no longer be roused from sleep.
The gap between what R2 showed at breakfast and what staff documented four hours later is where the citation lives. Nausea in a catheterized resident is not a routine complaint to monitor from a distance. It is one of the ways the body signals that something is wrong in the urinary tract. By the time R2 was drowsy and his vitals had shifted, the infection had already progressed far enough to require hospitalization in another city.
His spouse had been closely involved in his care throughout. The inspection report does not say whether she was called that morning, when he vomited and said he felt sick. It does not say whether she was in the building.
What it says is that by the time staff contacted the physician, her husband was hard to wake up.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bethany Home Association from 2025-09-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 1, 2026 · Our methodology
BETHANY HOME ASSOCIATION in LINDSBORG, KS was cited for violations during a health inspection on September 2, 2025.
By early afternoon, he was hard to wake up.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.