Bethany Home Association

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 75 residents. The sample included three residents, with one reviewed for a change of condition. Based on observation, record review, and interview, the facility failed to notify Resident (R) 1's representative when Resident R1 had a change in condition. This deficient practice placed Resident R1 at risk for a lack of required decision from her representative for treatment.Findings included:- Resident R1's Electronic Medical Record (EMR) documented Resident R1 had diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) and thrombophilia (blood disorder that makes the blood in your veins (blood vessels that carry oxygen filled blood towards the heart) and arteries (blood vessels that carry blood away from the heart) more likely to clot).Resident R1's Quarterly Minimum Data Set (MDS) dated [DATE REDACTED], documented the resident had a Brief Interview of Mental Status (BIMS) of nine, which indicated moderately impaired cognition. The MDS documented Resident R1 had no upper or lower extremity impairment and used a walker for mobility. The MDS documented Resident R1 required supervision with transfers and ambulation 10 feet (ft).Resident R1's Care Plan, revised 08/05/25, documented Resident R1 required limited one staff assistance with mobility in the room with a walker. The Nurse's Note dated 07/12/25 at 10:34 PM documented the nurse observed Resident R1 with vomiting and diarrhea throughout the day. Staff administered Maalox (antacid medication), 10 milliliters (ml), and two Imodium (over-the-counter medication used to treat diarrhea), 2 milligrams (mg), tablets to Resident R1. Review of Resident R1's clinical record revealed a lack of documentation. Resident R1's representative was informed of the change in condition.The Nurse's Note dated 07/14/25 at 01:17 PM documented Resident R1 had a rough weekend with nausea, vomiting, and diarrhea, and had a hard time transferring. The note documented Resident R1 slept in, took her morning medications, got up for lunch, and ate some of her meal. The note documented staff checked her vitals, and they were within normal limits for Resident R1. The nurse assessed Resident R1's hand grasp, and they were equal on both sides. The note documented Resident R1 had a hard time cutting up her meat, and the nurse notified

the physician and Resident R1's representative three days after Resident R1's initial change in condition.On 09/02/25 at 10:22 AM, Administrative Nurse D verified a lack of documentation in Resident R1's clinical record, regarding staff notifying

the resident's representative of Resident R1's change of condition on 07/12/25. Administrative Nurse D stated she would expect staff to notify the representative as soon as Resident R1 had nausea, vomiting, and diarrhea.Upon request, the facility failed to provide a change in condition policy.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/02/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Bethany Home Association

321 N Chestnut Street Lindsborg, KS 67456

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

10:26 AM, documented that staff reported Resident R2 had emesis (vomit) at breakfast. Resident R2 stated he was nauseous and felt his medication caused this; no temperature was noted, and nursing staff would continue to monitor Resident R2. The Nurse's Note dated 06/19/25 at 02:00 PM, documented that staff reported to the physician that Resident R2 had increased drowsiness, was hard to arouse, had vital signs on the lower end, urine output and color, and the physician directed staff to send him to the emergency room for evaluation.The Nurse's Note dated 06/19/25 at 05:28 PM, documented Resident R2's spouse reported that he was transferred from the local hospital to

the hospital in [NAME], where he was admitted for a UTI.On 09/02/25 at 01:15 PM, Resident R2 was in his room, in bed. His catheter bag was fastened to his bed. On 09/02/25 at 12:05 PM, Certified Nurse Aide (CNA) M stated she would contact the nurse if the resident did not act right or out of his normal behaviors. On 09/02/25 at 12:17 PM, Licensed Nurse (LN) G stated that if she had to change Resident R2's catheter more than once in a short time, she would contact the physician. LN G further stated Resident R2's spouse was very involved with his care, and she would make sure she was notified of any changes in his health. LN G further stated that nursing staff had recently been reeducated on when to contact the physician and responsible parties when there was a change in the status of residents.On 09/02/25 at 10:28 AM, Administrative Nurse D stated she would expect the physician to be notified if Resident R2 had not had any output of urine in his catheter and any changes with the resident.The facility's Indwelling Catheter Protocol policy, dated 08/27/24, documented that every resident with an indwelling catheter would be reassessed by a licensed nurse every shift. Each resident with an indwelling catheter would be assessed for pain/discomfort related to the use of

the catheter, and if any, the location of the pain/discomfort and what non-pharmacological interventions were attempted. If the bladder had been overly distended for a period of time, urine may become bloody. If clots are noted or bleeding appears excessively, notify the physician immediately.

Event ID:

Facility ID:

If continuation sheet