Public Record
Bethany Lutheran Home
From CMS
Facility profile
- CMS overall rating
- 1 / 5
- Certified beds
- 112
- Avg. residents per day
- 91.9
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 61
- Inspections on file
- 12
- Last inspection
- 2025-10-02
*CMS
*CMS
*CMS
Citations
61 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0741Generalpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0637Generalpotential for harm
Assess the resident when there is a significant change in condition
- 0644Generalpotential for harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0689Seriousimmediate jeopardy
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0761Generalpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0658Seriousactual harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0761Generalpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0644Generalpotential for harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- 0727Generalpotential for harm
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
- 0744Generalpotential for harm
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0921Generalpotential for harm
Ensure that testing and maintenance of electrical equipment is performed.
- 0625Generalpotential for harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0689Seriousactual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0684Seriousimmediate jeopardy
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0585Generalpotential for harm
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0695Seriousactual harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0625Generalpotential for harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0741Generalpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0761Generalpotential for harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0607Generalpotential for harm
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection12 deficiencies
- View inspection reportInspection12 deficiencies
- View inspection reportInspection2 deficiencies
- View inspection reportInspection4 deficiencies
- View inspection reportInspection13 deficiencies
- View inspection reportInspection13 deficiencies
- View inspection reportInspection2 deficiencies
- View inspection reportInspection2 deficiencies
- View inspection reportInspection2 deficiencies
- View inspection reportInspection18 deficiencies
Showing the 10 most recent inspections. 2 earlier inspections are also on record.
FAQ
Questions and answers
- What is Bethany Lutheran Home?
- Bethany Lutheran Home is a Medicare- and Medicaid-certified nursing home in Council Bluffs, IA, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 165524.
- What is the CMS rating for Bethany Lutheran Home?
- Bethany Lutheran Home has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Bethany Lutheran Home have?
- Bethany Lutheran Home is certified for 112 beds. It serves an average of 91.9 residents per day.
- How many citations does Bethany Lutheran Home have?
- Bethany Lutheran Home has 61 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Bethany Lutheran Home last inspected?
- Bethany Lutheran Home was last inspected on October 2, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/165524-bethany-lutheran-home