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Inspection visit

Health inspection

Bethany Lutheran HomeCMS #1655248 citations on this visit
8 citations recorded

Citations

8 citations recorded*CMS

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.

  • 0637GeneralS&S Dpotential for harm

    F637 - Within 14 days after the facility determines, or should have determined,

    Assess the resident when there is a significant change in condition

  • 0644GeneralS&S Dpotential for harm

    F644 - Coordination

    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0658GeneralS&S Dpotential for harm

    F658 - Comprehensive Care Plans

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0689SeriousS&S Jimmediate jeopardy

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0725GeneralS&S Epotential for harm

    F725 - Nursing Services

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  • 0760GeneralS&S Dpotential for harm

    F760 - Residents are free of any significant medication errors

    Ensure that residents are free from significant medication errors.

  • 0880GeneralS&S Fpotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the October 2, 2025 survey of Bethany Lutheran Home?

This was a inspection survey of Bethany Lutheran Home on October 2, 2025. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Bethany Lutheran Home on October 2, 2025?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Assess the resident when there is a significant change in condition"

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.