Bethany Lutheran Home
Inspection Findings
F-Tag F0637
Federal health inspectors cited Bethany Lutheran Home in Council Bluffs, IA for a deficiency under regulatory tag F-F0637 during a standard health inspection conducted on 2025-10-02.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Assess the resident when there is a significant change in condition
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of Bethany Lutheran Home.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-25.
F-Tag F0644
Federal health inspectors cited Bethany Lutheran Home in Council Bluffs, IA for a deficiency under regulatory tag F-F0644 during a standard health inspection conducted on 2025-10-02.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of Bethany Lutheran Home.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-25.
F-Tag F0656
Federal health inspectors cited Bethany Lutheran Home in Council Bluffs, IA for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-10-02.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of Bethany Lutheran Home.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-25.
F-Tag F0658
Federal health inspectors cited Bethany Lutheran Home in Council Bluffs, IA for a deficiency under regulatory tag F-F0658 during a standard health inspection conducted on 2025-10-02.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of Bethany Lutheran Home.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-25.
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
alarm, not the Wander Guard alarm system. The staff stated he was not aware of a resident going out the door until much later. The staff stated when he came to the front door Staff L was attempting to shut the door alarm off. Staff A stated when the Wander Guard alarm went off a XD number code was revealed on
the call light screen in the hallways indicating it was the Wander Guard. The staff stated when the alarm went off at the time of elopement the screen revealed R meaning right main door. On 10/2/25 at 8:00 AM
the Administrator stated she would need the facility's policy regarding the frequency of doors to be checked. The Administrator expected staff to respond and follow the policies for door alarms and missing residents. The facility's Elopement Awareness Protocol, 7/21/22, provided door alarm checks and Wander Guard/Code alert checks were to be completed Monday through Saturday and Elopement Drills were to be completed routinely and documented. The facility's Door Alarm Response, 11/2/18, revealed staff were to immediately respond to the door that was sounding, walk outside, and scan the grounds to identify the source of the alarm. The document revealed if the source of the alarm was not identified, account for all residents and if a resident was unaccountable to initiate the missing resident policy.
Event ID:
Facility ID:
If continuation sheet
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
10/02/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bethany Lutheran Home
Seven Elliott Street Council Bluffs, IA 51503
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-Tag F0725
F 0725
9/28/25 at 7:24 PM 21 minutes and 38 seconds.
Level of Harm - Minimal harm or potential for actual harm
9/29/25 at 7:10 PM 22 minutes and 47 seconds.
Residents Affected - Some
c. room [ROOM NUMBER] had call lights with a response time of longer than 15 minutes from 9/24/25 10/1/25 on: 9/24/25 at 4:31 AM 44 minutes and 15 seconds. 9/24/25 at 6:53 AM 17 minutes and 49 seconds. 9/27/25 at 5:42 AM 17 minutes and 7 seconds. 9/27/25 at 6:38 PM 18 minutes and 51 seconds. 9/28/25 at 6:24 AM 18 minutes and 23 seconds. 9/28/25 at 6:28 PM 21 minutes and 15 seconds. 9/29/25 at 5:41 AM 17 minutes and 30 seconds. 9/30/25 at 4:20 AM 18 minutes and 44 seconds. 9/30/25 at 8:29 AM 18 minutes and 42 seconds. d. room [ROOM NUMBER] had call lights with a response time of longer than 15 minutes from 9/24/25 10/1/25 on: 9/30/25 at 1:38 PM 22 minutes and 22 seconds. 10/1/25 at 4:50 AM 24 minutes and 34 seconds.
On 10/2/25 at 1:45 PM the DON stated the facility's expectation was that call lights would be responded to
in less than 15 minutes.
On 10/2/25 at 2:00 PM the Administrator stated she expected the call lights would be responded to in less than 15 minutes. The Administrator acknowledged on the Alarm Response Report there were several call light times that were reported longer than 15 minutes.
Review of policy dated 10/31/24 titled, Call Light Response documented the objective was to ensure timely and efficient response to resident call lights, enhancing resident safety and satisfaction. Staff members were required to respond to resident call lights within 15 minutes of activation. Call light response data would be recorded and stored for a period of 7 days. This data would be reviewed regularly to identify patterns, improve response times and address any issues related to call light usage.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
F-Tag F0760
Federal health inspectors cited Bethany Lutheran Home in Council Bluffs, IA for a deficiency under regulatory tag F-F0760 during a standard health inspection conducted on 2025-10-02.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure that residents are free from significant medication errors.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of Bethany Lutheran Home.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-25.
F-Tag F0880
Federal health inspectors cited Bethany Lutheran Home in Council Bluffs, IA for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-10-02.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 8 deficiencies cited during this inspection of Bethany Lutheran Home.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-25.
Bethany Lutheran Home in Council Bluffs, IA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Council Bluffs, IA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Bethany Lutheran Home or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.