Bethany Lutheran Home

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.

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.

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.

jeopardy to resident health or safety

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/02/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Bethany Lutheran Home

Seven Elliott Street Council Bluffs, IA 51503

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

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.

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.