Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Bethany Lutheran Home
Council Bluffs, IA · 112 certified beds · Last Life Safety survey October 2, 2025
CMS Certification Number 165524 · first certified November 2003
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Other
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IA
13 citations — more than 53% of the 387 certified nursing homes in IA. Compared within IA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: August 2026 to October 2026. This facility’s last Life Safety survey was October 2025. Facilities in IA are typically surveyed 11–13 months after the last one (median 12), measured over 700 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
8 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 13 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in IA, and nationally. Surveyors differ markedly between states, so the IA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 13 |
| Median facility in IA | 12 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 21, 2023 | 4 |
| October 31, 2024 | 5 |
| October 2, 2025 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 3 | 2025-10-02 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-10-02 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 2 | 2025-10-02 |
| K-0923 | Have proper medical gas storage and administration areas. | 2 | 2024-10-31 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2024-10-31 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2023-08-21 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2025-10-02 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2024-10-31 |
What the citations cover
- Miscellaneous Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 1
- Smoke Deficiencies 1
| Category | Citations |
|---|---|
| Miscellaneous Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 1 |
| Smoke Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 2, 2025 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 1, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (October 1, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (October 1, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 1, 2025) |
October 31, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 7, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (November 13, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 19, 2024) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (November 27, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (November 5, 2024) |
August 21, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (September 6, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (September 6, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (September 6, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (September 6, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.