Inspection Reports for Bethany Lutheran Home
Seven Elliott Street, IA, 515030297
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 2, 2025 identified deficiencies in several areas including care planning, nursing staff sufficiency, medication management, infection control, and accident prevention. Earlier inspections showed a pattern of similar issues with care planning, medication administration, staffing levels, and resident dignity, with multiple substantiated complaints and some immediate jeopardy findings in prior years. Notable enforcement actions included removal of immediate jeopardy in late 2023 and fines were not listed in the available reports. Most complaint investigations were substantiated, often involving inadequate supervision, failure to follow physician orders, and dignity concerns. The facility’s inspection history shows ongoing challenges with care coordination and staffing, with no clear improvement trend in recent inspections.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
16.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
275% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
90 residents
Based on a October 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 90
Deficiencies: 8
Oct 2, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of multiple complaints and a facility-reported incident.
Findings
The facility was found deficient in several areas including failure to complete a significant change assessment, coordination of PASARR assessments, development and implementation of comprehensive care plans, provision of professional standards in services, free of accident hazards, sufficient nursing staff, and infection prevention and control. Multiple residents showed declines or risks that were not adequately addressed in care plans or assessments.
Complaint Details
The inspection included investigation of complaints #1657218-C, #2607003-C, #2632458-C, and a facility reported incident #2568153-I, all of which resulted in deficiencies.
Severity Breakdown
Level D: 5
Level E: 1
Level F: 1
Level J: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to complete a significant change assessment within 14 days after determining a significant change in a resident's condition. | Level D |
| Failure to coordinate PASARR assessments and reviews for residents with serious mental illness or related conditions. | Level D |
| Failure to develop and implement comprehensive care plans that meet regulatory requirements and professional standards. | Level D |
| Failure to provide services that meet professional standards of quality, including medication administration and nebulizer treatments. | Level D |
| Failure to ensure the resident environment remains free of accident hazards and provide adequate supervision to prevent accidents and elopement. | Level J |
| Failure to have sufficient nursing staff with appropriate competencies and skills to assure resident safety and care. | Level E |
| Failure to ensure residents are free of significant medication errors. | Level D |
| Failure to establish and maintain an infection prevention and control program including appropriate use of PPE and hand hygiene. | Level F |
Report Facts
Resident census: 90
Deficiencies cited: 8
Response times for call lights: Multiple call light response times recorded, ranging from 15 minutes to over 30 minutes.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Licensed Practical Nurse (LPN) | Named in findings related to medication administration and nebulizer treatments. |
| Staff C | Licensed Practical Nurse (LPN) | Interviewed regarding care plans and medication administration. |
| Staff P | Certified Nurse Aide (CNA) | Interviewed and observed assisting residents with care. |
| Staff D | Licensed Practical Nurse (LPN) | Involved in medication errors and administration. |
| Staff E | Certified Medication Aide (CMA) | Involved in medication errors and administration. |
| Staff G | Wound Care Nurse | Observed providing wound care and hygiene. |
| Staff J | Nurse | Observed performing catheter care and hygiene. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding medication administration and facility policies. |
| Administrator | Facility Administrator | Interviewed regarding policies and procedures. |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 2
May 30, 2025
Visit Reason
Investigation of complaints #127962-C, #127968-C, and facility reported incident #128348-I conducted from May 27, 2025 to May 30, 2025.
Findings
The facility failed to ensure the implementation of a morphine order for Resident #2 after a 30-day review, resulting in withdrawal symptoms and an emergency room visit. Additionally, the facility failed to transfer Resident #3 safely, resulting in injury to the resident's toe due to improper use of mechanical lift and inadequate staff assistance.
Complaint Details
The deficiencies resulted from investigation of complaints #127962-C, #127968-C, and facility reported incident #128348-I. Complaint #127968-C and incident #128348-I resulted in deficiencies. The facility corrected the deficiencies at the time of the survey; therefore, a plan of correction was not required.
Severity Breakdown
SS=G: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to implement morphine orders for Resident #2 after 30-day review, causing withdrawal symptoms and ER visit. | SS=G |
| Failure to transfer Resident #3 safely, resulting in injury to the resident's toe due to improper use of mechanical lift and inadequate staff assistance. | SS=D |
Report Facts
Census: 88
Duration without morphine: 11
BIMS score: 3
BIMS score: 15
Date range of survey: May 27, 2025 to May 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Registered Nurse Practitioner (ARNP) | Noted morphine order was not written on 3/20/2025 and later ordered dose to start same day after discovering omission. |
| Assistant Director of Nursing | ADON | Acknowledged failure to write morphine order and lack of nurse continuity; explained corrective actions. |
| Director of Nursing | DON | Explained the morphine order issue and acknowledged Resident #2 experienced opioid withdrawal. |
| Staff A | Certified Nursing Assistant (CNA) | Assisted Resident #3 with mechanical lift alone despite care plan requiring two staff; used outdated care sheet. |
| Staff B | Certified Nursing Assistant (CNA) | Assisted Resident #3 with mechanical lift on 5/29/2025. |
| Staff C | Certified Nursing Assistant (CNA) | Assisted Resident #3 with mechanical lift on 5/29/2025. |
| Staff D | Certified Medication Aide | Assisted Resident #3 with mechanical lift on 5/29/2025. |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 24, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, leading to certification effective March 24, 2025.
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 4
Mar 13, 2025
Visit Reason
Investigation of complaints #125820-C, #126615-C, #126722-C and facility reported incidents #125671-I, #126616-I, #127005-I and #126721-M conducted March 4, 2025 through March 13, 2025.
Findings
Complaints #126615-C and #126722-C and facility reported incident #125671-I were substantiated. The facility failed to treat Resident #3 with dignity during medication administration and failed to report an allegation of abuse involving Resident #3 within required timeframes. The facility also failed to revise care plans for residents with significant changes and failed to ensure residents' rights were protected.
Complaint Details
Complaints #126615-C and #126722-C were substantiated. Facility reported incident #125671-I was substantiated. The investigation revealed failure to treat Resident #3 with dignity, failure to report abuse allegations timely, and failure to revise care plans for residents with significant changes.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to treat Resident #3 with dignity during medication administration. | SS=D |
| Facility failed to report an allegation of abuse involving Resident #3 within 2 hours of the allegation. | SS=D |
| Facility failed to review and revise care plans for residents with significant changes (Residents #5 and #6). | SS=D |
| Facility failed to provide services in accordance with professional standards for Resident #3. | SS=D |
Report Facts
Resident census: 86
Medication administration refusals: 3
Care plans reviewed: 7
Medication administration audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Certified Medication Aide (CMA) | Named in medication administration and refusal incidents involving Resident #3 |
| Staff F | Certified Nursing Assistant (CNA) | Involved in incidents with Resident #3 including throwing Stanley cups and assisting with care |
| Staff B | Involved in incidents with Resident #3 and care plan discussions | |
| Staff C | Certified Medication Aide (CMA) | Administered medications and involved in refusal incidents with Resident #3 |
| Administrator | Administrator | Signed initial comments and stated investigation conclusions |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication administration and care plan issues |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding medication refusal and care plan issues |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 8, 2025
Visit Reason
The document is a Plan of Correction submitted following a credible allegation of substantial compliance to certify the facility in compliance with health requirements.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective January 2, 2025. The Discretionary Denial of Payment for New Admissions was not effectuated.
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 11
Dec 6, 2024
Visit Reason
A health comparative Federal Monitoring Survey (FMS) was conducted by the Centers for Medicare & Medicaid Services (CMS) on December 6, 2024, following an Iowa Department of Inspection and Appeals recertification survey on October 31, 2024.
Findings
The facility was found to have multiple deficiencies including failure to assess residents for self-administration of medications, failure to implement a tracking system for residents' laundered clothing, failure to provide choice in shower frequency, failure to maintain accurate accounting and records of personal funds, failure to provide proper notice before transfer or discharge, failure to ensure accuracy of resident assessments, failure to develop and implement comprehensive care plans, failure to maintain infection preventionist training, and failure to properly manage bed rails and respiratory care equipment.
Deficiencies (11)
| Description |
|---|
| Failure to assess one resident for self-administration of medications and lack of physician's order for self-administration. |
| Failure to implement a tracking and handling system to prevent loss of residents' laundered clothing. |
| Failure to provide choice in shower frequency for one resident. |
| Failure to ensure one resident received quarterly statements of personal funds. |
| Failure to provide proper written notice for transfer or discharge for three residents. |
| Failure to ensure accuracy of resident assessments for two residents. |
| Failure to develop and implement comprehensive care plans for residents, including timely completion and addressing specific needs. |
| Failure to maintain infection preventionist training and ensure infection prevention and control measures for all residents. |
| Failure to assess risks and benefits and obtain consent for use of bed rails for multiple residents. |
| Failure to provide proper respiratory care and maintain equipment for residents requiring oxygen and CPAP/Bi-PAP therapy. |
| Failure to properly manage psychotropic medication administration and documentation. |
Report Facts
Resident sample size: 20
Resident census: 81
Deficiency count: 11
Training days: 20
Audit period: 3
Audit frequency: 12
Inspection Report
Annual Inspection
Census: 85
Deficiencies: 8
Oct 31, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey with an investigation of a facility reported incident #124207-I.
Findings
The facility was found not in compliance with several requirements including failure to notify the Long-Term Care Ombudsman of resident transfers, failure to offer bed hold notices, failure to coordinate PASARR assessments, insufficient nursing staff and RN coverage, inadequate dementia care planning, improper food handling and infection control practices.
Complaint Details
Facility reported incident #124207-I was investigated and found not substantiated.
Severity Breakdown
SS=D: 5
SS=E: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to notify the Long-Term Care Ombudsman of a resident transfer to hospital. | SS=D |
| Failure to provide notice of bed hold policy and offer bed hold to resident or representative. | SS=D |
| Failure to coordinate PASARR Level II referrals for residents with newly evident serious mental disorders. | SS=D |
| Failure to provide sufficient nursing staff to respond to call lights in a timely manner. | SS=E |
| Failure to provide RN coverage for at least 8 consecutive hours a day, 7 days a week. | SS=E |
| Failure to provide appropriate treatment and services for dementia care. | SS=D |
| Failure to prepare, serve, and distribute food in accordance with professional food safety standards. | SS=E |
| Failure to implement infection prevention and control practices including medication administration, catheter care, and wound care. | SS=D |
Report Facts
Residents reviewed: 6
Residents reviewed: 2
Residents reviewed: 4
Facility census: 85
Call light response times: 59
Call light response times: 46
Call light response times: 42
Call light response times: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Registered Nurse | Observed pouring medications into bare hands during medication administration. |
| Staff J | Certified Nursing Assistant | Observed performing catheter care without proper hand hygiene and gown use. |
| Staff E | Licensed Practical Nurse | Observed performing wound care without proper hand hygiene and gown use. |
| Staff H | Cook | Observed improper glove use and hand hygiene during food preparation. |
| Director of Nursing | Interviewed regarding multiple deficiencies including PASARR, medication administration, infection control, and call light response. | |
| Administrator | Acknowledged staffing shortages and lack of RN coverage on specific dates. | |
| Staff Coordinator | Reported RN walkout and staffing issues. | |
| Staff D | Certified Nursing Assistant | Reported call light response times often exceeded 15 minutes. |
| Staff A | Registered Nurse | Reported call light response delays when short staffed. |
| Staff B | Certified Nursing Assistant | Reported inability to answer call lights timely when short staffed. |
| Staff C | Certified Nursing Assistant | Reported rushing care and inability to answer call lights timely when short staffed. |
| Staff F | Certified Nursing Assistant | Reported call lights run longer when residents have behaviors. |
| Staff G | Certified Nursing Assistant | Reported call lights run longer when residents repeatedly activate call lights. |
| Dining Services Manager | Interviewed regarding food handling and glove use deficiencies. |
Inspection Report
Re-Inspection
Deficiencies: 0
Aug 31, 2024
Visit Reason
An onsite revisit for the survey ending August 12, 2024 and a complaint investigation for facility reported incident #123062-I was conducted on August 30-31, 2024.
Findings
The facility was found to be in substantial compliance effective the plan of correction dated August 20, 2024.
Complaint Details
Complaint investigation related to incident #123062-I was conducted during the visit.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 2
Aug 12, 2024
Visit Reason
The inspection was conducted as a result of complaints #122185-C and #122255-I investigated from August 9, 2024 through August 12, 2024.
Findings
The facility was found to have deficiencies related to failure to follow the care plan for Resident #1, resulting in a fall and injury. The facility failed to provide adequate supervision and assistance with repositioning, leading to a resident fall and subsequent fracture. The facility provided a plan of correction including audits and staff education.
Complaint Details
Complaint #112185-C was substantiated with no deficiency. Facility reported incident #122255-I was substantiated.
Deficiencies (2)
| Description |
|---|
| Failure to develop and implement a comprehensive care plan consistent with resident needs, including measurable objectives and timeframes. |
| Failure to ensure the resident environment remains free of accident hazards and provide adequate supervision and assistance devices to prevent accidents. |
Report Facts
Deficiencies cited: 2
Census: 84
Fine Amount: 7750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Assisted Resident #1 with repositioning and involved in fall incident |
| Staff B | Certified Nursing Assistant (CNA) | Assisted Resident #1 with repositioning and stated preference not to hurt resident |
| Staff C | Certified Medication Aide (CMA) | Assisted Resident #1 with positioning and commented on staffing |
| Staff D | Certified Medication Aide (CMA) | Assisted Resident #1 with repositioning and commented on resident weight and staffing |
| Director of Nursing (DON) | Director of Nursing | Provided statements regarding care plan and staffing during fall incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 27, 2024
Visit Reason
A complaint investigation for complaint #121265-C was conducted from June 26, 2024 to June 27, 2024.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint #121265-C was investigated and the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
May 30, 2024
Visit Reason
The document serves as a Plan of Correction following a survey, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, leading to certification effective May 30, 2024.
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 2
May 14, 2024
Visit Reason
Investigation of complaints #120633-C and #120634-C and facility reported incidents #118050-1, #119386-1, #119957-1, #120251-1, #120639-1, #120640-1, and #120641-1 conducted May 7, 2024 through May 14, 2024.
Findings
The facility failed to treat 5 residents with dignity and respect during transfers and showers, and failed to provide adequate supervision and assistance during mechanical lift transfers for 2 residents, resulting in substantiated complaints and incidents.
Complaint Details
Complaints #120633-C and #120634-C were substantiated. Facility reported incidents #119386-1, #120639-1, #120640-1, and #120641-1 were substantiated.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to treat residents #2, #5, #6, #7, and #8 with dignity and respect during transfers to and from showers, including exposing residents inappropriately. | SS=E |
| Failure to provide adequate supervision and assistance during mechanical lift transfers for residents #5 and #6, including use of lifts by single staff member contrary to policy. | SS=D |
Report Facts
Residents involved: 5
Residents involved: 2
Facility census: 85
Audit frequency: 3
Audit frequency: 1
Audit review period: 3
Mechanical lift transfer audits: 3
Mechanical lift transfer audits: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Agency Certified Nursing Assistant | Named in dignity and respect deficiency for exposing Resident #2 and Resident #7 during shower transfers. |
| Staff E | Certified Nursing Assistant | Named in mechanical lift transfer deficiency for transferring Resident #5 alone and improper handling causing resident distress. |
| Staff C | Certified Nursing Assistant | Named in mechanical lift transfer deficiency for transferring Resident #5 alone and causing injury to resident's hands. |
| Director of Nursing | Administrator | Interviewed residents and staff, confirmed deficiencies and corrective actions. |
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 29, 2023
Visit Reason
A revisit of the survey ending November 2, 2023 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities effective November 3, 2023.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Nov 2, 2023
Visit Reason
The inspection was conducted as a result of investigations of two substantiated complaints (#116541-C and #116581-C) regarding quality of care and medication administration at Bethany Lutheran Home.
Findings
The facility failed to follow physician orders for medication administration and failed to properly assess and intervene when a resident became unresponsive after receiving Oxycodone. The resident was transported to the emergency room after Narcan administration due to suspected overdose. The facility was cited for not completing assessments and notifying physicians of changes in condition as required by professional standards.
Complaint Details
Complaint #116541-C and #116581-C were substantiated. Immediate Jeopardy was identified starting October 20, 2023 and removed on November 1, 2023 after corrective actions were implemented.
Deficiencies (2)
| Description |
|---|
| Failed to provide professional standard of quality by not following physician orders for medication administration for 1 of 5 residents reviewed. |
| Failed to ensure a resident received treatment and care in accordance with professional standards of practice, including failure to complete assessment and intervene with a significant change in condition. |
Report Facts
Facility Census: 90
Medication Dosage: 5
Medication Administration Times: 3
Blood Pressure: 62
Pulse: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nurse | Named in failure to assess and intervene after medication administration and failure to respond to resident's wife concerns |
| Director of Nursing | Director of Nursing | Provided statements on facility expectations and re-education of staff |
| Assistant Director of Nursing | Assistant Director of Nursing | Participated in re-education of nursing staff |
| Staff D | Aide | Witnessed resident condition and interactions with Staff A and resident's wife |
| Physician Assistant | Physician Assistant | Provided clinical assessment at clinic and described resident's unresponsiveness and Narcan administration |
| Staff F | Van Driver | Transported resident to clinic and observed resident's confused state |
| Police Detective | Police Detective | Interviewed resident's wife and staff regarding incident |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 12, 2023
Visit Reason
A revisit of the Recertification and Complaint Survey ending August 21, 2023 was conducted from October 10, 2023 to October 12, 2023 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective the original plan of correction date September 14, 2023.
Report Facts
Survey end date: Aug 21, 2023
Plan of correction date: Sep 14, 2023
Inspection Report
Annual Inspection
Census: 87
Deficiencies: 14
Aug 21, 2023
Visit Reason
The inspection was conducted as an annual recertification survey including investigation of multiple complaints and facility reported incidents.
Findings
The facility was found deficient in multiple areas including resident privacy during personal care, grievance handling, bed hold policy compliance, comprehensive care planning, quality of care related to positioning, pressure ulcer treatment, accident prevention and supervision, catheter and incontinence care, respiratory care, dialysis services, sufficient nursing staff, medication administration, and infection prevention and control.
Complaint Details
The visit included investigation of complaints #111765-C, #111884-C, #111890-C, #113791-C, #114562-C, and #114728-C. Complaints #111765-C, #111884-C, #111890-C, #113791-C, and #114562-C were substantiated. Complaint #114728-C was not substantiated. Facility reported incidents #113220-I and #114555-I were substantiated.
Severity Breakdown
Level 3: 14
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to provide privacy during personal cares to 1 of 3 residents reviewed (Resident #10). | Level 3 |
| Failed to ensure grievances were reported and followed through for 1 of 1 residents reviewed (Resident #195). | Level 3 |
| Failed to obtain a bed hold within 24 hours of hospitalization for 3 of 5 residents reviewed (Residents #1, #52, #65). | Level 3 |
| Failed to implement comprehensive care plans related to pain, infection, and transfers for 3 of 18 residents reviewed (Residents #23, #52, #72). | Level 3 |
| Failed to adhere to professional standards for assessing and diagnosing a resident with a new antipsychotic medication order (Resident #39). | Level 3 |
| Failed to provide proper positioning in a wheelchair of appropriate size for 1 of 1 resident reviewed (Resident #53). | Level 3 |
| Failed to provide necessary treatment to prevent developing avoidable pressure ulcers for 1 of 2 residents reviewed (Resident #25). | Level 3 |
| Failed to prevent unsupervised falls and failed to provide transfers with appropriate number of staff for 3 of 3 residents reviewed (Residents #1, #9, #72). | Level 3 |
| Failed to ensure a resident was not catheterized unless clinically necessary, failed to provide appropriate care to prevent urinary tract infections, and failed to provide incontinence care for 2 of 2 residents reviewed (Residents #76, #10). | Level 3 |
| Failed to provide respiratory care by sending a resident to an appointment without oxygen when oxygen was required (Resident #192). | Level 3 |
| Failed to provide dialysis services consistent with professional standards by not completing a post dialysis assessment (Resident #84). | Level 3 |
| Failed to answer call lights in a timely manner for 4 of 18 residents reviewed (Residents #50, #72, #10, #195). | Level 3 |
| Failed to ensure residents were free of significant medication errors including improper nebulizer medication administration for 3 of 3 residents reviewed (Residents #10, #62, #191). | Level 3 |
| Failed to perform hand hygiene during toileting and/or incontinence care for 2 of 8 residents reviewed (Residents #72, #10). | Level 3 |
Report Facts
Complaints investigated: 6
Facility reported incidents investigated: 2
Residents reviewed: 18
Residents reviewed for call light response: 18
Residents reviewed for medication errors: 3
Residents reviewed for catheter and incontinence care: 2
Residents reviewed for falls: 3
Residents reviewed for pressure ulcers: 2
Residents reviewed for respiratory care: 1
Residents reviewed for dialysis: 1
Residents reviewed for medication administration: 3
Residents reviewed for hand hygiene: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Certified Nurse Aide | Named in privacy during personal care finding and incontinence care observation |
| Staff P | Certified Nurse Aide | Named in privacy during personal care finding and incontinence care observation |
| Director of Nursing | Director of Nursing | Named in multiple findings including privacy, grievance, bed hold, care planning, medication administration, hand hygiene, and call light response |
| Staff T | Named in grievance finding | |
| Staff U | Housekeeping and Laundry Supervisor | Named in grievance finding |
| Staff V | Social Worker | Named in grievance finding |
| Staff F | Registered Nurse | Named in respiratory care and medication administration findings |
| Staff DD | Named in dialysis care finding | |
| Staff G | Registered Nurse | Named in medication administration finding |
| Staff EE | Named in medication administration finding | |
| Staff Z | Registered Nurse | Named in respiratory care finding |
| Staff A | Named in medication administration finding | |
| Staff Y | Named in incontinence care observation | |
| Staff X | Named in incontinence care observation | |
| Staff C | Certified Nurse Assistant | Named in incontinence care observation |
| Staff H | Certified Nurse Assistant | Named in call light response finding |
| Staff I | Licensed Practical Nurse | Named in call light response finding |
| Staff J | Director of Nursing | Named in fall prevention and call light response findings |
| Staff L | Certified Nurse Aide | Named in fall prevention and accident prevention findings |
| Staff M | Certified Nurse Aide | Named in accident prevention finding |
| Staff N | Certified Nurse Aide | Named in accident prevention finding |
| Staff Q | Certified Nurse Aide | Named in accident prevention finding |
| Staff R | Named in accident prevention finding | |
| Staff CC | Named in oxygen storage finding |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 6
Mar 8, 2023
Visit Reason
The inspection was conducted as an investigation of multiple complaints and a facility reported incident between February 17 and March 8, 2023, including a COVID-19 focused infection control survey.
Findings
The facility was found to have multiple deficiencies related to resident rights, abuse prevention, oral care, quality of care, and pressure ulcer prevention. Several complaints were substantiated, including failure to treat residents with dignity and respect, failure to investigate abuse allegations thoroughly, and inadequate oral and skin care. The facility was found to be in compliance with COVID-19 infection control requirements.
Complaint Details
The investigation involved complaints 110843-C, 110852-C, 110848-C, 111233-C, 111300-C, and 111409-C, and a facility reported incident 110891-I. Complaints 110843-C, 110852-C, 110848-C, 111300-C, and 111409-C were substantiated, while complaint 111233-C was not substantiated.
Severity Breakdown
SS=D: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to treat residents with dignity and respect, including interference with residents' rights and retaliation by staff. | SS=D |
| Failure to develop and implement abuse/neglect policies and procedures, including investigation and reporting of abuse allegations. | SS=D |
| Failure to investigate and prevent alleged abuse, neglect, exploitation, or mistreatment thoroughly. | SS=D |
| Failure to provide adequate oral care for residents. | SS=D |
| Failure to provide quality care, including incomplete assessments during COVID-19 and failure to complete resident assessments. | SS=D |
| Failure to provide adequate care to prevent and treat pressure ulcers, including failure to assess and document wounds properly. | SS=D |
Report Facts
Total Residents: 85
BIMS score: 15
BIMS score: 9
Pressure ulcer measurement: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Named in findings related to resident abuse and retaliation. |
| Staff G | Social Worker | Provided statements regarding resident abuse allegations. |
| Director of Nursing (DON) | Director of Nursing | Spoke with residents and staff regarding abuse allegations and facility compliance. |
| Staff C | Certified Nursing Assistant (CNA) | Witness and involved in abuse investigation. |
| Staff D | Certified Nursing Assistant (CNA) | Witness and involved in abuse investigation. |
| Staff E | Kitchen Worker/Dietary Aide | Witness and involved in abuse investigation. |
| Staff B | Registered Nurse (RN) | Witness and involved in abuse investigation. |
| Staff N | Licensed Practical Nurse (LPN) | Provided statements regarding resident care and skin assessments. |
| Staff M | Certified Medication Aide (CMA) | Provided statements regarding oral care and resident treatment. |
| Staff L | Nurse | Performed skin assessments and provided wound care. |
| Staff F | Licensed Practical Nurse (LPN) | Performed wound assessment and care. |
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 6, 2023
Visit Reason
A revisit was conducted following a previously reported incident and complaint investigation that ended on October 17, 2022.
Findings
All deficiencies identified in the prior investigation were corrected, and the facility was found to be in substantial compliance effective December 21, 2022.
Complaint Details
The visit was related to a complaint investigation that was resolved with all deficiencies corrected.
Inspection Report
Re-Inspection
Deficiencies: 0
Jan 6, 2023
Visit Reason
A revisit of the facility reported incident and complaint investigation that ended on December 8, 2022 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective December 21, 2022.
Complaint Details
The visit was a follow-up to a complaint investigation that ended on December 8, 2022; all deficiencies were corrected.
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 4
Dec 8, 2022
Visit Reason
The inspection was conducted as an investigation of complaints 108448-C, 108599-C, and 109186-C from November 28 to December 7, 2022.
Findings
The facility was found to have deficiencies related to failure to develop and implement comprehensive care plans, failure to obtain vital signs daily as required, failure to complete pre and post dialysis assessments, and failure to ensure residents were free of significant medication errors. Immediate Jeopardy was identified but later removed after corrective actions.
Complaint Details
The investigation involved complaints 108448-C (not substantiated), 108599-C (substantiated), and 109186-C (substantiated).
Severity Breakdown
Immediate Jeopardy (removed): 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to develop and implement a comprehensive person-centered care plan including measurable objectives and timeframes. | — |
| Failure to obtain vital signs daily in accordance with the resident's care plan for 1 of 3 residents reviewed (Resident #1). | — |
| Failure to complete pre and post dialysis assessments as required for 1 of 3 residents reviewed (Resident #1). | — |
| Failure to ensure residents were free of significant medication errors for 1 of 4 residents reviewed (Resident #2), including failure to administer medications as ordered and failure to obtain required lab tests. | Immediate Jeopardy (removed) |
Report Facts
Resident census: 92
Number of residents reviewed for vital signs deficiency: 3
Number of residents reviewed for medication errors: 4
Dates of survey completion: Survey completed on 2022-12-08
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to findings on dialysis assessments and medication administration |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 5
Oct 17, 2022
Visit Reason
The inspection was conducted as an investigation of multiple complaints (105482-C, 106459-C, 106881-C, 107421-C, 107660-C) and self-reports related to the facility.
Findings
The facility was found deficient in meeting professional standards related to medication administration and resident care, including failure to ensure staff followed physician orders for medications and failure to provide resident-centered care and services. Several residents' care plans and clinical records lacked proper documentation and assessments.
Complaint Details
Complaints 106459-C, 106881-C, 107421-C, and 107660-C and facility reported incidents 105318-I and 107641-I were substantiated. Complaint 105482-C was not substantiated. Facility reported incident 105366-I was not substantiated.
Deficiencies (5)
| Description |
|---|
| Facility failed to ensure staff followed physician orders related to medications for 4 of 5 residents reviewed. |
| Facility failed to provide resident-centered care and services, including bathing opportunities for 2 of 3 residents reviewed. |
| Facility failed to provide timely assessments for 4 of 5 residents reviewed. |
| Facility failed to ensure sufficient nursing staff with appropriate competencies and skills. |
| Facility failed to provide quality care related to skin integrity and wound care. |
Report Facts
Residents reviewed: 5
Residents reviewed: 3
Residents reviewed: 5
Census: 88
BIMS score: 15
Deficiency completion date: Multiple corrective action completion dates listed as 12-19-2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Stated facility does not have residents who can self-administer medications and discussed medication administration processes. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Discussed bathing expectations and documentation. |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 12, 2022
Visit Reason
The document serves as a plan of correction following a prior inspection, indicating acceptance of a credible allegation of compliance and certifying the facility as in compliance effective July 12, 2022.
Findings
The facility was found to be in compliance based on the acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 1, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction for Bethany Lutheran Home, indicating acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was certified as in compliance effective July 1, 2022, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 3
Jun 23, 2022
Visit Reason
The inspection was conducted as a result of complaints #104948-C, #105020-C, #105148-C, #105163-C, and #105197-C between June 10, 2022 and June 23, 2022. Complaint #105020-C was substantiated while the others were not.
Findings
The facility failed to ensure quality of care related to a resident fall and subsequent injury, and failed to provide sufficient nursing staff to answer call lights in a timely manner. Infection prevention and control deficiencies were also identified, including improper mask usage and failure to follow infection control guidelines. The facility reported a census of 77 residents.
Complaint Details
Complaint #105020-C was substantiated. Complaints #104948-C, #105148-C, #105163-C, and #105197-C were not substantiated.
Deficiencies (3)
| Description |
|---|
| Quality of care failure related to resident #7's fall and injury, including inadequate assessment and improper handling by staff. |
| Insufficient nursing staff to answer call lights timely, with documented delays up to 32 minutes. |
| Infection prevention and control deficiencies including improper mask wearing and failure to follow infection control procedures for resident #3. |
Report Facts
Resident census: 77
Call light response times: 32
Number of complaints investigated: 5
Number of substantiated complaints: 1
Dates of complaint investigation: June 10, 2022 to June 23, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Unit Manager | Documented findings related to resident #7's fall and injury, and infection control observations |
| Staff H | Licensed Practical Nurse (LPN) | Documented resident #7's fall incident and handling |
| Staff J | Certified Nursing Assistant (CNA) | Involved in resident #7's fall incident and handling |
| Director of Nursing | Director of Nursing | Interviewed regarding staff expectations and call light response |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 6
Jun 9, 2022
Visit Reason
A Recertification and Complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the Iowa Department of Inspections and Appeals. The survey was triggered by substantiated complaints 104771 and 104908.
Findings
The facility was found not in substantial compliance with 42 CFR 483 subpart B, with deficiencies related to failure to determine residents' advanced directives, improper Medicaid/Medicare coverage notices, incomplete comprehensive care plans, inadequate bed rail assessments, and lack of a certified infection preventionist. The facility failed to meet requirements for documentation, resident rights, and infection control.
Complaint Details
Complaints 104771 and 104908 were substantiated.
Deficiencies (6)
| Description |
|---|
| Failure to determine whether residents had an advanced directive for six of seven residents reviewed. |
| Failure to complete correct Medicaid/Medicare coverage notices for residents. |
| Failure to develop a comprehensive care plan for one resident regarding side rails. |
| Failure to assess and obtain physician orders and consents for bed rail use for one resident. |
| Failure to designate a certified infection preventionist responsible for the infection control program. |
| Failure to conduct regular inspections of all bed frames, mattresses, and bed rails to identify areas of possible entrapment. |
Report Facts
Survey Census: 78
Sample Size: 19
Correction Date: Jul 1, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracey Gabehart | Administrator | Signed the plan of correction |
| Melissa Jack | Infection Preventionist | Named as the infection preventionist with certification planned by 7/5/2022 |
Inspection Report
Plan of Correction
Deficiencies: 0
May 19, 2022
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and demonstrate compliance for certification.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification effective May 9, 2022. No specific deficiencies or severity levels are detailed in the report.
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 2
Apr 19, 2022
Visit Reason
The inspection was conducted as an investigation of complaints 102594-C, 103686-C, 103712-C, 103742-C, and 103744-C from April 7 to April 19, 2022.
Findings
The facility failed to follow physician orders for two residents, failed to provide sufficient nursing staff to ensure timely response to call lights and adequate eating assistance for residents, and had substantiated complaints related to these issues. Specific deficiencies included failure to administer nutritional supplements and treatments, failure to provide timely toileting assistance, and inadequate staffing levels.
Complaint Details
The investigation involved five complaints (102594-C, 103686-C, 103712-C, 103742-C, and 103744-C), all of which were substantiated. Complaints included failure to follow physician orders, insufficient staffing, and failure to respond to call lights in a timely manner.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to follow physician orders for 2 of 3 residents reviewed, including failure to administer Ensure Enlive supplement and sitz baths as ordered. | SS=D |
| Facility failed to provide sufficient nursing staff to ensure call lights were answered timely and residents received eating assistance for 3 of 4 residents reviewed. | SS=D |
Report Facts
Weight loss: 10.8
Weight loss percentage: 6.2
Weight loss: 23.2
Weight loss percentage: 12
Residents reviewed: 3
Residents reviewed: 4
Residents census: 75
Call light response time expectation: 10
Staffing shortfall: 6
Staffing shortfall: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurse Aide (CNA) | Reported working alone responsible for up to 32 residents and insufficient staffing to assist Resident #1 with meals. |
| Staff D | Agency CNA | Failed to respond appropriately to Resident #2's call light and was told not to return to the facility. |
| Staff E | Certified Nurse Aide (CNA) | Assisted Resident #2 on commode and reported other staff's failure to communicate resident status. |
| Staff C | Certified Nurse Aide (CNA) | Reported call lights could be on for 30 to 45 minutes due to insufficient staffing. |
| Assistant Director of Nursing (ADON) | Confirmed failure to provide sitz baths, acknowledged insufficient staffing, and described ongoing investigations and corrective actions. | |
| Staffing Coordinator | Reported insufficient staffing and challenges scheduling agency staff. |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 1, 2022
Visit Reason
A second revisit was conducted via desk review regarding the investigation of multiple complaints and facility reported incidents.
Findings
Based on acceptance of the credible allegation of compliance and plan of correction, the facility will be certified in compliance effective March 1, 2021.
Complaint Details
The revisit was related to investigations of complaints 90477-C, 92266-C, 94717-C, 95012-C, 96000-C, 96434-C, 97328-C, 99473-C, and 100254-C, and facility reported incidents 92298-I, 95854-M, 99146-I, 99453-I, 99692-I, 100109-I, 100449-I.
Inspection Report
Complaint Investigation
Census: 95
Deficiencies: 2
Jan 28, 2022
Visit Reason
The inspection was conducted as a first revisit related to the investigation of multiple complaints (90477-C, 92266-C, 94717-C, 95012-C, 96000-C, 96434-C, 97328-C, 99473-C, 100254-C) and facility-reported incidents.
Findings
The facility failed to provide adequate bathing opportunities for residents, with documentation showing residents refused or were not offered baths on scheduled days. Additionally, the facility failed to ensure a safe environment when transporting residents in wheelchairs without foot pedals, and staff failed to properly use and audit wheelchair foot pedals. Staff education and audits were initiated to address these issues.
Complaint Details
The visit was a first revisit related to multiple complaints. The facility was found noncompliant in bathing services and safe wheelchair use. The complaints were substantiated based on record reviews, observations, and staff interviews.
Deficiencies (2)
| Description |
|---|
| Failure to provide adequate bathing opportunities for residents #4 and #5, with missing documentation and refusals. |
| Failure to ensure a safe environment during transport of residents #7 and #10 in wheelchairs without foot pedals. |
Report Facts
Resident census: 95
BIMS score: 15
BIMS score: 14
BIMS score: 8
BIMS score: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Certified Nursing Assistant | Reported on bathing documentation and acknowledged foot pedal application |
| Staff A | Certified Nursing Assistant | Reported on bathing frequency and challenges |
| Staff B | Hospice Certified Nursing Assistant | Observed assisting resident to shower room without foot pedals |
| Staff G | Hospice Registered Nurse | Assisted resident to shower room without foot pedals |
| Staff C | Licensed Practical Nurse | Found foot pedals and attempted to attach to wheelchair |
| Staff H | Conducted wheelchair pedal audits and education | |
| Director of Nursing | Director of Nursing | Provided bathing spreadsheet and education, acknowledged documentation issues |
| Administrator | Administrator | Reported ongoing staff documentation issues and audit completion |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 6
Dec 1, 2021
Visit Reason
The inspection was conducted as a result of complaints and facility-reported incidents related to resident care and rights, including allegations of neglect and dignity violations.
Findings
The investigation substantiated multiple complaints regarding failure to provide incontinence care, transfer and assistance in a kind and considerate manner, and failure to provide dignity bags for urinary drainage bags. Additional findings included inadequate bathing assistance and supervision, rough handling of residents, and failure to prevent accidents and wandering risks.
Complaint Details
Complaints 90477-C, 92266-C, 94717-C, 95012-C, 96000-C, 96434-C, 97328-C, 99473-C, and facility reported incidents 92298-I, 95854-M, 99146-I, 99453-I, 99692-I, 100109-I, 100449-I were substantiated.
Deficiencies (6)
| Description |
|---|
| Failure to provide incontinence care and transfer assistance in a kind and considerate manner for multiple residents. |
| Failure to provide dignity bags for urinary drainage bags as required. |
| Failure to provide adequate bathing opportunities for residents. |
| Failure to prevent accidents and ensure adequate supervision and assistance devices to prevent hazards. |
| Failure to adequately monitor and prevent wandering and elopement risks. |
| Failure to provide respectful and dignified care, including rough handling and verbal mistreatment of residents. |
Report Facts
Census: 89
Residents reviewed: 7
Residents reviewed: 9
Residents reviewed: 5
Inspection Report
Abbreviated Survey
Census: 64
Deficiencies: 0
Dec 23, 2020
Visit Reason
A focused COVID-19 infection control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 64
Inspection Report
Abbreviated Survey
Census: 64
Deficiencies: 0
Dec 23, 2020
Visit Reason
A focused COVID-19 infection control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 64
Inspection Report
Abbreviated Survey
Census: 77
Deficiencies: 1
Nov 24, 2020
Visit Reason
A focused COVID-19 Infection Control Survey was conducted from November 24 to December 1, 2020, by the Department of Inspections and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found not in compliance with infection prevention and control requirements, including failure of staff to wear appropriate Personal Protective Equipment (PPE) while cleaning resident rooms on the Skyline Yellow unit. The facility reported 18 positive COVID-19 cases at the time of the survey.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure of facility staff to wear appropriate PPE while cleaning resident rooms on the Skyline Yellow unit. | SS=D |
Report Facts
Total residents: 77
Positive COVID-19 cases: 18
Inspection Report
Routine
Census: 121
Deficiencies: 0
Jun 18, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. Complaint #91507-C was not substantiated.
Complaint Details
Complaint #91507-C was investigated and found not substantiated.
Report Facts
Total residents: 121
Inspection Report
Annual Inspection
Census: 107
Deficiencies: 11
Feb 17, 2020
Visit Reason
The inspection was conducted as part of the facility's annual health survey and investigation of facility reported incidents and complaints.
Findings
The facility was found deficient in updating advanced directive statuses, notifying physicians and representatives of significant changes, maintaining accurate assessments, ensuring infection control practices, and providing adequate supervision to prevent accidents. Several residents had discrepancies in code status documentation, delayed antibiotic initiation, inaccurate MDS documentation, and pressure ulcer care issues.
Complaint Details
Complaint 86903-C and facility reported incident 89153-1 were substantiated. Complaints 88172-C, 89184-C, and 87905-C were not substantiated.
Deficiencies (11)
| Description |
|---|
| Failed to update advanced directive status for residents #51 and #102, with discrepancies between electronic health records, door magnets, and signed directives. |
| Failed to notify physician and resident representative of significant changes for residents #100 and #115. |
| Failed to maintain a safe, clean, and comfortable environment; resident #73's wheelchair was dirty and in need of cleaning. |
| Failed to obtain a record check evaluation from the Department of Human Services for Staff I prior to hire. |
| Failed to notify the Ombudsman of resident #106's discharge from the facility following hospitalization. |
| Failed to complete accurate and timely comprehensive and significant change assessments for residents #15, #44, and #100. |
| Failed to accurately document medications with diagnoses on MDS for residents #3, #34, #92, and #100. |
| Failed to initiate antibiotic therapy timely for resident #62 after hospital readmission. |
| Failed to provide necessary treatment and services to promote healing and prevent infection of pressure ulcers for resident #115. |
| Failed to provide adequate supervision and assistive devices to prevent accidents for residents #3, #70, and #93; wheelchairs lacked foot pedals or were improperly used. |
| Failed to assure appropriate infection control practices for residents #15, #42, #109, and #111, including improper handling of medications and gloves. |
Report Facts
Residents reviewed: 31
Census: 107
Deficiency counts: 11
MDS BIMS scores: 6
Pressure ulcer size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Employee with missing DHS record check prior to hire | |
| Staff G | Registered Nurse | Named in infection control deficiency related to medication handling |
| Staff D | Licensed Practical Nurse / MDS Coordinator | Named in MDS documentation deficiencies |
| Staff F | Social Worker | Named in complaint investigation and Ombudsman notification deficiency |
| Staff N | Registered Nurse | Named in pressure ulcer treatment deficiency |
| Staff A | Certified Nursing Assistant | Named in infection control deficiency related to catheter care |
| Staff B | Certified Nursing Assistant | Named in infection control deficiency related to catheter care |
| Staff C | Certified Nursing Assistant | Named in wheelchair safety deficiency |
| Staff M | Licensed Practical Nurse | Named in wheelchair safety deficiency |
| Staff O | Certified Nursing Assistant | Named in pressure ulcer care deficiency |
| Staff S | Certified Medication Aide | Named in pressure ulcer care deficiency |
| Staff T | Registered Nurse Wound Nurse | Named in pressure ulcer care deficiency |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including advanced directives, infection control, and pressure ulcer care |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in multiple deficiencies including advanced directives, infection control, and pressure ulcer care |
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