Iowa ›Council Bluffs

Bethany Lutheran Home

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Seven Elliott Street, Council Bluffs, IA 51503 (opens Google Maps) · Pottawattamie County · (712) 328-9500· 112 certified beds · avg 95 residents/day · certified since Nov 1, 2003 · Medicare and Medicaid certified

Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →

1/5
Health inspection rating (on-site)
inspected Oct 2, 2025
5
Serious findings on record
most recent Oct 2, 2025
$46,914
Fines, last 3 years
4.68
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

New to these records? How to read an inspection report →

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5 · how star ratings work →

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and quality measures from resident assessments and claims.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, isolated · Oct 2, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Jul 21, 2025 (Past Non-Compliance)

▲ Immediate jeopardy, isolated · Nov 2, 2023 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Nov 3, 2023 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · May 30, 2025 · F-0658 · triggered by a complaint

The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.

Why it matters: Care that falls below professional standards can directly harm a resident's health and recovery.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Apr 5, 2025 (Past Non-Compliance)

▲ Actual harm, isolated · Aug 12, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Aug 20, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Aug 21, 2023 · F-0695 · triggered by a complaint

The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.

Why it matters: Mistakes in breathing care can quickly become life-threatening for residents who depend on oxygen or equipment.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Sep 14, 2023 (Deficient, Provider has date of correction)

Inspection findings in the public record

Showing the latest 3 of 43 inspection findings. Open the full record below to read every finding.

  1. D · Potential for more than minimal harm, isolated

    The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint F-0602

  2. J · Immediate jeopardy, isolated

    The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint F-0689

  3. F · Potential for more than minimal harm, widespread

    The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. F-0880

View all 43 inspection findingsShow only the latest 3 findings

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.

DateSeverityWhat the facility was cited for
May 21, 2026D · Potential for more than minimal harm, isolatedThe facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint · F-0602
Oct 2, 2025▲ J · Immediate jeopardy, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Oct 2, 2025F · Potential for more than minimal harm, widespreadThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880
Oct 2, 2025E · Potential for more than minimal harm, patternThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint · F-0725
Oct 2, 2025D · Potential for more than minimal harm, isolatedThe facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. · F-0637
Oct 2, 2025D · Potential for more than minimal harm, isolatedThe facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · F-0644
Oct 2, 2025D · Potential for more than minimal harm, isolatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · F-0656
Oct 2, 2025D · Potential for more than minimal harm, isolatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658
Oct 2, 2025D · Potential for more than minimal harm, isolatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · F-0760
May 30, 2025▲ G · Actual harm, isolatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint · F-0658
May 30, 2025D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Mar 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint · F-0550
Mar 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint · F-0609
Mar 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint · F-0657
Mar 13, 2025D · Potential for more than minimal harm, isolatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint · F-0658
Oct 31, 2024E · Potential for more than minimal harm, patternThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · F-0725
Oct 31, 2024E · Potential for more than minimal harm, patternThe facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · F-0727
Oct 31, 2024E · Potential for more than minimal harm, patternThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · F-0623
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · F-0625
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · F-0644
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · F-0744
Oct 31, 2024D · Potential for more than minimal harm, isolatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880
Aug 12, 2024▲ G · Actual harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Aug 12, 2024D · Potential for more than minimal harm, isolatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint · F-0656
May 14, 2024E · Potential for more than minimal harm, patternThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint · F-0550
May 14, 2024D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Nov 2, 2023▲ J · Immediate jeopardy, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
Nov 2, 2023D · Potential for more than minimal harm, isolatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint · F-0658
Aug 21, 2023▲ G · Actual harm, isolatedThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint · F-0695
Aug 21, 2023E · Potential for more than minimal harm, patternThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint · F-0725
Aug 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint · F-0550
Aug 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint · F-0585
Aug 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · F-0625
Aug 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint · F-0656
Aug 21, 2023D · Potential for more than minimal harm, isolatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint · F-0658
Aug 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
Aug 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint · F-0686
Aug 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Aug 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint · F-0690
Aug 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint · F-0698
Aug 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint · F-0760
Aug 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (8 → 8).

Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2023
All citations: 16
Serious citations (G–L): 2
2024
All citations: 12
Serious citations (G–L): 1
2025
All citations: 14
Serious citations (G–L): 2
2026
All citations: 1
Serious citations (G–L): 0

All bars start at zero. Exact values and supporting details remain below.

YearCitationsSerious (G–L)Worst severity that year
2023162J ▲
2024121G ▲
2025142J ▲
202610D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

How to file a complaint about care →

3 fines totaling $46,914.

Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.

DateTypeAmount / length
Oct 2, 2025Fine$16,588
Nov 2, 2023Fine$11,183
Aug 21, 2023Fine$19,143

Nurse staffing (from payroll records, adjusted for how much care residents need)

What these staffing numbers mean →

Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilityIowa averageU.S. average
Total nurse staffing (hours per resident per day)
This facility: 4.68
Iowa average: 4.37
U.S. average: 3.95
Registered Nurse hours
This facility: 0.36
Iowa average: 0.85
U.S. average: 0.69
Weekend total nurse staffing
This facility: 4.34
Iowa average: 3.86
U.S. average: 3.50

All bars start at zero. Exact values and supporting details remain below.

MeasureThis facilityIowa avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)4.684.373.95top 32% in Iowa; top 19% in the U.S.
Registered Nurse hours0.360.850.69bottom 2% in Iowa; bottom 16% in the U.S.
Weekend total nurse staffing4.343.863.50top 23% in Iowa; top 15% in the U.S.
Weekend RN hours (not acuity-adjusted)0.330.510.48bottom 24% in Iowa; bottom 38% in the U.S.
Total nursing staff turnover (%)30.444.045.8top 18% in Iowa; top 15% in the U.S.
RN turnover (%)50.042.142.9bottom 41% in Iowa; bottom 39% in the U.S.

Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.99, RN 0.30, weekend 3.70.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.99 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 4/5.

Quality measures: assessments & claims

Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 3/5

Costs & payment

Price evidence · separate from quality

No verified facility-specific private-pay price is available in our data for Bethany Lutheran Home. CMS inspection and staffing records do not tell us what this home will charge you.

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Who owns this facility

How to read ownership records →

Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →

Non profit - Other

Owner / managerTypeRoleStakeSince
Bishop, AndrewIndividualOperational/Managerial ControlNOT APPLICABLE07/01/2024
Bishop, AndrewIndividualADP of the SNFNOT APPLICABLE07/01/2024
Carlon, DianeIndividualCorporate DirectorNOT APPLICABLE01/01/2024
Carlon, DianeIndividualCorporate OfficerNOT APPLICABLE01/12/2025
Eilts, SusanneIndividualCorporate DirectorNOT APPLICABLE01/13/2026
Goodell, AliceIndividualCorporate DirectorNOT APPLICABLE01/01/2024
Gustafson, ChandraIndividualOperational/Managerial ControlNOT APPLICABLE12/29/2023
Gustafson, ChandraIndividualADP of the SNFNOT APPLICABLE12/29/2023
Kraul-Henkel, BeckyIndividualCorporate DirectorNOT APPLICABLE01/13/2026
Pfitzer, GenevieveIndividualOperational/Managerial ControlNOT APPLICABLE06/21/2025
Pfitzer, GenevieveIndividualADP of the SNFNOT APPLICABLE06/21/2025
Steensland, GregIndividualCorporate DirectorNOT APPLICABLE01/12/2025
Steensland, GregIndividualCorporate OfficerNOT APPLICABLE01/13/2026
Swalwell, JohnIndividualCorporate DirectorNOT APPLICABLE01/01/2024
Swalwell, JohnIndividualCorporate OfficerNOT APPLICABLE01/13/2026
Worthington, SharonIndividualCorporate DirectorNOT APPLICABLE09/01/2021
Worthington, SharonIndividualCorporate OfficerNOT APPLICABLE01/13/2026

All 17 owning or managing parties CMS has on file are shown — none excluded.

Questions to ask on your visit

Full visit checklist →

Print visit checklist

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

  • "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
  • "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
  • "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
  • "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
  • "What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
  • "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
  • "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
  • "If my family member's health suddenly changes, how quickly do you reassess them and update their care?"

Also worth asking anywhere

  • "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
  • "Can I see the plan of correction for the findings in your most recent state inspection?"
  • "CMS reports 30% total nursing staff turnover here — who on the care team has been with you longest?"
  • "The ownership record on file lists 17 owning or managing parties — who makes the decisions about staffing levels?"
  • "Can I visit again unannounced, at a mealtime or on a weekend?"

Nearby facilities (12 closest of 31 within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Prairie Gate0.8 miCouncil Bluffs, IA★★☆☆☆2/5
North Crest Living Center0.8 miCouncil Bluffs, IA★☆☆☆☆1/5
Midlands Living Center L L C1.6 miCouncil Bluffs, IA★★★★☆3/5
Chapters Living of Council Bluffs2.4 miCouncil Bluffs, IA★☆☆☆☆1/5SFF
St. Joseph Villa Nursing Center6.0 miOmaha, NE★☆☆☆☆1/5
Ambassador Health of Omaha7.0 miOmaha, NE★★★★★4/5
The Cypress at Midtown8.0 miOmaha, NE★★★☆☆3/5
Douglas County Health Center8.2 miOmaha, NE★★★☆☆2/5
Emerald Nursing & Rehab Legacy Pointe LLC8.5 miOmaha, NE★☆☆☆☆1/5SFF
Florence Home8.7 miOmaha, NE★★★★☆3/5
Omaha Nursing and Rehabilitation Center9.6 miOmaha, NE★☆☆☆☆1/5
Emerald Nursing & Rehab Omaha9.7 miOmaha, NE★☆☆☆☆1/5SFF

Compare this facility with the 3 closest →

Other facilities in the same county

CMS records place this facility in Pottawattamie, IA — 7 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.

Listed by facility name — not a ranking. Homes already in the table above are not repeated here.

All facilities in Council Bluffs →

Facility data as of CMS processing date 2026-08-01. CCN 165524.

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