Nursing Care Index

Bethany Lutheran Home

Council Bluffs, Pottawattamie County, Iowa · CCN 165524 · Non-profit (Other) · not part of a chain

CMS rates Bethany Lutheran Home 1 of 5 overall as of August 2026. 112 certified beds, 95 residents a day on average. 43 citations on record from the current inspection cycles, 2 at immediate jeopardy; 3 fines totalling $46,914.

CMS’s ratings

The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.

Overall★☆☆☆☆ 1 of 5
Health inspections★☆☆☆☆ 1 of 5
Staffing★★★★☆ 4 of 5
Quality measures★★★☆☆ 3 of 5
Quality: long-stay / short-stay3 / 3 of 5

Staffing

Total nurse staffing3.98778 hours per resident per day
Registered nurses0.30457 hours per resident per day
Weekend total3.69574 hours per resident per day
Nursing staff turnover30.4% (registered nurses 50%)
Administrators who left0

Citations from health inspections

Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.

SurveyFindingSeverityStatus
2026-05-21
complaint survey
Protect each resident from the wrongful use of the resident's belongings or money.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0602
D No actual harm, with potential for more than minimal harm; isolated Past Non-Compliance
2025-10-02
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
J Immediate jeopardy to resident health or safety; isolated Past Non-Compliance
2025-07-21
2025-10-02 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
F No actual harm, with potential for more than minimal harm; widespread Deficient, Provider has date of correction
2025-11-25
2025-10-02
complaint survey
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-11-25
2025-10-02 Assess the resident when there is a significant change in condition
Resident Assessment and Care Planning Deficiencies · tag F0637
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-25
2025-10-02 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · tag F0644
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-25
2025-10-02 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-25
2025-10-02 Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-25
2025-10-02 Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-11-25
2025-05-30
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
G Actual harm that is not immediate jeopardy; isolated Past Non-Compliance
2025-04-05
2025-05-30
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Past Non-Compliance
2025-05-12
2025-03-13
complaint survey
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Past Non-Compliance
2025-02-14
2025-03-13
complaint survey
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609
D No actual harm, with potential for more than minimal harm; isolated Past Non-Compliance
2025-02-14
2025-03-13
complaint survey
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · tag F0657
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-24
2025-03-13
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-03-24
2024-10-31 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-01-02
2024-10-31 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Nursing and Physician Services Deficiencies · tag F0727
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-01-02
2024-10-31 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · tag F0812
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2025-01-02
2024-10-31 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies · tag F0623
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-02
2024-10-31 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Resident Rights Deficiencies · tag F0625
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-02
2024-10-31 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies · tag F0644
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-02
2024-10-31 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies · tag F0744
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-02
2024-10-31 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2025-01-02
2024-08-12
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2024-08-20
2024-08-12
complaint survey
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-08-20
2024-05-14
complaint survey
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2024-05-30
2024-05-14
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2024-05-30
2023-11-02
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
J Immediate jeopardy to resident health or safety; isolated Deficient, Provider has date of correction
2023-11-03
2023-11-02
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-11-03
2023-08-21
complaint survey
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · tag F0695
G Actual harm that is not immediate jeopardy; isolated Deficient, Provider has date of correction
2023-09-14
2023-08-21
complaint survey
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies · tag F0725
E No actual harm, with potential for more than minimal harm; pattern Deficient, Provider has date of correction
2023-09-14
2023-08-21
complaint survey
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · tag F0550
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-14
2023-08-21
complaint survey
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Resident Rights Deficiencies · tag F0585
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-14
2023-08-21 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Resident Rights Deficiencies · tag F0625
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-14
2023-08-21
complaint survey
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · tag F0656
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-14
2023-08-21
complaint survey
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · tag F0658
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-14
2023-08-21
complaint survey
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · tag F0684
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-14
2023-08-21
complaint survey
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · tag F0686
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-14
2023-08-21
complaint survey
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · tag F0689
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-14
2023-08-21
complaint survey
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · tag F0690
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-14
2023-08-21
complaint survey
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · tag F0698
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-14
2023-08-21
complaint survey
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · tag F0760
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-14
2023-08-21 Provide and implement an infection prevention and control program.
Infection Control Deficiencies · tag F0880
D No actual harm, with potential for more than minimal harm; isolated Deficient, Provider has date of correction
2023-09-14

Fines and payment denials

DatePenaltyAmount
2025-10-02Fine$16,588
2023-11-02Fine$11,183
2023-08-21Fine$19,143

Who owns and runs it

Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.

NameRoleShareSince
Bishop, Andrew
Individual
adp of the snf2024-07-01
Gustafson, Chandra
Individual
adp of the snf2023-12-29
Pfitzer, Genevieve
Individual
adp of the snf2025-06-21
Carlon, Diane
Individual
corporate director2024-01-01
Eilts, Susanne
Individual
corporate director2026-01-13
Goodell, Alice
Individual
corporate director2024-01-01
Kraul-Henkel, Becky
Individual
corporate director2026-01-13
Steensland, Greg
Individual
corporate director2025-01-12
Swalwell, John
Individual
corporate director2024-01-01
Worthington, Sharon
Individual
corporate director2021-09-01
Carlon, Diane
Individual
corporate officer2025-01-12
Steensland, Greg
Individual
corporate officer2026-01-13
Swalwell, John
Individual
corporate officer2026-01-13
Worthington, Sharon
Individual
corporate officer2026-01-13
Bishop, Andrew
Individual
operational/managerial control2024-07-01
Gustafson, Chandra
Individual
operational/managerial control2023-12-29
Pfitzer, Genevieve
Individual
operational/managerial control2025-06-21

What changed

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Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Pottawattamie County.