Bethany Lutheran Home
Seven Elliott Street · Council Bluffs, IA · 51503 · 7123289500
112 certified beds Non profit - Other
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $16,588 in fines in the last 24 months.
- 3 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 4 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 3.92 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.34 | 0.55–0.75 |
| Weekend hours / resident-day | 3.52 | ≈ weekday level |
| Nursing turnover / year | 36% | median 45% |
| Fines (3-yr window) | 3 · $46,914 |
Inspection citations (42 in the current record)
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Immediate jeopardy · J October 2, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 21, 2025 · Quality of Life and Care
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Potential for harm · D October 2, 2025
Assess the resident when there is a significant change in condition
Corrected November 25, 2025 · Resident Assessment and Care Planning
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Potential for harm · D October 2, 2025
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected November 25, 2025 · Resident Assessment and Care Planning
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Potential for harm · D October 2, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected November 25, 2025 · Resident Assessment and Care Planning
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Potential for harm · D October 2, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected November 25, 2025 · Resident Assessment and Care Planning
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Potential for harm · D October 2, 2025
Ensure that residents are free from significant medication errors.
Corrected November 25, 2025 · Pharmacy Service
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Potential for harm · F October 2, 2025
Provide and implement an infection prevention and control program.
Corrected November 25, 2025 · Infection Control
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Potential for harm · E October 2, 2025 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected November 25, 2025 · Nursing and Physician Services
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Actual harm · G May 30, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected April 5, 2025 · Resident Assessment and Care Planning
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Potential for harm · D May 30, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 12, 2025 · Quality of Life and Care
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Potential for harm · D March 13, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected February 14, 2025 · Resident Rights
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Potential for harm · D March 13, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected February 14, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 13, 2025 · found via complaint
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected March 24, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 13, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected March 24, 2025 · Resident Assessment and Care Planning
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Potential for harm · D October 31, 2024
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected January 2, 2025 · Resident Rights
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Potential for harm · D October 31, 2024
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.
Corrected January 2, 2025 · Resident Rights
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Potential for harm · D October 31, 2024
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected January 2, 2025 · Resident Assessment and Care Planning
-
Potential for harm · E October 31, 2024
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected January 2, 2025 · Nursing and Physician Services
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Potential for harm · E October 31, 2024
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.
Corrected January 2, 2025 · Nursing and Physician Services
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Potential for harm · D October 31, 2024
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected January 2, 2025 · Quality of Life and Care
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Potential for harm · E October 31, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 2, 2025 · Nutrition and Dietary
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Potential for harm · D October 31, 2024
Provide and implement an infection prevention and control program.
Corrected January 2, 2025 · Infection Control
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Actual harm · G August 12, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 20, 2024 · Quality of Life and Care
-
Potential for harm · D August 12, 2024 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected August 20, 2024 · Resident Assessment and Care Planning
-
Potential for harm · E May 14, 2024 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected May 30, 2024 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 2, 2025 | Fine | $16,588 |
| November 2, 2023 | Fine | $11,183 |
| August 21, 2023 | Fine | $19,143 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 165524 · certified since November 1, 2003. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.