01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-10-02 | 9 | 2025-10-02 | 4 |
| Cycle 2 | 2024-10-31 | 16 | 2024-10-31 | 5 |
| Cycle 3 | 2023-08-21 | 18 | 2023-08-21 | 4 |
CMS CCN 1655242026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Bethany Lutheran Home
Seven Elliott Street · Council Bluffs, IA 51503 · Pottawattamie County
Certified beds112CMS provider file
Recent citation rows56current CMS citation release
Penalty rows3current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
56 rows in the current release
5 rows carry G–L scope/severity codes; 2 carry J–L. 14 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-05-21 · HEALTHF0602Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Correction field: Past Non-Compliance · complaint2025-10-02 · HEALTHF0637Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident when there is a significant change in condition
Correction field: Deficient, Provider has date of correction · 2025-11-252025-10-02 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2025-11-252025-10-02 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-11-252025-10-02 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2025-11-252025-10-02 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Past Non-Compliance · 2025-07-21 · complaint2025-10-02 · HEALTHF0725Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Correction field: Deficient, Provider has date of correction · 2025-11-25 · complaint2025-10-02 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-11-252025-10-02 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-11-252025-10-02 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-10-02 · FIREK0741Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-10-02 · FIREK0761Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-10-02 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-05-30 · HEALTHF0658Severity G · isolated actual harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Past Non-Compliance · 2025-04-05 · complaint2025-05-30 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Past Non-Compliance · 2025-05-12 · complaint2025-03-13 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Past Non-Compliance · 2025-02-14 · complaint2025-03-13 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Past Non-Compliance · 2025-02-14 · complaint2025-03-13 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2025-03-24 · complaint2025-03-13 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2025-03-24 · complaint2024-10-31 · HEALTHF0623Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Correction field: Deficient, Provider has date of correction · 2025-01-022024-10-31 · HEALTHF0625Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-01-022024-10-31 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2025-01-022024-10-31 · HEALTHF0725Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Correction field: Deficient, Provider has date of correction · 2025-01-022024-10-31 · HEALTHF0727Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-01-0203 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-10-02 | Fine | $16,588 | 0 |
| 2023-11-02 | Fine | $11,183 | 0 |
| 2023-08-21 | Fine | $19,143 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CARLON, DIANEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- EILTS, SUSANNEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/13/2026
- GOODELL, ALICEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- KRAUL-HENKEL, BECKYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/13/2026
- STEENSLAND, GREGIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/12/2025
- SWALWELL, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2024
- WORTHINGTON, SHARONIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/01/2021
- CARLON, DIANEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/12/2025
- STEENSLAND, GREGIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/13/2026
- SWALWELL, JOHNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/13/2026
- WORTHINGTON, SHARONIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/13/2026
- BISHOP, ANDREWIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2024
- GUSTAFSON, CHANDRAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/29/2023
- PFITZER, GENEVIEVEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/21/2025
- BISHOP, ANDREWIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/01/2024
- GUSTAFSON, CHANDRAIndividual · ADP OF THE SNFNOT APPLICABLE · since 12/29/2023
- PFITZER, GENEVIEVEIndividual · ADP OF THE SNFNOT APPLICABLE · since 06/21/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.99per resident day
RN hours0.30per resident day
Weekend nurse hours3.70per resident day
Staff turnover30.4%CMS reported field
06 / LOCAL RECORDS
Open the Council Bluffs ledger →