Report
TheVardellReport
Bethany Lutheran Home
Skilled nursing facility and nursing facility
Seven Elliott Street
Council Bluffs, IA 51503
Report
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The Vardell Report.Bethany Lutheran Home
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Council Bluffs, IA
- Record Period
- 2023–2026
- Source Documents
- 11
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 9 inspections from August 2023 to May 2026, state surveyors documented 43 findings at Bethany Lutheran Home; 42 have a recorded correction and 1 awaits one; CMS lists 2 enforcement actions in the window.
- Inspections
- 9
- 2023–2026, complaint and standard
- Findings
- 43
- Deficiencies cited by state inspectors
- Corrected
- 42
- Of 43 findings, with a recorded correction date
- Penalties
- 2
- 2 fines; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 2 | 16 | 2 |
| 2024 | 3 | 12 | 1 |
| 2025 | 3 | 14 | 2 |
| 2026 | 1 | 1 | 0 |
What the Record Shows
- 42 of 43 findings have a recorded correction date.
- CMS lists 2 enforcement actions in the window: 2 fines totaling $27,771, their payment not published.
- 7 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, October 2, 2025, recorded 8 findings (most serious: Level J).
What to Ask About
- Professional Standards, Cited in Five Inspections
- Accident Hazards and Supervision, Cited in Five Inspections
- Dignity and Resident Rights, Cited in Three Inspections
- Care Plans, Cited in Three Inspections
- Nursing Staff Levels, Cited in Three Inspections
- Infection Control, Cited in Three Inspections
- Citation F625, Cited in Two Inspections
- Coordinating Mental Health Screening, Cited in Two Inspections
- Quality of Care, Cited in Two Inspections
- Significant Medication Errors, Cited in Two Inspections
- Citation F602, No Recorded Correction
Report at a Glance
- Facility
- Bethany Lutheran Home
- Address
- Seven Elliott Street, Council Bluffs, IA 51503
- CMS Certification Number
- 165524
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 112
- Ownership
- Non profit - Other
- Record Window
- August 21, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
1 finding
- F602Protect each resident from the wrongful use of the resident's belongings or money.Level DNo actual harm, potential for morePast Non-Compliance
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
8 findings
The same visit included a complaint investigation.
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level JImmediate jeopardyCorrected Jul 21, 2025
- F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Nov 25, 2025
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Nov 25, 2025
- F637Assess the resident when there is a significant change in conditionLevel DNo actual harm, potential for moreCorrected Nov 25, 2025
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Nov 25, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Nov 25, 2025
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Nov 25, 2025
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Nov 25, 2025
Enforcement Action
Civil money penalty, $16,588 imposed October 2, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of October 2, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
2 findings
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level GActual harmCorrected Apr 5, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected May 12, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
4 findings
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Feb 14, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Feb 14, 2025
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected Mar 24, 2025
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Mar 24, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
8 findings
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Jan 2, 2025
- F727Have 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.Level ENo actual harm, potential for moreCorrected Jan 2, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Jan 2, 2025
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level DNo actual harm, potential for moreCorrected Jan 2, 2025
- F625Notify 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.Level DNo actual harm, potential for moreCorrected Jan 2, 2025
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Level DNo actual harm, potential for moreCorrected Jan 2, 2025
- F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level DNo actual harm, potential for moreCorrected Jan 2, 2025
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Jan 2, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Aug 20, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Aug 20, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
2 findings
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected May 30, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected May 30, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
2 findings
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level JImmediate jeopardyCorrected Nov 3, 2023
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Nov 3, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
14 findings
- F695Provide safe and appropriate respiratory care for a resident when needed.Level GActual harmCorrected Sep 14, 2023
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Sep 14, 2023
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
- F585Honor 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.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
- F625Notify 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.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Sep 14, 2023
Enforcement Action
Civil money penalty, $11,183 imposed November 2, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 21, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Professional Standards, Cited in Five Inspections
Inspectors cited F658 in August 2023, November 2023, March 2025, May 2025 and October 2025. This citation covers whether the home’s services meet professional standards of quality. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252526F658 across all 9 inspections, oldest to newest - 2
Accident Hazards and Supervision, Cited in Five Inspections
Inspectors cited F689 in August 2023, May 2024, August 2024, May 2025 and October 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252526F689 across all 9 inspections, oldest to newest - 3
Dignity and Resident Rights, Cited in Three Inspections
Inspectors cited F550 in August 2023, May 2024 and March 2025. This citation covers residents’ right to dignity, to make their own choices and to communicate. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252526F550 across all 9 inspections, oldest to newest - 4
Care Plans, Cited in Three Inspections
Inspectors cited F656 in August 2023, August 2024 and October 2025. This citation covers whether each resident has a written care plan that meets their needs, with goals that can be measured. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252526F656 across all 9 inspections, oldest to newest - 5
Nursing Staff Levels, Cited in Three Inspections
Inspectors cited F725 in August 2023, October 2024 and October 2025. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252526F725 across all 9 inspections, oldest to newest - 6
Infection Control, Cited in Three Inspections
Inspectors cited F880 in August 2023, October 2024 and October 2025. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252526F880 across all 9 inspections, oldest to newest - 7
Citation F625, Cited in Two Inspections
Inspectors cited F625 in August 2023 and October 2024. The agency describes it this way: 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. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252526F625 across all 9 inspections, oldest to newest - 8
Coordinating Mental Health Screening, Cited in Two Inspections
Inspectors cited F644 in October 2024 and October 2025. This citation covers whether assessments are coordinated with the state’s pre-admission screening for mental illness and intellectual disability (PASARR), and referrals made. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252526F644 across all 9 inspections, oldest to newest - 9
Quality of Care, Cited in Two Inspections
Inspectors cited F684 in August 2023 and November 2023. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level J (immediate jeopardy). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252526F684 across all 9 inspections, oldest to newest - 10
Significant Medication Errors, Cited in Two Inspections
Inspectors cited F760 in August 2023 and October 2025. This citation covers whether residents are free from significant medication errors. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232324242425252526F760 across all 9 inspections, oldest to newest - 11
Citation F602, No Recorded Correction
F602 was cited in May 2026. The agency describes it this way: Protect each resident from the wrongful use of the resident's belongings or money. The most serious was level D (no actual harm, potential for more). The May 2026 citation has no recorded correction date; its status reads “Past Non-Compliance.” The record does not show whether the problem was fixed.
232324242425252526F602 across all 9 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How do you check that nurses and aides follow professional standards, and what happens when they do not?
Professional Standards: cited in five inspections, most seriously at level G.
- 02
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in five inspections, most seriously at level J.
- 03
How do staff learn each resident’s preferences, and how is a complaint about dignity handled?
Dignity and Resident Rights: cited in three inspections, most seriously at level E.
- 04
How is a care plan written and reviewed here, and how do families take part in it?
Care Plans: cited in three inspections, most seriously at level D.
- 05
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Nursing Staff Levels: cited in three inspections, most seriously at level E.
- 06
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level F.
- 07
What changed after F625 was cited, and how do you check it now?
Citation F625: cited in two inspections, most seriously at level D.
- 08
How do you arrange services for residents with a mental illness or an intellectual disability?
Coordinating Mental Health Screening: cited in two inspections, most seriously at level D.
- 09
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in two inspections, most seriously at level J.
- 10
What happened after the medication error citation, and how are high-risk drugs double-checked?
Significant Medication Errors: cited in two inspections, most seriously at level D.
- 11
What changed after F602 was cited, and how do you check it now?
Citation F602: cited in one inspections, most seriously at level D. The May 21, 2026 citation has no recorded correction date.
- 12
What led to the 2025 fine, and has it been paid?
A $16,588 civil money penalty was imposed October 2, 2025. CMS publishes the fine, not whether it has been paid. The record holds two enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Iowa state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Aug 21, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Nov 2, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection May 14, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Aug 12, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Oct 31, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Mar 13, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection May 30, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection Oct 2, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Iowa state survey agency
Inspection May 21, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 165524
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowAugust 21, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before August 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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