See every facility — official ratings, family reviews, no referral fees.
Nursing HomeMedicaid Investigative

Bethany Lutheran Home

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

Seven Elliott Street, Council Bluffs, IA 51503112 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
3.3/5

based on 13 Google reviews

Bethany Lutheran Home Nursing Home in Council Bluffs, IA — Street View
Street View

Watch Bethany Lutheran Home

Get an email when new inspections, ratings, or penalties are published for this facility.

We’ll only email you about this — no spam, unsubscribe anytime.

4/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Above-median deficiencies (14 vs median 5)
  • High RN turnover (64%)

Bottom 25% in IA · Critically understaffed (RN) · Above average staffing · $55,846 in fines

Source: Medicare data

What this means for your family

While the physical therapy department is highly regarded, the facility has significant issues with administrative communication and staff responsiveness. We strongly recommend that you observe call light response times during a visit and clarify the specific frequency of physician visits before committing to this facility.

Google Reviews

Google Reviews

13 reviews on Google
Bethany Lutheran Home receives highly polarized feedback, with some families praising the physical therapy and meal variety while others report significant neglect and administrative hostility. Recurring complaints highlight long response times for call lights, poor communication from management, and inconsistent access to medical doctors.

Quality Themes

Tap a score for details
Food5.0Staff3.0Clean2.0ActivitiesN/AMedsN/AMemoryN/AComms2.0ValueN/A

Strengths

  • Effective physical therapy team
  • Diverse and high-quality meal options
  • Open visitation policy

Concerns

  • Excessive call light response times (mentioned by 2 reviewers)
  • Poor administrative communication and rude staff (mentioned by 3 reviewers)
  • Inconsistent access to medical doctors (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2345.0'17(3)1.02.0'19(1)5.03.0'22(2)1.55.0'25(2)1.0'26(1)

Distribution · 13 analyzed

5
7
4
0
3
0
2
2
1
4

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1We've heard great things about the physical therapy team here; could you tell us more about how they work with residents to maintain their mobility?
  • 2With the open visitation policy, how do families typically stay involved in their loved one's daily routine?
  • 3What are some of the favorite meal options currently being served to the residents?
  • 4How does the nursing staff ensure that call lights are answered promptly, especially during the night shifts?
  • 5Could you explain the process for how residents are connected with doctors and how medical updates are shared with the family?
  • 6What steps is the facility taking to ensure the highest standards of cleanliness and facility maintenance for the residents?

Personalized based on this facility's data


Key Review Excerpts

The physical therapy staff is fantastic. I had wonderful care from nursing and generally all staff. Food is very good and contained a wide variety.

Rehab patient · 2022★★★★★

Mom’s first day at facility and she had to wait over 17 minutes to get staff in so she could use the restroom. Staff came in argumentative and saying if there was a problem we could go speak to the director of nursing.

Long-term resident's family · 2019★★☆☆☆

STAY AWAY WHATEVER YOU DO. THE ADMINSTATION WILL THREATEN YOU WITH ELDER ABUSE TO KEEP YOUR FAMILY MEMBER IN THEIR FACILITY LONGER. FACILITY IS NOT KEPT CLEAN. LACK OF BATHING PATIENTS. LACK OF ACCESS TO MEDICAL DOCTORS. 2 HOURS CALL LIGHT TIMES.

Family member · 2022☆☆☆☆
Source: 13 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.34hrs
46%
Registered nurses for medical care
Total Nursing
3.92hrs
96%
All nurses + aides combined
Staff Turnover
36%
Lower is better (< 30% = good)
RN Turnover
55%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
2/ 5
Better Than Avg

6

measures

Worse Than Avg

6

measures

Mixed Results

5

measures

Long-Stay Residents
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
12.1%
IA
4.1%
Pottawattamie
4.1%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility10.0%
Better than Avg
Here
10.0%
US
19.5%
IA
20.7%
Pottawattamie
15.4%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility23.6%
Worse than Avg
Here
23.6%
US
14.4%
IA
17.6%
Pottawattamie
16.8%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility16.3%
Mixed vs Avgs
Here
16.3%
US
15.3%
IA
17.5%
Pottawattamie
22.7%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility25.7%
Mixed vs Avgs
Here
25.7%
US
19.4%
IA
25.9%
Pottawattamie
28.4%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility97.8%
Better than Avg
Here
97.8%
US
93.4%
IA
93.9%
Pottawattamie
92.2%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility46.2%
Worse than Avg
Here
46.2%
US
79.8%
IA
73.3%
Pottawattamie
75.6%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility54.8%
Worse than Avg
Here
54.8%
US
81.8%
IA
84.1%
Pottawattamie
81.5%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility4.2%
Worse than Avg
Here
4.2%
US
1.6%
IA
2.0%
Pottawattamie
1.0%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

8deficiencies
3penalties
Above state avg (6.2)
26 complaint-triggered
$55,846 in fines

Bethany Lutheran Home shows concerning patterns with families frequently filing complaints that triggered over half of its 61 deficiencies across recent surveys. The facility has persistent issues with nursing staffing levels, care planning, and safety hazards that recur across multiple inspections despite correction dates. Most troubling are repeated problems with accident prevention, medication management, and ensuring adequate nursing coverage, suggesting ongoing challenges in providing consistent, safe care for residents.

Oct 2, 2025Routine
10
0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0741Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

0761Potential for harm · PatternCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0637Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Assess the resident when there is a significant change in condition

0644Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0656Potential for harm · IsolatedCorrected

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.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Oct 2, 2025Complaint
2
0689Immediate jeopardy · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0725Potential for harm · PatternCorrected

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.

May 30, 2025Complaint
2
0658Actual harm · IsolatedResolved (past non-compliance)

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0689Potential for harm · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Mar 13, 2025Complaint
4
0550Potential for harm · IsolatedResolved (past non-compliance)

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0609Potential for harm · IsolatedResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0657Potential for harm · IsolatedCorrected

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.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Oct 31, 2024Routine
13
0712Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0725Potential for harm · PatternCorrected

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.

0727Potential for harm · PatternCorrected

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.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0761Potential for harm · PatternCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0623Potential for harm · IsolatedCorrected

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.

0625Potential for harm · IsolatedCorrected

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.

0644Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0744Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0921Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure that testing and maintenance of electrical equipment is performed.

0923Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Aug 12, 2024Complaint
2
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0656Potential for harm · IsolatedCorrected

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.

Federal Penalties

Fine

Oct 2, 2025

$16,588

Fine

Nov 2, 2023

$11,183

Fine

Aug 21, 2023

$19,143

State Inspection History

State Inspections

Source: Iowa Dept. of Inspections, Appeals & Licensing

10total
45deficiencies
May 21, 2026Complaint
Clean

Fed violations: 1, State violations: 0

Oct 2, 2025Inspection
Clean

Fed violations: 8, State violations: 1

May 30, 2025Complaint
Clean

Fed violations: 2, State violations: 1

Mar 24, 2025Complaint
Clean

Fed violations: 0, State violations: 0

Mar 13, 2025Complaint
Clean

Fed violations: 4, State violations: 1

Jan 8, 2025Inspection
Clean

Fed violations: 0, State violations: 0

Dec 6, 2024Other
Clean

Fed violations: 16, State violations: 0

Oct 31, 2024Inspection
Clean

Fed violations: 8, State violations: 0

Ownership & Operations

Who Operates This Facility

Owner / Operator

Bethany Lutheran Home

Organization Type

nonprofit

Ownership & Management

Key personnel

Burris, JuliaOfficer / DirectorCarlon, DianeOfficer / DirectorGoodell, AliceOfficer / DirectorSteensland, GregOfficer / DirectorSwalwell, JohnOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

Call