Bethel Lutheran Home
1001 S Egan Ave, Madison, SD 57042 · Non profit - Church related · 59 certified beds · (605) 256-4539 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a high payroll-based staffing rating (4/5)
- it has 2 actual-harm citations
- the CMS record shows $56,430 in federal fines (most recent 2025-07-17)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 19.1% | 21.3% | 15.4% | worse |
| Long-stay residents who lose too much weight | 4.8% | 5.6% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.5% | 2.1% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 3.0% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 5.7% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 2.0% | 5.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 14.5% | 19.4% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 16.4% | 17.4% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 92.9% | 96.9% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.3% | 4.6% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 21.4% | 25.4% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 12.3% | 24.6% | 17.1% | better |
| Long-stay hospitalizations per 1,000 resident days | 0.96 | 1.52 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 2.18 | 1.75 | 1.80 | worse |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.10 therapist hours per resident per day in 2026Q1 — more than 6% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 5.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 10.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.77 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 59 beds and averages 54.7 residents a day — about 93% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.73 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.00 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.42 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.20 hrs/resident/day on weekends vs 3.94 on weekdays — 19% thinner on weekends. RN hours go from 1.15 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
12 citations, most serious first — scroll within the box to see all.
- Actual harm · G2025-07-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the facility failed to ensure one of one sampled resident (3) who was at risk of developing a pressure ulcer did not develop a new pressure ulcer.Findings include: 1. Observation on 7/15/25 at 8:45 a.m. of resident 3 in her room revealed she was resting in her recliner with her feet elevated and had blue heel protector boots [padded to relieve pressure] on. 2. Interview on 7/15/25 at 10:34 a.m. with infection preventionist C revealed that resident 3 was receiving wound care for a pressure ulcer. 3. Review of resident 3's electronic medical record (EMR) revealed:*She was admitted on [DATE] after a fall that resulted in a broken hip, which required surgical repair.*She had a 4/3/25 Brief Interview for Mental Status (BIMS) assessment score of 3, which indicated she had severe cognitive impairment.*A 4/15/25 initiated care plan intervention area indicated the need for Weekly skin assessment by a licensed nurse.*A 4/15/25 initiated care plan…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Actual harm · G2024-11-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, interview, and manufacturer's reference guide review the provider failed to ensure the safety of one of one sampled resident (1) who fell from a mechanical lift (a lift and sling used to lift a person's body) that was not used by staff as the manufacturer directed and received skin injuries to her scalp and her elbow. Findings include: 1. Review of the provider's 10/18/24 SD DOH FRI regarding resident 1 revealed: *On 10/17/24 at 7:05 p.m. she fell out of a mechanical lift sling while being transferred by staff while using the lift. *Her Brief Interview for Mental Status (BIMS) assessment score was 2 which indicated she had severe cognitive impairment. *She is a bilateral lower amputee. *After supper resident was taken to room and was yelling out due to pain from sore on [her] bottom. *Vital signs and neuros were initiated and were stable. *The sling and Arjo [mechanical lift] got caught and resident slipped thru sling onto floor. *Superficial abrasion found on back of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-07-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to follow food safety standards by having failed to: *Maintain a sanitary kitchen environment in one of one kitchen.*Discard expired foods (spinach and white icing) in one of one walk-in cooler and one of one dry storage area.*Store perishable foods (sweet cream butter) at the appropriate temperatures.*Practice safe food handling with glove use by one of one dietary aide (R).*Practice appropriate hand hygiene (washing hands or using hand sanitizer) while assisting residents to eat by one of two paid feeding assistants (GG).*Practice appropriate hand hygiene with glove use by one of one cook (HH).Findings include: 1. Observations on 7/15/25 from 8:31 a.m. to 9:35 a.m. during the initial kitchen tour revealed: *The tea dispenser in the beverage preparation area was visibly soiled. -The spout had a buildup of sticky brown residue, the bag of tea concentrate inside the machine was starting to deposit clumps of dried tea on the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-17 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and policy review, the provider failed to ensure a resident's right to a sense of dignity and respect was maintained by failing to promptly serve residents' meals for one of two observed meal services.Findings include: 1. Interview on 7/15/25 at 3:17 p.m. with resident 26, the resident council president, revealed: *She felt there was a problem with residents waiting a long time to have their food served. *She stated, “We wait an hour to eat, and that happens a lot.” *She stated that other residents had expressed the same concern. -Residents came to speak with her individually because many of them did not like to speak in front of a large group. -She did not say if she had brought those concerns to the dietary manager or administrator. Review of the resident council minutes from the past three months revealed no comments or notes about excessive wait times at meals. 2. Observation in the main dining room of the 7/15/25 evening meal revealed: *At 5:05 p.m. residents were entering…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-17 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the provider failed to provide range of motion (measurement of movement around a joint or body part) (ROM) exercises for two of two residents (26 and 36) in an attempt to prevent a decline (worsening in physical status) in ROM.Findings include: 1. Observation and interview on 7/15/25 at 3:40 p.m. with resident 26 revealed she:*Was lying in bed and had some deformity to her fingers. She indicated she had arthritis.*Was alert and capable of making her needs known.*Participated in a restorative program Whenever I can get in and indicated that occurred approximately twice per week.*Wanted to have restorative programming more than she was, because she felt the more she moved around, the less pain she had.*Indicated she does not wear any type of splints or devices to help with stretching, preventing further ROM decline in her hands. 2. Interview on 7/17/25 at 9:56 a.m. with certified nursing assistant (CNA)/restorative aide Z regarding restorative exercises…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-07-17 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure appropriate infection prevention and control measures were effectively implemented and followed for:*One of one sampled resident (26) with an indwelling catheter and who was dependent on staff for transfer assistance, toileting needs, and catheter care received those cares with necessary enhanced barrier precautions (EBP).*Three of three sampled residents (1, 9, and 28) who received medications per nebulizer equipment had their equipment maintained and stored properly when not being used.*One of two clean linen distributing carts lacked a suitable protective cover while transporting items.Findings include: 1. Observation and interview on 7/15/25 at 3:40 p.m. with resident 26 revealed she: *Was lying in her bed with a catheter bag hanging from the bed frame. *Had the catheter for a few months. *Stated that the staff had sometimes worn gowns and gloves when they cared for her. *A sign was hanging on the inside of her…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-17 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure accurate documentation of the resident's wishes involving their advance directives/code status for one of one sampled resident (5).Findings include:1. Record review of the medical record for resident 5 revealed:*She was admitted on [DATE].*Her Brief Interview for Mental Status (BIMS) assessment score was 8, which indicated she had moderate cognitive impairment.*The CPR (cardiopulmonary resuscitation, an emergency procedure to provide chest compression and often rescue breathing to preserve brain function and maintain blood circulation) Statement of Decision indicated the resident wanted CPR.*Her advance directive (a legal document that expresses a person's health care wishes if they become unable to speak for themselves) indicated she did not want CPR, signed on [DATE]. 2. Interview and medical record review on [DATE] at 9:26 a.m. with registered nurse (RN) H about resident 5 revealed:*Resident 5's CPR status in the paper medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-01-18 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and policy review the provider failed to maintain sanitary conditions in the kitchen and to ensure foods were stored, handled, prepared and served in a safe and sanitary manner for the following: *Appropriate glove use and hand hygiene for one of one cook (D) while preparing and serving food. *Appropriate glove use and hand hygiene for two of two dietary aides (G and H) while handling food. *Appropriate glove use and hand hygiene for one of one cook assistant/dietary aide (L) while serving food. Findings include: 1. Initial kitchen tour on 1/16/24 at 3:41 p.m. revealed: *One container of Orchard Splash prune juice with an expiration date of 10/12/23 was open, and in the refrigerator *Two boxes of food items (hoagie buns and garlic toast) was sitting on the floor of the walk-in freezer. *Cook D put on gloves, placed those gloved hands on a wheeled garbage can and moved it, then begun slicing strawberries with those same gloves on. *Cook D then walked over to the stovetop, stirred a food item in a pot, returned and continued to cut the strawberries, all…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-01-18 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and policy review, the provider failed to ensure the following: *Appropriate use, storage, and disposal of personal protective equipment (PPE) by three of three registered nurses (RNs) (E, I, and J) after entering two of two sampled resident's (2 and 7) rooms who were on transmission-based precautions (TBP) for influenza A and COVID-19. *Signage for the type of isolation precautions required for two of two sampled residents (2 and 7). *Storage and labeling of resident's personal care items in one of one bathtub rooms. *Cleanliness was maintained in one of one bathtub room to prevent the buildup of residue and dust. Findings include: 1. Observation and interview on 1/16/24 at 4:16 p.m. with RN I outside resident 2's room revealed: *She was wearing a gown, mask, and gloves when she exited the room. *There was no signage on the resident's door to indicate she was on TBP. *There was a PPE cart in the hallway to the right of resident 2's room and there were two laundry hampers a few steps away to the left of her room. *There was a blue rectangular sign on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-18 · tag F0625 — isolatedNotify 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and policy review the provider failed to ensure resident and/or their representative received a written notification with information regarding a transfer to the hospital and was provided a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman for one of one sampled resident (42) that was reviewed for facility initiated hospital transfers. Findings include: 1. Review of resident 42's electronic medical record (EMR) revealed: *She was complaining of chest pain in the dining room on 12/6/23. *A standing order for Mylanta 15 mL was given at 12:30 p.m. *She was transported to her room. *Her vital signs were: -Temperature 97.3. -Blood pressure 171/91. -Respirations 26 -Oxygen 93% room air. *She was given an Albuterol nebulizer treatment per physician's order. *After nebulizer treatment she stated, Something is wrong, and I need to go to the hospital now. *Her son was called and agreed resident should go to the emergency room. *She was admitted to the local hospital…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-01-26 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the provider failed to ensure a dressing change for one of three sampled residents (13) with a pressure ulcer had been: *Completed with appropriate and sanitary technique. *Completed according to the provider's wound care policy: Findings include: 1. Observation on 1/26/23 at 9:35 a.m. of registered nurse (RN)/wound care nurse (WCN) C while completing a dressing change for resident 13's pressure ulcer on her coccyx revealed: *She had completed hand hygiene upon entering the room and went to the closet to obtain the wound care supplies. She realized an item was missing and told the resident, I'll be right back, and left the room to obtain it. *Came back into the room, performed hand hygiene and put on clean gloves. *With those gloved hands she: -Put the packaged supplies on the bedside table without a barrier. -Opened the bottle of Dakin's 0.25 % solution and poured the solution into a four-ounce plastic cup. -Used the bed's remote to raise the resident's bed. -Loosened the resident's incontinent product and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-07-17 · tag F0576 — widespreadEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — the official record, unedited, may be distressing
Based on interview, the provider failed to ensure the residents' right was maintained to have their mail delivered to all residents on Saturdays. The resident census was 52.Findings include: Interview on 7/17/25 at 2:18 p.m. with activities coordinator K revealed:*She did not think that the mail was delivered on the weekend. *The activities staff typically delivered mail during the week. *She was unsure whether mail was delivered to the facility on Saturdays.Interview on 7/17/25 at 2:43 p.m. with business manager P revealed: *Mail was delivered to the facility on Saturdays. *She stated that administrative assistant Q delivered Saturday's mail to the residents on Monday mornings.*Mail that was delivered to the facility on Monday was given to residents later that same day.Interview on 7/17/25 at 3:11 p.m. with administrator A revealed: *The activities staff usually delivered the mail during the week. *He was unaware that mail was required to be delivered to residents within 24 hours of delivery to the facility by the post office.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$56,430 in federal fines across 2 penalties.
- $48,412 — penalty dated 2025-07-17
- $8,018 — penalty dated 2024-11-06
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BETHEL LUTHERAN HOME | Organization | DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/1966 |
| BARBER, DAWN | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2024 |
| BREDDIN, KARL | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2021 |
| CLEM, JUSTIN | Individual | INDIRECT OWNERSHIP INTEREST; CONTRACTED MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/11/2018 |
| FELDHAUS, MARIA | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2023 |
| GLANZER, REBECCA | Individual | INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/20/2015 |
| SCHNEIDER, JEREMIAH | Individual | INDIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 07/18/2022 |
| VOELKER, JACKIE | Individual | INDIRECT OWNERSHIP INTEREST; MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL | since 10/01/2022 |
CMS files one row per role, so the 28 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in SD
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the South Dakota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 435076. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-17, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.