Bethel Lutheran Home
1001 S Egan Ave, Madison, SD 57042 · Lake County · 59 certified beds · avg 55 residents/day · certified since Apr 1, 1994
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jul 17, 2025 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 13, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 6, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 21, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (12)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 17, 2025 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jul 17, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 17, 2025 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jul 17, 2025 | E · Potential for harm, repeated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Jul 17, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 17, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jul 17, 2025 | C · Minimal risk, facility-wide | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Nov 6, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 18, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 18, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 18, 2024 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Jan 26, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | D |
| 2024 | 4 | 1 | G ▲ |
| 2025 | 7 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $56,430.
| Date | Type | Amount / length |
|---|---|---|
| Jul 17, 2025 | Fine | $48,412 |
| Nov 6, 2024 | Fine | $8,018 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | South Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.08 | 4.32 | 3.95 | bottom 48% in South Dakota; top 36% in the U.S. |
| Registered Nurse hours | 1.10 | 0.91 | 0.69 | top 25% in South Dakota; top 12% in the U.S. |
| Weekend total nurse staffing | 3.50 | 3.71 | 3.50 | bottom 47% in South Dakota; top 42% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.64 | 0.51 | 0.48 | top 22% in South Dakota; top 20% in the U.S. |
| Total nursing staff turnover (%) | 52.2 | 48.2 | 45.8 | bottom 40% in South Dakota; bottom 31% in the U.S. |
| RN turnover (%) | 27.3 | 34.7 | 42.9 | top 38% in South Dakota; top 24% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.73, RN 1.00, weekend 3.20. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: —/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Barber, Dawn | Individual | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2024 |
| Bethel Lutheran Home | Organization | Direct Ownership Interest | NOT APPLICABLE | 01/01/1966 |
| Breddin, Karl | Individual | Indirect Ownership Interest | NOT APPLICABLE | 10/01/2021 |
| Clem, Justin | Individual | Indirect Ownership Interest | NOT APPLICABLE | 07/11/2018 |
| Feldhaus, Maria | Individual | Indirect Ownership Interest | NOT APPLICABLE | 10/01/2023 |
| Glanzer, Rebecca | Individual | Indirect Ownership Interest | NOT APPLICABLE | 07/20/2015 |
| Schneider, Jeremiah | Individual | Indirect Ownership Interest | NOT APPLICABLE | 07/18/2022 |
| Voelker, Jackie | Individual | Indirect Ownership Interest | NOT APPLICABLE | 10/01/2022 |
| Barber, Dawn | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/01/2024 |
| Barber, Dawn | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/13/2024 |
| Bethel Lutheran Home | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/13/2024 |
| Bethel Lutheran Home | Organization | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Breddin, Karl | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/2021 |
| Breddin, Karl | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/13/2024 |
| Clem, Justin | Individual | Contracted Managing Employee | NOT APPLICABLE | 07/11/2018 |
| Clem, Justin | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/13/2024 |
| Clem, Justin | Individual | ADP of the SNF | NOT APPLICABLE | 12/20/2024 |
| Feldhaus, Maria | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/2023 |
| Feldhaus, Maria | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/13/2024 |
| Glanzer, Rebecca | Individual | W-2 Managing Employee | NOT APPLICABLE | 07/20/2015 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "How can my family member make private phone or video calls, and can we see where?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Good Samaritan Society Howard | 20.7 mi | Howard, SD | ★★★★★ | 5/5 | |
| Dells Nursing and Rehab Center INC | 23.0 mi | Dell Rapids, SD | ★★★★☆ | 4/5 | |
| Flandreau Santee Sioux Tribe Care Center | 25.6 mi | Flandreau, SD | ★★★☆☆ | 3/5 | |
| Riverview Healthcare Center | 26.5 mi | Flandreau, SD | ★☆☆☆☆ | 1/5 | abuseSFF |
| United Living Community | 26.7 mi | Brookings, SD | ★★☆☆☆ | 2/5 | |
| The Neighborhoods at Brookview | 27.7 mi | Brookings, SD | ★★★★★ | 5/5 | |
| Good Samaritan Society Canistota | 28.9 mi | Canistota, SD | ★★★☆☆ | 3/5 | |
| Good Samaritan Society de Smet | 34.5 mi | De Smet, SD | ★☆☆☆☆ | 2/5 | |
| Dow Rummel Village | 35.2 mi | Sioux Falls, SD | ★★★☆☆ | 2/5 | |
| Good Samaritan Society Sioux Falls Center | 35.8 mi | Sioux Falls, SD | ★★☆☆☆ | 2/5 | abuse |
| Diamond Care Center | 35.9 mi | Bridgewater, SD | ★☆☆☆☆ | 1/5 | |
| Palisade Healthcare Center | 36.3 mi | Garretson, SD | ★☆☆☆☆ | 1/5 | abuse |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 435076.