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2/5
Health inspection rating (on-site)
inspected Jul 17, 2025
2
Serious findings on record
most recent Jul 17, 2025
$56,430
Fines, last 3 years
4.08
Nurse hours/resident/day (adjusted)
Every record stays on this page.
What health inspectors found (on-site government inspections — the most independent evidence available)
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 quality measures from resident assessments and claims.
Most serious findings (actual harm or immediate jeopardy)
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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Aug 13, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · 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): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Nov 21, 2024 (Deficient, Provider has date of correction)
Inspection findings in the public record
Showing the latest 3 of 12 inspection findings. Open the full record below to read every finding.
G · Actual harm, isolated
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. F-0686
F · Potential for more than minimal harm, widespread
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. F-0812
E · Potential for more than minimal harm, pattern
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. F-0550
View all 12 inspection findingsShow only the latest 3 findings
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
Date
Severity
What the facility was cited for
Jul 17, 2025
▲ G · Actual harm, isolated
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. · F-0686
Jul 17, 2025
F · Potential for more than minimal harm, widespread
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. · F-0812
Jul 17, 2025
E · Potential for more than minimal harm, pattern
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. · F-0550
Jul 17, 2025
E · Potential for more than minimal harm, pattern
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. · F-0688
Jul 17, 2025
E · Potential for more than minimal harm, pattern
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. · F-0880
Jul 17, 2025
D · Potential for more than minimal harm, isolated
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. · F-0578
Jul 17, 2025
C · Potential for minimal harm, widespread
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. · F-0576
Nov 6, 2024
▲ G · Actual harm, isolated
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 · F-0689
Jan 18, 2024
F · Potential for more than minimal harm, widespread
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. · F-0812
Jan 18, 2024
E · Potential for more than minimal harm, pattern
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. · F-0880
Jan 18, 2024
D · Potential for more than minimal harm, isolated
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. · F-0625
Jan 26, 2023
D · Potential for more than minimal harm, isolated
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. · F-0880
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 7).
Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2023
All citations:
1
Serious citations (G–L):
0
2024
All citations:
4
Serious citations (G–L):
1
2025
All citations:
7
Serious citations (G–L):
1
All bars start at zero. Exact values and supporting details remain below.
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.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
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)
Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilitySouth Dakota averageU.S. average
Total nurse staffing (hours per resident per day)
This facility:
4.08
South Dakota average:
4.32
U.S. average:
3.95
Registered Nurse hours
This facility:
1.10
South Dakota average:
0.91
U.S. average:
0.69
Weekend total nurse staffing
This facility:
3.50
South Dakota average:
3.71
U.S. average:
3.50
All bars start at zero. Exact values and supporting details remain below.
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 for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.73 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 4/5.
Quality measures: assessments & claims
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
No verified facility-specific private-pay price is available in our data for Bethel Lutheran Home. CMS inspection and staffing records do not tell us what this home will charge you.
Calculate a stay from a quote you receive
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
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Request the room type, effective date and itemized daily rate in writing.
Ask about therapy, medicines, supplies, care-level charges, deposits, refunds and annual increases.
Confirm insurance or Medicaid eligibility and bed availability directly; certification alone does not guarantee either.
Facility data as of CMS processing date 2026-08-01. CCN 435076.
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The Care File
Visit checklist — Bethel Lutheran Home
1001 S Egan Ave, Madison, SD 57042 · (605) 256-4539
Health inspection rating 2/5 · CMS overall 2/5· Fines (3y): $56,430
Most serious findings on record:
▲ Jul 17, 2025 (F-0686, Actual harm, isolated): 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.
▲ Nov 6, 2024 (F-0689, Actual harm, isolated): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Questions for the administrator:
☐ "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?"
☐ "Your weekend nurse staffing is reported below the South Dakota midpoint — how does the weekend schedule differ from a weekday?"
☐ "Can I see the plan of correction for the findings in your most recent state inspection?"
☐ "CMS reports 52% total nursing staff turnover here — who on the care team has been with you longest?"
☐ "The ownership record on file lists 28 owning or managing parties — who makes the decisions about staffing levels?"
☐ "Can I visit again unannounced, at a mealtime or on a weekend?"
While you're there, notice:
☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)
Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 435076 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)