Bethesda of Beresford
606 W Cedar, Beresford, SD 57004 · Union County · 39 certified beds · avg 34 residents/day · certified since Sep 1, 1994
2/5
Health inspection rating (on-site)
1
Serious findings on record
$16,088
Fines, last 3 years
3.75
Nurse hours/resident/day (adjusted)
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 · Oct 4, 2023 · 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 2, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (27)
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 |
|---|---|---|
| Jun 11, 2026 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 11, 2026 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Aug 13, 2025 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 13, 2025 | E · Potential for harm, repeated | 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. |
| Aug 13, 2025 | D · Potential for 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 |
| Aug 13, 2025 | 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. |
| Aug 8, 2024 | E · Potential for harm, repeated | 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. · from a complaint |
| Apr 25, 2024 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Apr 25, 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. |
| Apr 25, 2024 | F · Potential for harm, facility-wide | The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. |
| Apr 25, 2024 | F · Potential for harm, facility-wide | 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. |
| Apr 25, 2024 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Apr 25, 2024 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Apr 25, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 25, 2024 | E · Potential for harm, repeated | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Apr 25, 2024 | E · Potential for harm, repeated | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Apr 25, 2024 | D · Potential for harm, one-off | The facility did not post the names, addresses, and phone numbers of state agencies and advocacy groups, along with a notice that residents may file complaints with the state survey agency. |
| Apr 25, 2024 | D · Potential for harm, one-off | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Apr 25, 2024 | 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. |
| Apr 25, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Apr 25, 2024 | D · Potential for harm, one-off | 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. |
| Oct 4, 2023 | ▲ 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 |
| Oct 4, 2023 | F · Potential for harm, facility-wide | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Apr 5, 2023 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Apr 5, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 5, 2023 | E · Potential for harm, repeated | 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. |
| Apr 5, 2023 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (14 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 6 | 1 | G ▲ |
| 2024 | 15 | 0 | F |
| 2025 | 4 | 0 | E |
| 2026 | 2 | 0 | E |
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)
1 fine totaling $16,088.
| Date | Type | Amount / length |
|---|---|---|
| Oct 4, 2023 | Fine | $16,088 |
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) | 3.75 | 4.32 | 3.95 | bottom 37% in South Dakota; bottom 49% in the U.S. |
| Registered Nurse hours | 1.17 | 0.91 | 0.69 | top 19% in South Dakota; top 10% in the U.S. |
| Weekend total nurse staffing | 3.15 | 3.71 | 3.50 | bottom 31% in South Dakota; bottom 39% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.06 | 0.51 | 0.48 | top 3% in South Dakota; top 5% in the U.S. |
| Total nursing staff turnover (%) | 50.0 | 48.2 | 45.8 | bottom 47% in South Dakota; bottom 38% in the U.S. |
| RN turnover (%) | 12.5 | 34.7 | 42.9 | top 10% in South Dakota; top 6% 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 3.69, RN 1.15, weekend 3.10. 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 - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bethesda of Beresford | Organization | 5% or Greater Direct Ownership Interest | 100% | 11/19/2009 |
| Bethesda of Beresford | Organization | ADP of the SNF | NOT APPLICABLE | 11/19/2009 |
| Caring Professionals INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/14/2021 |
| Caring Professionals INC | Organization | ADP of the SNF | NOT APPLICABLE | 11/25/2025 |
| Chadwell, Dean | Individual | Corporate Director | NOT APPLICABLE | 05/01/2023 |
| Hansen, Chris | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/14/2021 |
| Hansen, Chris | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/14/2021 |
| Hansen, Chris | Individual | ADP of the SNF | NOT APPLICABLE | 04/14/2021 |
| Rohlfs, Karsten | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2024 |
| Rohlfs, Karsten | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2024 |
| Savey, Amelia | Individual | Corporate Director | NOT APPLICABLE | 05/01/2023 |
| Senger, Britney | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/28/2021 |
| Senger, Britney | Individual | ADP of the SNF | NOT APPLICABLE | 06/28/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "If my family member goes to the hospital, how long will you hold their bed, and will we get that in writing?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
- "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 |
|---|---|---|---|---|---|
| Alcester Care and Rehab Center, INC | 9.1 mi | Alcester, SD | ★★★★★ | 5/5 | |
| Centerville Care and Rehab Center INC | 9.1 mi | Centerville, SD | ★☆☆☆☆ | 1/5 | abuse |
| Hillcrest Health Care Center | 16.1 mi | Hawarden, IA | ★☆☆☆☆ | 1/5 | abuse |
| Pioneer Memorial Nursing Home | 16.4 mi | Viborg, SD | ★★★★★ | 5/5 | |
| Wakonda Heritage Manor | 17.0 mi | Wakonda, SD | ★★★★★ | 4/5 | |
| Good Samaritan Society Canton | 18.4 mi | Canton, SD | ★★☆☆☆ | 3/5 | |
| Sunset Manor Avera Health | 18.9 mi | Irene, SD | ★★☆☆☆ | 2/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 435080.