Bethel Lutheran Home
1001 S Egan Ave · Madison, SD · 57042 · 6052564539
59 certified beds Non profit - Church related
Why this verdict
- Inspection results are getting worse cycle over cycle, not better.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
$56,430 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 4 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.68 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.02 | 0.55–0.75 |
| Weekend hours / resident-day | 2.93 | ≈ weekday level |
| Nursing turnover / year | 55% | median 45% |
| Fines (3-yr window) | 2 · $56,430 |
Inspection citations (12 in the current record)
-
Actual harm · G July 17, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected August 13, 2025 · Quality of Life and Care
-
Potential for harm · E July 17, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected August 13, 2025 · Resident Rights
-
Potential for harm · D July 17, 2025
Honor 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.
Corrected August 15, 2025 · Resident Rights
-
Potential for harm · E July 17, 2025
Provide 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.
Corrected August 12, 2025 · Quality of Life and Care
-
Potential for harm · F July 17, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 9, 2025 · Nutrition and Dietary
-
Potential for harm · E July 17, 2025
Provide and implement an infection prevention and control program.
Corrected August 16, 2025 · Infection Control
-
No harm found · C July 17, 2025
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected August 9, 2025 · Resident Rights
-
Actual harm · G November 6, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected November 21, 2024 · Quality of Life and Care
-
Potential for harm · D January 18, 2024
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.
Corrected March 3, 2024 · Resident Rights
-
Potential for harm · F January 18, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 3, 2024 · Nutrition and Dietary
-
Potential for harm · E January 18, 2024
Provide and implement an infection prevention and control program.
Corrected March 3, 2024 · Infection Control
-
Potential for harm · D January 26, 2023
Provide and implement an infection prevention and control program.
Corrected February 15, 2023 · Infection Control
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| July 17, 2025 | Fine | $48,412 |
| November 6, 2024 | Fine | $8,018 |
Better-scoring options nearby
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 435076 · certified since April 1, 1994. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.