Cycle 1
Health 2025-12-18 · Fire 2025-12-18
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Brandon, SD
Bethany Home - Brandon
1-star overall rating with 1-star inspections with $24,385 in total fines with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3012 E Aspen Blvd, Brandon, SD
(605) 582-5200
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
56
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2012-10-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.89
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.33
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
3.70
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
4.93
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
4.21
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
5.24
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,782
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9917
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.26
Baseline 20.10% · Performance 19.00% · Measure score 5.26 · Achievement 5.26 · Improvement 3.09
Healthcare-associated infections
0
Baseline 6.17% · Performance 7.85% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.35
Performance 50.00% · Measure score 3.35 · Achievement 3.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.83
Baseline 4.37 hours · Performance 5.02 hours · Measure score 6.83 · Achievement 6.83 · Improvement 4.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.58% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 4.1% · Lower 95% interval 5.91% |
| Discharge to community | 39.04% |
50.57%
11.5 pts worse
|
Worse than the National Rate · Eligible stays 109 · Observed rate 34.86% · Lower 95% interval 32.05% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.14% |
95.27%
3.9 pts better
|
Numerator 115 · Denominator 116 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 116 |
| Discharge self-care score | 63.92% |
53.69%
10.2 pts better
|
Numerator 62 · Denominator 97 |
| Discharge mobility score | 60.82% |
50.94%
9.9 pts better
|
Numerator 59 · Denominator 97 |
| Pressure ulcers or injuries, new or worsened | 5.17% |
2.29%
2.9 pts worse
|
Numerator 6 · Denominator 116 · Adjusted rate 5.14% |
| Healthcare-associated infections requiring hospitalization | 7.85% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 76 · Observed rate 7.89% · Lower 95% interval 4.48% |
| Staff COVID-19 vaccination coverage | 1.56% |
8.2%
6.6 pts worse
|
Numerator 3 · Denominator 192 |
| Staff flu vaccination coverage | 51.02% |
42%
9 pts better
|
Numerator 100 · Denominator 196 |
| Discharge function score | 73.2% |
56.45%
16.8 pts better
|
Numerator 71 · Denominator 97 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 98.25% |
96.28%
2 pts better
|
Numerator 56 · Denominator 57 |
| Resident COVID-19 vaccinations up to date | 42.37% |
25.2%
17.2 pts better
|
Numerator 25 · Denominator 59 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.2 |
1.5
1.7 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 2.6 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.9
0.7 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
95.4%
2.6 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 100.0% · Q3 97.9% · Q4 95.9% · 4Q avg 98.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.9%
3.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.1% |
5.1%
3 pts worse
|
3.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 8.2% · Q3 10.6% · Q4 8.2% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
4.6%
1.8 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.1% · Q3 2.7% · Q4 2.7% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
5.5%
2.1 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 0.0% · Q3 2.5% · Q4 2.6% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
17.8%
5.5 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 14.3% · Q3 12.2% · Q4 14.6% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 32.8% |
25.1%
7.7 pts worse
|
16.7%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 37.0% · Q3 31.4% · Q4 30.3% · 4Q avg 32.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 38.4% |
21.3%
17.1 pts worse
|
16.3%
22.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.9% |
21.6%
6.3 pts worse
|
14.9%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 50.0% · Q3 21.1% · Q4 17.5% · 4Q avg 27.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.7% |
2.0%
2.7 pts worse
|
1.0%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 8.0% · Q3 1.5% · Q4 1.6% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.3%
3.3 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 40.7% |
25.8%
14.9 pts worse
|
19.8%
20.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q2 50.8% · Q3 38.6% · Q4 41.8% · 4Q avg 40.7% |
| Percentage of long-stay residents with pressure ulcers | 9.1% |
4.6%
4.5 pts worse
|
5.1%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 14.3% · Q3 7.3% · Q4 4.7% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
83.2%
16.8 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.4% |
11.7%
3.3 pts better
|
12.0%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.4% · Observed 7.7% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.7%
0.9 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.2%
21.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.1% |
21.5%
11.6 pts worse
|
23.9%
9.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.1% · Observed 29.2% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-08 · Fire 2024-11-08
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-07-20 · Fire 2023-07-20
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-01
D · Potential for more than minimal harm
2024-11-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-12-10
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-18
F578 · Resident Rights Deficiencies
Health
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 2026-02-01
E · Potential for more than minimal harm
2025-12-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-11
E · Potential for more than minimal harm
2025-12-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-02-01
E · Potential for more than minimal harm
2025-12-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-01
E · Potential for more than minimal harm
2025-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-01
D · Potential for more than minimal harm
2025-12-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-02-01
D · Potential for more than minimal harm
2025-12-18
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-02-01
D · Potential for more than minimal harm
2025-12-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-01
D · Potential for more than minimal harm
2025-12-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-01
G · Actual harm
2025-10-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
G · Actual harm
2025-05-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-05-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-25
D · Potential for more than minimal harm
2025-05-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-27
K · Immediate jeopardy
2024-11-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-11-08
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-08
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-08
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-11-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-06
E · Potential for more than minimal harm
2023-07-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-03
D · Potential for more than minimal harm
2023-07-20
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-03
D · Potential for more than minimal harm
2023-07-20
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2023-09-03
D · Potential for more than minimal harm
2023-07-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-09-03
Penalties and ownership
What sits behind the stars
$24,385
2024-11-08
Fine
Fine · fine $24,385
Fine
Ownership
Augustana Lutheran Church
5% Or Greater Direct Ownership Interest · Organization
Benton Lutheran Church
5% Or Greater Direct Ownership Interest · Organization
Nathanael Lutheran Church
5% Or Greater Direct Ownership Interest · Organization
St Marks Lutheran Church
5% Or Greater Direct Ownership Interest · Organization
Anderson, Robert
Corporate Officer · Individual
Beaver Valley Lutheran Church
5% Or Greater Direct Ownership Interest · Organization
Compeer Financial
5% Or Greater Mortgage Interest · Organization
Flier, Joel
Corporate Officer · Individual
Fonder, Lynda
Corporate Officer · Individual
Grant, Rose
Corporate Officer · Individual
Heinemann, Daniel
Operational/Managerial Control · Individual
Hendricks-Wilkens, Mary
Corporate Officer · Individual
Herrboldt, Deborah
Operational/Managerial Control · Individual
Herrboldt, Deborah
Corporate Officer · Individual
Hope, Lori
Corporate Officer · Individual
Johnson, Ellen
Corporate Officer · Individual
Johnson, Gregory
Corporate Officer · Individual
Kroger, Heather
Operational/Managerial Control · Individual
Kroger, Heather
Corporate Officer · Individual
Kruse, Susan
Corporate Officer · Individual
Neiderhiser, Debra
Corporate Officer · Individual
Paulson, John
Corporate Officer · Individual
Person, Lee
Corporate Officer · Individual
Sanden, James
Corporate Officer · Individual
Winklepleck, Hunter
Operational/Managerial Control · Individual
Zingmark, Karen
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Avera Prince Of Peace
Sioux Falls, SD
3-star overall rating with 2-star inspections with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Palisade Healthcare Center
Garretson, SD
1-star overall rating with 1-star inspections with $235,809 in total fines with 11 recent health deficiencies
#3
Good Samaritan Society Sioux Falls Center
Sioux Falls, SD
2-star overall rating with 2-star inspections with $11,261 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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