Cycle 1
Health 2025-12-18 · Fire 2025-12-18
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Sioux Falls, SD
Bethany Home Sioux Falls
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1901 South Holly Avenue, Sioux Falls, SD
(605) 338-2351
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
52
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-03-01
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
0.80
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
3.53
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
5.25
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
4.61
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
5.49
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,531
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.44% · Performance 21.56% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.68% · Performance 7.87% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 63.33% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
6.57
Baseline 3.36 hours · Performance 4.95 hours · Measure score 6.57 · Achievement 6.57 · Improvement 6.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.19% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 183 · Observed rate 7.65% · Lower 95% interval 6.28% |
| Discharge to community | 38.28% |
50.57%
12.3 pts worse
|
Worse than the National Rate · Eligible stays 173 · Observed rate 32.37% · Lower 95% interval 31.5% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 87.82% |
95.27%
7.5 pts worse
|
Numerator 137 · Denominator 156 |
| Falls with major injury | 4.49% |
0.77%
3.7 pts worse
|
Numerator 7 · Denominator 156 |
| Discharge self-care score | 56.64% |
53.69%
3 pts better
|
Numerator 64 · Denominator 113 |
| Discharge mobility score | 60.18% |
50.94%
9.2 pts better
|
Numerator 68 · Denominator 113 |
| Pressure ulcers or injuries, new or worsened | 2.56% |
2.29%
0.3 pts worse
|
Numerator 4 · Denominator 156 · Adjusted rate 2.98% |
| Healthcare-associated infections requiring hospitalization | 7.87% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 119 · Observed rate 8.4% · Lower 95% interval 4.9% |
| Staff COVID-19 vaccination coverage | 10.19% |
8.2%
2 pts better
|
Numerator 11 · Denominator 108 |
| Staff flu vaccination coverage | 92.8% |
42%
50.8 pts better
|
Numerator 116 · Denominator 125 |
| Discharge function score | 61.95% |
56.45%
5.5 pts better
|
Numerator 70 · Denominator 113 |
| Transfer of health information to provider | 72.73% |
95.95%
23.2 pts worse
|
Numerator 40 · Denominator 55 |
| Transfer of health information to patient | 98.33% |
96.28%
2 pts better
|
Numerator 59 · Denominator 60 |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 39 · Denominator 78 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
1.5
1.8 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.9
0.2 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
95.4%
1.2 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 96.9% · Q3 96.7% · Q4 96.3% · 4Q avg 96.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 63.6% |
96.9%
33.3 pts worse
|
95.5%
31.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 63.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
5.1%
0.8 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.2% · Q3 6.7% · Q4 3.7% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
4.6%
1.6 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 4.2% · Q4 4.5% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
5.5%
2.5 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 12.0% · Q4 0.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.2% |
17.8%
4.6 pts better
|
19.6%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 13.8% · Q3 15.4% · Q4 8.7% · 4Q avg 13.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
25.1%
6.7 pts better
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 17.4% · Q3 16.7% · Q4 25.0% · 4Q avg 18.4% · 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 | 23.8% |
21.3%
2.5 pts worse
|
16.3%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.6% |
21.6%
About the same
|
14.9%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 14.3% · Q3 20.0% · Q4 27.3% · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
2.0%
0.1 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 3.2% · Q4 2.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
3.3%
0.6 pts better
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 7.4% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 38.3% |
25.8%
12.5 pts worse
|
19.8%
18.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.9% · Q2 24.9% · Q3 36.8% · Q4 47.6% · 4Q avg 38.3% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
4.6%
0.6 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.1% · Q3 5.1% · Q4 5.2% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
83.2%
8.1 pts better
|
81.7%
9.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.8% · Q2 92.5% · Q3 93.8% · Q4 88.5% · 4Q avg 91.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
11.7%
2.3 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 9.4% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.7%
0.2 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.2% · Q3 1.9% · Q4 1.6% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.6% |
78.2%
8.4 pts better
|
79.7%
6.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
21.5%
2.9 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 22.9% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-07 · Fire 2024-11-07
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-07-20 · Fire 2023-07-20
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-12-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-02-01
Inspection history
Recent health citations
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 2026-02-05
D · Potential for more than minimal harm
2025-10-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
F · Potential for more than minimal harm
2024-11-07
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-11-07
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
E · Potential for more than minimal harm
2024-11-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-05
E · Potential for more than minimal harm
2024-11-07
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 2024-12-06
D · Potential for more than minimal harm
2024-11-07
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-11-07
F625 · Resident Rights Deficiencies
Health
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 2024-11-05
D · Potential for more than minimal harm
2024-11-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-06
F · 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
E · Potential for more than minimal harm
2023-07-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-09-03
D · Potential for more than minimal harm
2023-07-20
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-09-03
Penalties and ownership
What sits behind the stars
Ownership
Augustana Lutheran Church
5% Or Greater Direct Ownership Interest · Organization
Beaver Valley 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 Director · Individual
Flier, Joel
Corporate Director · Individual
Fonder, Lynda
Corporate Director · Individual
Heinemann, Daniel
General Partnership Interest · Individual
Heinemann, Daniel
Operational/Managerial Control · Individual
Hendricks-Wilkens, Mary
Corporate Director · Individual
Herrboldt, Deborah
Operational/Managerial Control · Individual
Herrboldt, Deborah
Corporate Director · Individual
Hope, Lori
Corporate Director · Individual
Johnson, Ellen
Corporate Director · Individual
Kroger, Heather
Corporate Officer · Individual
Kruse, Susan
Corporate Director · Individual
Neiderhiser, Debra
Corporate Director · Individual
Paulson, John
Corporate Director · Individual
Person, Lee
Corporate Director · Individual
Sanden, James
Corporate Director · Individual
Zingmark, Karen
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Good Samaritan Society Luther Manor
Sioux Falls, SD
2-star overall rating with 3-star inspections with $11,466 in total fines with 6 recent health deficiencies
#2
Avantara Norton
Sioux Falls, SD
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $191,055 in total fines with 19 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Dow Rummel Village
Sioux Falls, SD
3-star overall rating with 2-star inspections with $8,018 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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