Cycle 1
Health 2025-07-17 · Fire 2025-07-17
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Madison, SD
Bethel Lutheran Home
2-star overall rating with 2-star inspections with $56,430 in total fines with 7 recent health deficiencies
1001 S Egan Ave, Madison, SD
(605) 256-4539
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
52
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-04-01
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
0.77
Registered nurse staffing · state 0.80 · national 0.68
LPN hours / resident day
0.39
Licensed practical nurse staffing · state 0.49 · national 0.87
Aide hours / resident day
2.65
Nurse aide staffing · state 2.61 · national 2.35
Total nurse hours
3.82
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.17
RN + LPN hours · state 1.28 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.32 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
4.29
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,695
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.01
Composite VBP score used to determine payment impact.
Payment multiplier
0.9868
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.53
Baseline 51.61% · Performance 53.33% · Measure score 2.53 · Achievement 2.53 · Improvement 0
Adjusted total nurse staffing
3.87
Baseline 4.15 hours · Performance 4.18 hours · Measure score 3.87 · Achievement 3.87 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 21 · Denominator 21 |
| Falls with major injury | 4.76% |
0.77%
4 pts worse
|
Numerator 1 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 21 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 4.26% |
8.2%
3.9 pts worse
|
Numerator 6 · Denominator 141 |
| Staff flu vaccination coverage | 62.5% |
42%
20.5 pts better
|
Numerator 70 · Denominator 112 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.9
0.9 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.4%
4.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.9% |
96.9%
4 pts worse
|
95.5%
2.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
5.1%
3.1 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 2.0% · Q4 2.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.6%
4.6 pts better
|
11.4%
11.4 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 who lose too much weight | 4.5% |
5.5%
1 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 0.0% · Q3 2.2% · Q4 4.2% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.8% |
17.8%
2 pts better
|
19.6%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 11.9% · Q3 17.4% · Q4 16.7% · 4Q avg 15.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.6% |
25.1%
16.5 pts better
|
16.7%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 2.8% · Q3 10.0% · Q4 12.8% · 4Q avg 8.6% · 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 | 14.9% |
21.3%
6.4 pts better
|
16.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 10.1% · Q3 18.1% · Q4 16.2% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.5% |
21.6%
4.1 pts better
|
14.9%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 2.4% · Q3 25.0% · Q4 15.2% · 4Q avg 17.5% · 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 8.3% · Q2 5.5% · Q3 0.0% · Q4 4.4% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.5% |
3.3%
0.2 pts worse
|
1.7%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 2.0% · Q3 2.0% · Q4 3.9% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.3% |
25.8%
1.5 pts better
|
19.8%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 37.3% · Q3 23.8% · Q4 11.8% · 4Q avg 24.3% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.6%
2.9 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.5% · Q3 0.0% · Q4 2.3% · 4Q avg 1.7% · 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 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-18 · Fire 2024-01-18
4 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-01-26 · Fire 2023-01-26
1 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-01-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-02
D · Potential for more than minimal harm
2023-01-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-02-08
D · Potential for more than minimal harm
2023-01-26
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-08
Inspection history
Recent health citations
G · Actual harm
2025-07-17
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-13
F · Potential for more than minimal harm
2025-07-17
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 2025-09-09
E · Potential for more than minimal harm
2025-07-17
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-13
E · Potential for more than minimal harm
2025-07-17
F688 · Quality of Life and Care Deficiencies
Health
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 2025-08-12
E · Potential for more than minimal harm
2025-07-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-16
D · Potential for more than minimal harm
2025-07-17
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 2025-08-15
C · Minimal harm
2025-07-17
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-08-09
G · Actual harm
2024-11-06
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 2024-11-21
F · Potential for more than minimal harm
2024-01-18
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 2024-03-03
E · Potential for more than minimal harm
2024-01-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-03
D · Potential for more than minimal harm
2024-01-18
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 2024-03-03
D · Potential for more than minimal harm
2023-01-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-15
Penalties and ownership
What sits behind the stars
$48,412
2025-07-17
Fine
Fine · fine $48,412
Fine
$8,018
2024-11-06
Fine
Fine · fine $8,018
Fine
Ownership
Barber, Dawn
Operational/Managerial Control · Individual
Bethel Lutheran Home
Operational/Managerial Control · Organization
Breddin, Karl
Operational/Managerial Control · Individual
Clem, Justin
Operational/Managerial Control · Individual
Clem, Justin
Contracted Managing Employee · Individual
Feldhaus, Maria
Operational/Managerial Control · Individual
Glanzer, Rebecca
Operational/Managerial Control · Individual
Glanzer, Rebecca
W-2 Managing Employee · Individual
Schneider, Jeremiah
Operational/Managerial Control · Individual
Schneider, Jeremiah
Corporate Officer · Individual
Schneider, Jeremiah
W-2 Managing Employee · Individual
Voelker, Jackie
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Good Samaritan Society Howard
Howard, SD
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Dells Nursing And Rehab Center Inc
Dell Rapids, SD
4-star overall rating with 4-star inspections with $176,155 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Flandreau Santee Sioux Tribe Care Center
Flandreau, SD
3-star overall rating with 3-star inspections with $17,007 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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