Home / South Dakota / Madison
Bethel Lutheran Home
1001 S Egan Ave, Madison, SD 57042 · Lake County · (605) 256-4539
59 certified beds, about 55 residents a day · Non profit - Church related · Medicare and Medicaid since 1994
Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
4 of 5
Quality measures
4 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 435076 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on July 17, 2025, inspectors cited 7 health deficiencies (the South Dakota average is 6.7, the national average 9.2).
Of 12 health citations since January 2023, 2 were rated as actual harm or immediate jeopardy to residents.
CMS lists 2 fines totaling $56,430 in the last three years; the largest was $48,412, and the latest is dated July 17, 2025.
Nurses and nurse aides worked 3.73 hours per resident per day, against 3.79 across South Dakota and 3.86 nationally. Registered nurses accounted for 1.00 of those hours.
52.2% of nursing staff left within the year CMS measured (South Dakota average 48.2%).
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
101/23
301/24
111/24
707/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 12 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
3D
4E
2F
Potential for minimal harm
0A
0B
1C
July 17, 2025Standard inspection · 7 citations
- G Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure one of one sampled resident (3) who was at risk of developing a pressure ulcer did not develop a new pressure ulcer.
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to follow food safety standards by having failed to: *Maintain a sanitary kitchen environment in one of one kitchen.*Discard expired foods (spinach and white icing) in one of one walk-in cooler and one of one dry storage area.*Store perishable foods (sweet cream butter) at the appropriate temperatures.*Practice safe food handling with glove use by one of one dietary aide (R).*Practice appropriate hand hygiene (washing hands or using hand sanitizer) while assisting residents to eat by one of two paid feeding assistants (GG).*Practice appropriate hand hygiene with glove use by one of one cook (HH).
- E Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on interview, observation, and policy review, the provider failed to ensure a resident's right to a sense of dignity and respect was maintained by failing to promptly serve residents' meals for one of two observed meal services.
- E 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.
Inspectors wroteBased on observation, interview, and record review, the provider failed to provide range of motion (measurement of movement around a joint or body part) (ROM) exercises for two of two residents (26 and 36) in an attempt to prevent a decline (worsening in physical status) in ROM.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure appropriate infection prevention and control measures were effectively implemented and followed for:*One of one sampled resident (26) with an indwelling catheter and who was dependent on staff for transfer assistance, toileting needs, and catheter care received those cares with necessary enhanced barrier precautions (EBP).*Three of three sampled residents (1, 9, and 28) who received medications per nebulizer equipment had their equipment maintained and stored properly when not being used.*One of two clean linen distributing carts lacked a suitable protective cover while transporting items.
- D 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.
Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure accurate documentation of the resident's wishes involving their advance directives/code status for one of one sampled resident (5).
- C Ensure residents have reasonable access to and privacy in their use of communication methods.
Inspectors wroteBased on interview, the provider failed to ensure the residents' right was maintained to have their mail delivered to all residents on Saturdays. The resident census was 52.
November 6, 2024Complaint inspection · 1 citation
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, interview, and manufacturer's reference guide review the provider failed to ensure the safety of one of one sampled resident (1) who fell from a mechanical lift (a lift and sling used to lift a person's body) that was not used by staff as the manufacturer directed and received skin injuries to her scalp and her elbow.
January 18, 2024Standard inspection · 3 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview and policy review the provider failed to maintain sanitary conditions in the kitchen and to ensure foods were stored, handled, prepared and served in a safe and sanitary manner for the following: *Appropriate glove use and hand hygiene for one of one cook (D) while preparing and serving food. *Appropriate glove use and hand hygiene for two of two dietary aides (G and H) while handling food. *Appropriate glove use and hand hygiene for one of one cook assistant/dietary aide (L) while serving food.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the following: *Appropriate use, storage, and disposal of personal protective equipment (PPE) by three of three registered nurses (RNs) (E, I, and J) after entering two of two sampled resident's (2 and 7) rooms who were on transmission-based precautions (TBP) for influenza A and COVID-19. *Signage for the type of isolation precautions required for two of two sampled residents (2 and 7). *Storage and labeling of resident's personal care items in one of one bathtub rooms. *Cleanliness was maintained in one of one bathtub room to prevent the buildup of residue and dust.
- D 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.
Inspectors wroteBased on record review, and policy review the provider failed to ensure resident and/or their representative received a written notification with information regarding a transfer to the hospital and was provided a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman for one of one sampled resident (42) that was reviewed for facility initiated hospital transfers.
January 26, 2023Standard inspection · 1 citation
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure a dressing change for one of three sampled residents (13) with a pressure ulcer had been: *Completed with appropriate and sanitary technique. *Completed according to the provider's wound care policy:
Fire safety inspections
3 fire safety citations on file: 1 on January 18, 2024, 2 on January 26, 2023.
Every fire safety citation3 citations
- D Ensure proper usage of power strips and extension cords.
- D Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D Have simulated fire drills held at unexpected times.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| July 17, 2025 | Fine | $48,412 |
| November 6, 2024 | Fine | $8,018 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | South Dakota | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.73 | 3.79 | 3.86 |
| Registered nurses | 1.00 | 0.80 | 0.69 |
| All nursing staff on weekends | 3.20 | 3.26 | 3.42 |
| Nurse aides | 2.42 | ||
| Licensed practical nurses | 0.31 | ||
| Nursing staff turnover (share who left in a year) | 52.2% | 48.2% | 45.8% |
| Registered nurse turnover | 27.3% | 34.7% | 42.9% |
| Administrators who left | 2 |
CMS expects 3.50 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.94 on weekdays and 3.20 on weekends, 19% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 3.6% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.48 in April to June 2025 to 3.73 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.73 | 1.00 | 3.94 | 3.20 | 3.6% | 0 of 90 | 55 |
| Oct to Dec 2025 | 3.68 | 1.02 | 3.98 | 2.93 | 0.0% | 0 of 92 | 52 |
| Jul to Sep 2025 | 3.82 | 0.77 | 4.07 | 3.20 | 0.0% | 0 of 92 | 52 |
| Apr to Jun 2025 | 3.48 | 0.86 | 3.76 | 2.77 | 2.8% | 0 of 91 | 54 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| South Dakota, Jan to Mar 2026 | 3.76 | 0.79 | 3.97 | 3.25 | 9.1% | 1.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
Staff pay at this home
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
Official wage estimates for South Dakota
| Job | Median | Middle half | Employed |
|---|---|---|---|
| South Dakota, all employers | |||
| CNAs (nursing assistants) | $18.65 | $17.71 to $21.12 | 6,860 |
| LPNs and LVNs | $25.36 | $23.88 to $29.47 | 2,050 |
| Registered nurses | $37.53 | $31.29 to $40.52 | 14,710 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | South Dakota | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 19.1 | 21.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.5 | 2.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 3.0 | 2.9 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.0 | 5.5 | 3.2 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 14.5 | 19.4 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 1.3 | 4.6 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 12.3 | 24.6 | 15.4 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.0 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.2 | 1.8 | 1.8 |
Owners and operators
Legal business name: BETHEL LUTHERAN HOME.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Bethel Lutheran Home | Direct ownership interest | Organization | 01/01/1966 | |
| Barber, Dawn | Indirect ownership interest | Individual | 04/01/2024 | |
| Breddin, Karl | Indirect ownership interest | Individual | 10/01/2021 | |
| Clem, Justin | Indirect ownership interest | Individual | 07/11/2018 | |
| Feldhaus, Maria | Indirect ownership interest | Individual | 10/01/2023 | |
| Glanzer, Rebecca | Indirect ownership interest | Individual | 07/20/2015 | |
| Schneider, Jeremiah | Indirect ownership interest | Individual | 07/18/2022 | |
| Voelker, Jackie | Indirect ownership interest | Individual | 10/01/2022 | |
| Barber, Dawn | Managing control - governing body | Individual | 04/01/2024 | |
| Breddin, Karl | Managing control - governing body | Individual | 10/01/2021 | |
| Feldhaus, Maria | Managing control - governing body | Individual | 10/01/2023 | |
| Voelker, Jackie | Managing control - governing body | Individual | 10/01/2022 | |
| Clem, Justin | Contracted managing employee | Individual | 07/11/2018 | |
| Glanzer, Rebecca | W-2 managing employee | Individual | 07/20/2015 | |
| Schneider, Jeremiah | W-2 managing employee | Individual | 07/18/2022 | |
| Schneider, Jeremiah | Corporate officer | Individual | 07/18/2022 | |
| Bethel Lutheran Home | Operational/managerial control | Organization | 12/13/2024 | |
| Barber, Dawn | Operational/managerial control | Individual | 12/13/2024 | |
| Breddin, Karl | Operational/managerial control | Individual | 12/13/2024 | |
| Clem, Justin | Operational/managerial control | Individual | 12/13/2024 | |
| Feldhaus, Maria | Operational/managerial control | Individual | 12/13/2024 | |
| Glanzer, Rebecca | Operational/managerial control | Individual | 12/13/2024 | |
| Schneider, Jeremiah | Operational/managerial control | Individual | 12/13/2024 | |
| Voelker, Jackie | Operational/managerial control | Individual | 12/13/2024 | |
| Bethel Lutheran Home | Adp of the SNF | Organization | 12/20/2024 | |
| Clem, Justin | Adp of the SNF | Individual | 12/20/2024 | |
| Glanzer, Rebecca | Adp of the SNF | Individual | 12/20/2024 | |
| Schneider, Jeremiah | Adp of the SNF | Individual | 12/20/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 4 problems in this area, most recently on July 17, 2025: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 3 problems in this area, most recently on July 17, 2025: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 3 problems in this area, most recently on July 17, 2025: "Provide and implement an infection prevention and control program."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 2 problems in this area, most recently on July 17, 2025: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.20 hours per resident per day, below the South Dakota average of 3.26.
- How long has the current administrator been here?CMS counts 2 administrators who left in the period it measured.
Other nursing homes nearby
- Good Samaritan Society Howard Howard, 20.7 mi · 5 of 5 stars · 4 citations
- Dells Nursing and Rehab Center Inc Dell Rapids, 23 mi · 4 of 5 stars · 16 citations
South Dakota contacts for a concern about a nursing home
These are the official offices in South Dakota. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: South Dakota Department of Health, Office of Health Facilities Licensure and Certification, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: South Dakota Long-Term Care Ombudsman Program, Department of Human Services. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: South Dakota Department of Health Nursing Facility Reports, where South Dakota publishes its own records on licensed homes.
Common questions
- What is Bethel Lutheran Home's Medicare star rating?
- CMS rates Bethel Lutheran Home 2 out of 5 stars overall, with 2 for health inspections, 4 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Bethel Lutheran Home get at its last inspection?
- 7 health deficiencies at the standard inspection on July 17, 2025. The South Dakota average is 6.7.
- Has Bethel Lutheran Home been fined?
- Yes. CMS lists 2 fines totaling $56,430 in the last three years.
- Does Bethel Lutheran Home accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Bethel Lutheran Home?
- CMS lists 28 owners and managers. Legal business name: BETHEL LUTHERAN HOME.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.