The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited July 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
Nursing home report
Bethel Lutheran Home
MADISON, SD · Medicare-certified · 59 beds
Needs attention
Non-profit
Data as of July 1, 2026
2 of 5 overall
Bethel Lutheran Home in Madison, SD has a 2-out-of-5 overall rating, with a 2-star health inspection score and a recent federal penalty plus $56,430 in fines over the last 24 months. Staffing is rated 4 stars, but reported nurse staffing is 3.73 hours per resident per day, below the federal benchmark of 4.1.
Facility ratings
Health inspections
Staffing
3.7281 hrs/resident/day
Quality measures
Last inspection: July 17, 2025Penalties, last 24 months: $56,430recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.7281.
Staffing detail
- Registered nurses
- 1.00
- Licensed practical nurses
- 0.31
- Nurse aides
- 2.42
- Weekend nursing
- 3.20
Hours per resident per day.
Total staff turnover: 52%
Registered nurse turnover: 27%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
7.9%15.2%Worsening
Residents with a fall causing major injury
2%1.9%No change
Residents with pressure ulcers (bedsores)
0%0%No change
Residents with a urinary tract infection
2%5.7%Worsening
Residents who lost too much weight
2.2%8.5%Worsening
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
25%23.4%Improving
Residents whose ability to walk got worse
18.1%16.4%Improving
Long-stay residents on antianxiety or sleep medication
17.4%16.7%Improving
Residents with a long-term catheter
0%1.8%Worsening
Residents with new or worsening incontinence
23.8%25.8%Worsening
Residents with depressive symptoms
0%0%No change
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—92.9%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the pneumonia vaccine
—100%—
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited November 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited July 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The home failed to ensure residents were treated with dignity and could make their own choices and communicate freely. Cited July 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 550 — 42 CFR §483.10(a) — S/S: E
The home failed to provide appropriate care to help a resident maintain or improve movement and mobility. Cited July 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 688 — 42 CFR §483.25(c) — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- PENALTY
A federal fine of $48,412 was recorded.
- INSPECTION
Health inspection found 7 health deficiencies.
See what inspectors found
- PENALTY
A federal fine of $8,018 was recorded.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 2 fines · $56,430 in total fines.
- $48,412
Federal fine
Jul 17, 2025
- $8,018
Federal fine
Nov 6, 2024
Operator & ownership
- Ownership
- Non profit - Church related
- Occupancy
- 54.7 residents on an average day (93% of 59 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 32 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.