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
3 of 5 overall
Bethel Lutheran Home (Madison, SD) has an overall 3-star rating, with stronger staffing and quality measures but a 2-star health inspection rating. Reported nurse staffing is 3.68 hours per resident per day, below the federal benchmark of 4.1, and the home had $56,430 in fines in the last 24 months with a recent federal penalty.
Facility ratings
Health inspections
Staffing
3.6825 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 3.6825.
Staffing detail
- Registered nurses
- 1.02
- Licensed practical nurses
- 0.41
- Nurse aides
- 2.26
- Weekend nursing
- 2.93
Hours per resident per day.
Total staff turnover: 55%
Registered nurse turnover: 36%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
9.2%Worsening
Residents with a fall causing major injury
2%Steady
Residents with pressure ulcers (bedsores)
1.9%Steady
Residents with a urinary tract infection
2%Improving
Residents who lost too much weight
2.7%Worsening
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
14.1%Worsening
Residents whose ability to walk got worse
13%Improving
Show all measures
Long-stay residents on antianxiety or sleep medication
15.3%Worsening
Residents with a long-term catheter
2.5%Improving
Residents with new or worsening incontinence
24.1%Improving
Residents with depressive symptoms
0%Steady
Long-stay residents given the seasonal flu vaccine
92.9%Steady
Long-stay residents given the pneumonia vaccine
100%Steady
Short-stay residents given the pneumonia vaccine
100%Steady
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
- 52.4 residents on an average day (89% 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.