Nursing HomeInspections

Bethel Lutheran Home

Nursing home in Madison, SD

Medicare & Medicaid certified2★ overall (CMS)

Call (605) 256-4539Send a messageMap ↗

Public-record details

Address
1001 S Egan Ave, Madison, SD 57042
Phone
(605) 256-4539
Listed under
Nonprofit
Medicare CCN
435076
Overall star rating
2 of 5 ★★☆☆☆
Health inspection rating
2 of 5
Staffing rating
4 of 5
Quality measures rating
4 of 5
Certified beds
59
Average residents per day
55
Ownership
Nonprofit, church related
Legal business name
Bethel Lutheran Home
Certified for
Medicare and Medicaid
First approved by Medicare/Medicaid
Apr 1, 1994
Changed ownership in last 12 months
No
Continuing care retirement community
No
Located inside a hospital
No
Resident or family council
Resident council
Sprinklers in all required areas
Yes

CMS certification number 435076. Source: CMS Nursing Home Provider Information, Health Deficiencies and Penalties (record). Data as of 2026-09-30.

Inspection record

Most recent standard health inspection: Jul 17, 2025. CMS lists 12 health citations for this facility across its last three standard inspection cycles and complaint inspections (Jan 26, 2023 to Jul 17, 2025): 1 from complaint inspections, 2 at the “actual harm” level or higher.

InspectionCitationSeverity
Jul 17, 2025Ensure residents have reasonable access to and privacy in their use of communication methods.
Resident Rights		C
Potential for minimal harm, widespread
Jul 17, 2025Honor 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…
Resident Rights		D
Potential for more than minimal harm, isolated
Jul 17, 2025Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights		E
Potential for more than minimal harm, pattern
Jul 17, 2025Provide 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.
Quality of Life and Care		E
Potential for more than minimal harm, pattern
Jul 17, 2025Provide and implement an infection prevention and control program.
Infection Control		E
Potential for more than minimal harm, pattern
Jul 17, 2025Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary		F
Potential for more than minimal harm, widespread
Jul 17, 2025Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care		G
Actual harm, isolated
Nov 6, 2024Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care · complaint inspection		G
Actual harm, isolated
Jan 18, 2024Notify 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.
Resident Rights		D
Potential for more than minimal harm, isolated
Jan 18, 2024Provide and implement an infection prevention and control program.
Infection Control		E
Potential for more than minimal harm, pattern
Jan 18, 2024Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary		F
Potential for more than minimal harm, widespread
Jan 26, 2023Provide and implement an infection prevention and control program.
Infection Control		D
Potential for more than minimal harm, isolated

Severity letters follow CMS's scope-and-severity grid: A–C potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, J–L immediate jeopardy. Most citations are corrected; a citation is what inspectors found on that date. Source: CMS Health Deficiencies file, processed Aug 1, 2026.

Fines and payment denials

CMS records 2 fines totalling $56,430 in the last three years.

Jul 17, 2025Fine: $48,412
Nov 6, 2024Fine: $8,018

Source: CMS Penalties file, processed Aug 1, 2026. Amounts are as CMS reports them and may reflect later reductions or appeals.

Staffing

Total nurse staffing per resident per day
3.73 hours
Registered nurse (RN) time per resident per day
1.00 hours
Nurse aide time per resident per day
2.42 hours
Total nurse staffing on weekends
3.20 hours
Nursing staff turnover (yearly)
52%
RN turnover (yearly)
27%
Administrators who left in the past year
2

From payroll-based staffing data the facility submits to CMS. Hours are per resident per day.

A citation is what inspectors found on one date; most are corrected within weeks. Look for patterns — the same problem cited in several inspections — and for anything at the G–L level (actual harm or immediate jeopardy). The full inspection narrative (Form CMS-2567) is linked from Medicare Care Compare, and your state long-term care ombudsman can tell you about complaints.