Bethel Lutheran Home

In the surveyor’s words

From the most serious findings on record at Bethel Lutheran Home, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 17, 2025

  Based 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.Findings include: 1. Observation on 7/15/25 at 8:45 a.m. of resident 3 in her room revealed she was resting in her recliner with her feet elevated and had blue heel protector boots [padded to relieve pressure] on. 2. Interview on 7/15/25 at 10:34 a.m. with infection preventionist C revealed that resident 3 was receiving wound care for a pressure ulcer. 3. […]

• Actual harm, isolatedF689Nov 6, 2024

  Based 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. Findings include: 1. Review of the provider's 10/18/24 SD DOH FRI regarding resident 1 revealed: *On 10/17/24 at 7:05 p.m. […]

• Actual harm, isolatedF697Aug 26, 2021

  Based on observation, interview, record review and policy review, the provider failed to ensure adequate pain control was monitored, reviewed, and appropriate interventions were implemented, including physician notification for one of one sampled resident (2) who had complaints of increased pain. Findings include: 1. Observation and interview on 8/24/21 at 4:31 p.m. with resident 2 revealed she: *Was alert and able to answer questions appropriately. *Had reported pain in her left knee related to an incident of being repositioned by night staff during which her left knee was twisted. -She could not recall the specific date this incident occurred. *Stated she felt she should have gone to the doctor. […]

• No harm, potential for more than minimal, widespreadF812Jul 17, 2025

  Based 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).Findings include: 1. Observations on 7/15/25 from 8:31 a.m. to 9:35 a.m. […]

• No harm, potential for more than minimal, widespreadF812Jan 18, 2024

  Based 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. Findings include: 1. Initial kitchen tour on [DATE] at 3:41 p.m. […]