Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethany Home Sioux Falls during CMS and state inspections, most recent first.
A resident with severe cognitive impairment eloped from the facility after the front door was left unmonitored and unalarmed when the administrative assistant stepped away without notifying staff. The resident exited undetected and was later found at a community member's home. Staff interviews and record review confirmed that required monitoring procedures were not followed, resulting in a lapse in supervision and resident safety.
A deficiency was identified when an LPN did not assess a resident or notify the physician after a family member reported concerns of a possible GI bleed, despite facility policy requiring immediate action for such symptoms. The resident, who had multiple co-morbidities and a significant drop in hemoglobin, did not receive timely evaluation or escalation of care, resulting in delayed medical intervention.
The provider failed to serve adequate portions during a lunch meal, affecting all residents on the main menu. The menu specified eight ounces of beef & broccoli and four ounces of diced carrots, but Cook L served only three ounces and two ounces, respectively. Despite knowing the correct portions, Cook L did not follow them, and the dietary manager was unaware of this issue.
The facility failed to maintain cleanliness in its kitchen equipment, with a convection oven and steamer found in unsanitary conditions. Observations revealed baked-on grease and food particles in the oven, and limescale and scum buildup in the steamer. Interviews indicated a lack of proper cleaning knowledge and adherence to cleaning schedules, despite audits marking the equipment as clean.
A resident did not receive the required SNF ABN and NOMNC before the end of their Medicare skilled services. The deficiency was linked to a lack of proper completion of these forms by a social worker, with conflicting reports on whether adequate training was provided.
An RN failed to provide necessary care and medication to 25 residents during a shift, as confirmed by video footage and staff interviews. The RN was absent from the unit for over an hour and did not perform required blood sugar checks, medication administrations, and treatments, despite documentation indicating otherwise. The facility's investigation revealed neglect of residents' needs, violating the policy on prevention of abuse and neglect.
The facility failed to provide written notices of transfer or discharge and notify the ombudsman for two residents. The deficiency was due to a previous social worker not fulfilling these responsibilities, as discovered during an investigation. Interviews with staff revealed uncertainty about the completion of required notices.
A facility failed to provide a written bed-hold notice to a resident's representative during a transfer to the emergency department. The social worker verbally communicated the policy, but no written documentation was made. The resident's representative declined to hold the bed and collected the resident's belongings.
The facility failed to update care plans for two residents to reflect their current medical conditions. One resident's care plan did not include a focus on dementia despite a diagnosis, and another's care plan did not reflect the initiation of a blood thinner for Atrial fibrillation. Interviews confirmed the oversight, contrary to the facility's policy requiring timely updates for significant changes.
Failure to Monitor Exit Door Results in Resident Elopement
Penalty
Summary
A resident with severely impaired cognition, as indicated by a BIMS score of seven, was admitted to the rehabilitation unit following a hospitalization for syncope and collapse. The resident was assessed as having a moderate risk for elopement due to her mobility, though she had not previously verbalized a desire to leave. On the day of the incident, the resident became upset after a care conference with her family, during which concerns about her ability to return home independently were discussed. Later that day, the resident exited the facility through the front door without staff knowledge. The front door was supposed to be locked and alarmed automatically at a certain time, but prior to that, it was to be monitored by staff. At the time of the elopement, the administrative assistant responsible for monitoring the front door had stepped away to make copies and did not notify other staff to monitor the door in her absence. As a result, the door was left unmonitored and unalarmed, allowing the resident to leave undetected. Staff only became aware of the elopement when a community member called to report that the resident was at their home nearby. Interviews with staff confirmed that rounds were conducted every two hours or less, but no one responded to a door alarm because none was triggered. The facility's elopement procedure required that residents' whereabouts be known at all times, but this was not followed due to the lapse in monitoring the front door. The resident was later found safe and returned to the facility, but the incident revealed a failure to ensure the area was free from accident hazards and that adequate supervision was provided to prevent accidents.
Failure to Assess and Notify Physician for Suspected GI Bleed
Penalty
Summary
A deficiency occurred when an LPN failed to follow facility policy and practice within the scope of licensure after a family member raised concerns about a resident potentially experiencing a gastrointestinal (GI) bleed, as evidenced by black, pasty stools. The LPN documented the family’s concern and attributed the symptoms to new medications but did not assess the resident, notify the physician, or contact on-call leadership staff, despite facility policy requiring immediate physician notification for bleeding or bloody stools not due to hemorrhoids. There was no documentation of an assessment or escalation of the concern on the evening the issue was reported. The resident involved had multiple co-morbidities, including osteomyelitis, long-term anticoagulant use, diabetes with polyneuropathy, peripheral vascular disease, congestive heart failure, hypertension, and atrial fibrillation. Upon admission, the resident was alert, oriented, and had stable vital signs, receiving IV antibiotics and regular lab monitoring. Lab results showed a significant drop in hemoglobin over several days, and the resident was dependent on staff for toileting. Despite the family’s report of black, tarry stools, there was no documentation of such findings in the medical record, and the required assessment and physician notification were not performed promptly. Interviews with other nursing staff and the DON confirmed that the expected protocol was to assess the resident and notify the physician or on-call leadership when concerns were raised by family members. The facility’s policy specified immediate physician notification for suspected GI bleeding. The LPN’s failure to assess the resident and escalate the concern as required led to a delay in appropriate medical intervention and contributed to the identified deficiency.
Inadequate Portion Sizes Served During Lunch
Penalty
Summary
The provider failed to ensure that adequate portions were served according to the menu during a lunch meal, which had the potential to affect all residents receiving the main menu in the facility. On 11/7/24, the menu for lunch included beef & broccoli with a serving size of eight ounces and diced carrots with a serving size of four ounces. However, during the lunch service, Cook L served only three ounces of beef & broccoli and a heaping two ounces of diced carrots, despite the availability of the correct serving utensils. Cook L was aware of the serving sizes on the printed menu but chose not to use the correct portions without providing a reason. The dietary manager, G, was unaware that incorrect portion sizes were served and acknowledged the importance of following the approved menu to meet residents' dietary requirements.
Failure to Maintain Cleanliness in Kitchen Equipment
Penalty
Summary
The facility failed to maintain cleanliness in its kitchen equipment, specifically a Vulcan brand convection oven and a Cleveland brand SteamChef steamer. During an initial kitchen tour, it was observed that the convection oven was heavily coated in baked-on grease and food particles, while the steamer had an excessive buildup of limescale and scum, with food particles sitting in standing water at the bottom of the basin. These observations indicate a lack of adherence to proper cleaning protocols and standards for kitchen equipment maintenance. Interviews with the kitchen staff revealed further issues contributing to the deficiency. A cook admitted to cleaning the equipment daily and deep-cleaning weekly, but acknowledged that the equipment had not been deep-cleaned in about a month and was unaware of the proper cleaning steps for the steamer. The dietary manager confirmed the existence of a cleaning schedule and monthly audits for kitchen cleanliness but was unaware of the equipment's dirty condition and also did not know the proper cleaning steps for the steamer. A review of the provider's monthly kitchen cleanliness audits showed that the ovens and steamer were marked as clean and in good repair, despite the observed conditions. Additionally, the manufacturer's cleaning guidelines for the steamer recommended daily descaling to prevent mineral buildup, which was not being followed.
Failure to Provide Required Medicare Notices
Penalty
Summary
The provider failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) for one of the sampled residents who received Medicare Part A skilled services. Specifically, Resident 247 did not receive the SNF ABN form CMS-10055 or NOMNC form CMS-10123 before the end of their Medicare skilled services on 9/23/24. This oversight was identified during a review of the provider's documentation and was attributed to a lack of proper completion of these forms by the previous social worker (SW) O. Interviews conducted with SW O and SW P revealed conflicting accounts regarding the training provided on completing the ABNs. SW O reported not receiving training upon hiring, while SW P claimed to have provided the necessary training. This discrepancy contributed to the failure in issuing the required notifications to Resident 247, leading to the identified deficiency.
RN Fails to Administer Care and Medications to Residents
Penalty
Summary
The report details a significant deficiency involving a registered nurse (RN) identified as RN F, who failed to provide necessary care and medication administration to 25 residents during a twelve-hour shift. On the specified date, RN F was absent from her unit for a period of time and was unaccounted for by the staff. During her shift, RN F was observed on video footage leaving the unit and not returning for over an hour and a half. Despite being reminded by a certified nursing assistant (CNA) to administer morning narcotics to three residents, RN F did not visibly enter the residents' rooms to provide the medications, although they were signed off as administered. The facility's investigation revealed that RN F did not perform the required blood sugar checks, medication administrations, and treatments for the residents under her care. The video footage confirmed that RN F did not enter the rooms of the residents to provide the documented care. The residents were supposed to receive various treatments, including pain management patches, insulin administration, blood sugar checks, and other medications, which were not carried out as per the orders. The documentation by RN F indicated that these tasks were completed, but the investigation and video evidence contradicted this. The director of nursing (DON) confirmed through interviews with other staff and video review that RN F did not provide the necessary care to the residents. The facility's policy on the prevention of resident abuse, neglect, and misappropriation of property was not adhered to, as RN F's actions constituted neglect of the residents' needs. The video surveillance footage that could have further substantiated these findings was not made available for survey review during the investigation.
Failure to Provide Required Transfer Notices
Penalty
Summary
The provider failed to provide a written notice of transfer or discharge and to notify the ombudsman for two residents. The deficiency was identified during an interview and record review, which revealed that the previous social worker did not provide the required written notices for transfers or discharges. Specifically, one resident was transferred to the local emergency department on two occasions, and another resident was transferred once, with no documentation of the required notices or ombudsman notification for any of these instances. The issue was discovered when the facility's management team conducted an investigation after noticing a lack of documentation for required notices. The investigation revealed that the previous social worker was responsible for the oversight. Interviews with staff, including a nurse manager, indicated uncertainty about whether the notices were completed correctly due to the previous social worker's actions.
Failure to Provide Written Bed-Hold Notice
Penalty
Summary
The provider failed to provide a written bed-hold notice to a resident or their representative when the resident was transferred to the emergency department. This deficiency was identified during an interview and record review, which revealed that the previous social worker responsible for issuing these notices did not provide the required written documentation. Specifically, for one resident, although the social worker verbally communicated the bed-hold policy to the resident's representative, there was no written notice documented. The resident's representative declined to hold the bed and collected the resident's belongings from the facility. The deficiency was discovered when the facility's management team conducted an investigation into the lack of documentation for various required notices. The investigation revealed that the former social worker had not been providing the necessary written notices, including bed-hold notices. This issue was identified as part of a broader problem with documentation that the facility addressed through corrective actions.
Care Plan Updates Not Reflecting Residents' Current Conditions
Penalty
Summary
The provider failed to ensure that the care plans for two residents were updated to reflect their current medical conditions. Resident 11 was diagnosed with dementia and other diseases on August 6, 2024, and was prescribed Seroquel for Major Depressive Disorder on August 15, 2024. However, the care plan updated on August 20, 2024, did not include a focus area for the resident's dementia diagnosis, only noting the use of psychotropic medications for pain management and depression. Similarly, Resident 25 was prescribed Apixaban for Atrial fibrillation on August 23, 2024, to prevent blood clots. Despite this, the care plan updated on October 29, 2024, failed to reflect the initiation of Apixaban. Interviews with the director of nursing, nurse manager, and administrator confirmed that the care plans for both residents had not been updated to meet their care needs. The facility's policy requires care plans to be updated with significant changes, but this was not adhered to in these cases.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sioux Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society Luther Manor | 0.9 mi | ★★★★★ | 11 | 0 |
| Avantara Norton | 1.5 mi | — | 21 | 0 |
| Dow Rummel Village | 2.2 mi | ★★★★★ | 6 | 0 |
| Good Samaritan Society Sioux Falls Center | 2.2 mi | ★★★★★ | 19 | 0 |
| Good Samaritan Society Sioux Falls Village | 2.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.