Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Bethel Lutheran Home during CMS and state inspections, most recent first.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found lapses in assessment, monitoring, and preventive strategies for pressure ulcer management.
Surveyors found extensive failures in food safety and sanitation, including unsanitary kitchen equipment, deteriorating cabinetry with possible mold, expired and improperly stored foods, and repeated lapses in hand hygiene and glove use by dietary staff and feeding assistants. These deficiencies were observed during meal preparation and service, with staff handling ready-to-eat foods and assisting multiple residents without proper handwashing or glove changes, contrary to facility policies.
During an observed meal service, multiple residents experienced significant delays in receiving their meals, with some waiting up to an hour after being seated. Staff interviews confirmed there was no clear serving order, and a bottleneck at the service window contributed to the delays. Several residents who required full assistance with eating were left unattended with their meals for several minutes. These actions failed to uphold residents' rights to dignity and respect as outlined in facility policy.
A resident did not receive the necessary care and services to maintain or improve ROM, limited ROM, or mobility, and there was no documented medical reason for the decline.
Surveyors found that staff did not consistently use required PPE during high-contact care for a resident with an indwelling catheter, failed to properly clean and store nebulizer equipment for three residents, and used a linen cart without an adequate protective cover, leaving clean linen exposed. These actions were not in accordance with facility policies and infection control standards.
A resident with moderate cognitive impairment had conflicting documentation regarding her CPR wishes, with her advance directive indicating DNR and a separate form in the paper chart indicating she wanted CPR. Staff referenced both the EMR and paper chart, which did not match, leading to confusion about the resident's true code status. Facility policy required honoring advance directives, but inconsistent records resulted in uncertainty.
The facility did not ensure that residents received their mail within 24 hours of delivery to the facility, as Saturday mail was routinely held and distributed on Mondays. Staff interviews confirmed a lack of awareness and inconsistent practices regarding weekend mail delivery.
A resident with severe cognitive impairment and bilateral lower amputations fell from a mechanical lift during a transfer, resulting in injuries. The incident occurred because the sling was not positioned correctly, causing the resident to slip through. The CNAs involved had varying levels of experience with the lift, and one had not received formal training at the facility.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving the necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The report highlights lapses in the facility's pressure ulcer care practices, including inadequate assessment, monitoring, and preventive strategies for at-risk residents.
Widespread Food Safety and Sanitation Deficiencies in Kitchen and Dining Areas
Penalty
Summary
Surveyors identified multiple failures in food safety and sanitation practices within the facility's kitchen and dining areas. Observations revealed that the kitchen environment was not maintained in a sanitary condition, with soiled equipment such as a tea dispenser with sticky residue, undated tea bags, and dust-covered filters. The cabinetry, made of wooden particle board, showed signs of water damage, warping, and possible mold, particularly under sinks and near the water heater. The dishwashing area had peeling paint, exposed and damaged drywall, and a makeshift sink basin using an old food bucket. The dishwasher itself had lint in the spray nozzles and a buildup of soap scum and food particles. Food preparation and storage areas were also unsanitary, with drawers containing food crumbs and dust, and perishable foods like butter being stored at room temperature against manufacturer instructions. Expired and improperly stored foods were found in both the walk-in cooler and dry storage areas. Several bags of spinach were wilted and leaking fluids, having been delivered over three weeks prior and not discarded. A bucket of white dipping icing was found with unclear labeling and an expired use-by date. Staff interviews confirmed a lack of awareness regarding proper food storage, with dietary aides admitting to storing butter at room temperature for spreadability, despite clear labeling that it should be refrigerated. The dietary manager, new to her position, acknowledged awareness of the deteriorating kitchen infrastructure but had not yet addressed these issues. Food handling practices among staff did not meet professional standards. Dietary aides and cooks were observed repeatedly failing to perform hand hygiene before donning gloves, after changing gloves, or between tasks. One dietary aide was seen touching multiple surfaces and ready-to-eat foods with the same pair of gloves, even after wiping her face. A paid feeding assistant assisted multiple residents with eating and personal care without performing hand hygiene between residents or after direct contact. These actions were inconsistent with the facility's own policies on glove use, hand hygiene, and food handling, which require handwashing before glove use, changing gloves between tasks, and preventing bare hand contact with ready-to-eat foods.
Failure to Serve Meals Promptly Undermines Resident Dignity
Penalty
Summary
The facility failed to maintain residents' dignity and respect by not serving meals promptly during one of two observed meal services. Multiple residents, including the resident council president, reported frequent and lengthy wait times for meals, with some residents waiting up to an hour. These concerns were not documented in the resident council minutes, and it was unclear if they had been communicated to facility management. Observations during the evening meal service confirmed that several residents waited between 23 and 66 minutes to receive their meals after being seated in the dining room. Some residents who required full assistance with eating were left with their meals untouched for several minutes before receiving help. Staff interviews revealed there was no established order for serving residents, and dietary aides prioritized residents with diabetes but otherwise served individuals as they arrived. The dietary manager and registered dietitian both acknowledged the issue, attributing delays to a bottleneck at the service window, where only one person was responsible for plating meals. The registered dietitian stated that ideally, residents should be served as soon as they arrive, and waiting over an hour was considered highly unusual. The facility's dining policy emphasized person-centered care, dignity, and serving all individuals at the same table simultaneously to the best of staff availability, but these procedures were not consistently followed during the observed meal service. Several residents expressed frustration and dissatisfaction with the long wait times, both in interviews and through their actions, such as attempting to leave the dining room before being served. Staff attempted to encourage residents to remain seated and order food, but delays persisted. The lack of timely meal service and assistance for residents who required help with eating directly impacted their dining experience and failed to uphold their right to dignity and respect as outlined in facility policy.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Infection Control Deficiencies in PPE Use, Nebulizer Equipment Handling, and Linen Transport
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control program. For a resident with an indwelling urinary catheter who required staff assistance for transfers, toileting, and catheter care, staff failed to consistently implement Enhanced Barrier Precautions (EBP) as required. Observations revealed that staff did not always wear gowns and gloves during high-contact care activities such as transferring and catheter care, despite clear signage and policy requirements. Staff interviews indicated a lack of understanding regarding when PPE was necessary, with some staff believing gowns and gloves were only needed for toileting or catheter care, not for transfers. Additionally, staff were observed reusing gowns or not donning PPE at all during resident care, and the resident’s catheter bag was placed on the floor without a barrier, contrary to infection control expectations. Further deficiencies were observed in the handling and storage of nebulizer equipment for three residents. Nebulizer masks and tubing were found lying uncovered directly on bedside tables or nightstands, with liquid visible in the medication reservoirs. Facility policy required that nebulizer equipment be rinsed after each use, washed daily, and stored on a clean barrier, but these procedures were not followed. Staff interviews confirmed that the expected cleaning and storage protocols were not consistently implemented, and the equipment was not replaced or stored as per policy. Additionally, the facility failed to ensure that clean linen was protected during transport. One of two clean linen carts used for distributing linens lacked a suitable protective cover, leaving the ends open and the linen exposed. The cover in use was made of fabric, was not cleanable, and was not being machine washed. Both the infection preventionist and environmental services director acknowledged that the cover did not adequately protect the linen from contamination, which was inconsistent with the facility’s policy requiring clean linen to be protected from dust and soiling during transport and storage.
Failure to Ensure Consistent Documentation of Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure accurate and consistent documentation of a resident's advance directives and code status. Record review showed that the resident, who had moderate cognitive impairment, had conflicting information regarding her wishes for cardiopulmonary resuscitation (CPR). Her advance directive, signed by the resident, indicated she did not want CPR, while a separate CPR Statement of Decision form, signed by her power of attorney and physician, indicated she did want CPR. The electronic medical record (EMR) listed her as do not resuscitate (DNR), and her physician had ordered DNR status in the EMR. However, the paper chart contained the conflicting CPR Statement of Decision form, and staff referenced both the paper chart and EMR to determine code status. Interviews with nursing staff revealed confusion regarding which document reflected the resident's true wishes, as the paper chart and EMR did not match. Staff indicated that the CPR Statement of Decision form was reviewed quarterly with the family, but discrepancies persisted. The director of nursing confirmed that code status should match in both the EMR and paper chart. Facility policy stated that advance directives would be honored and that residents have the right to formulate such directives, but the inconsistent documentation led to uncertainty about the resident's actual code status.
Failure to Timely Deliver Resident Mail on Weekends
Penalty
Summary
The facility failed to ensure that residents had reasonable access to their mail, as required. Interviews revealed that while mail was delivered to the facility on Saturdays, it was not distributed to residents until the following Monday. The activities coordinator was unaware of weekend mail delivery and stated that mail was typically delivered to residents only during the week. The business manager confirmed that Saturday mail was held and distributed on Monday mornings, and the administrator was unaware of the requirement to deliver mail to residents within 24 hours of receipt by the facility. The resident census at the time was 52.
Resident Falls from Mechanical Lift Due to Improper Use
Penalty
Summary
A resident with severe cognitive impairment and bilateral lower amputations fell from a mechanical lift while being transferred by staff. The incident occurred when the sling used in the transfer was not positioned according to the manufacturer's instructions, leading to the resident slipping through the sling and sustaining injuries. The resident had a history of dementia with behavioral disturbances, pressure ulcers, spinal stenosis, and was non-weight bearing, requiring full assistance for transfers. During the transfer, the certified nursing assistants (CNAs) involved did not attach the sling straps correctly, which contributed to the resident slipping out. The sling got caught on the wheelchair, causing the resident to slide through the sling and fall to the floor, resulting in a superficial abrasion on the back of the head and a skin tear on the left elbow. The CNAs involved had varying levels of experience with the mechanical lift, and one CNA had not received formal training on its use at the facility. The incident highlighted issues with staff training and the use of mechanical lifts, as well as the need for proper equipment and procedures to ensure resident safety. The facility's documentation and interviews with staff revealed gaps in training and competencies, particularly for agency staff, which may have contributed to the improper use of the lift and the resulting accident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 8 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society Howard | 20.7 mi | ★★★★★ | 4 | 0 |
| Dells Nursing And Rehab Center Inc | 23 mi | ★★★★★ | 4 | 0 |
| Flandreau Santee Sioux Tribe Care Center | 25.6 mi | ★★★★★ | 1 | 0 |
| Riverview Healthcare Center | 26.5 mi | ★★★★★ | 11 | 1 |
| United Living Community | 26.7 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bethel Lutheran Home.
100% money-back within 48 hours.
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.