Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethany Home - Brandon during CMS and state inspections, most recent first.
A CNA/CMA engaged in verbal abuse and neglect by withholding fluids, denying requests for beverages, yelling, and attempting to force-feed several residents in a memory care unit. These actions caused distress and agitation among cognitively impaired residents, and were corroborated by staff observations and interviews.
Multiple residents sustained serious injuries after CNAs failed to use whirlpool bath chair safety belts as required and did not follow care plan instructions for mechanical lift transfers. In two cases, residents fell from bath chairs after the safety belt was removed and staff turned away, resulting in fractures and hospitalization. In another case, a resident was transferred alone with the wrong lift device, leading to a leg fracture. Staff interviews and records confirmed that safety protocols were not followed despite prior training.
A resident with a history of falls and moderate cognitive impairment fell forward from her wheelchair and sustained a head laceration requiring sutures when staff transported her without the required wheelchair foot pedals in place. Staff interviews and record review confirmed that the facility's policy mandated the use of foot pedals for wheelchair users, but the pedals were not attached at the time of the incident, leading to the resident's injury.
Two residents with severe cognitive impairment experienced abuse and neglect by CNAs: one was subjected to aggressive handling and verbal abuse during care, while another was left on a bedpan for an extended period, resulting in a skin injury. Both incidents involved failure to follow care plans and required interventions for dependent residents.
A nurse failed to properly document the administration of controlled medications for a resident, leaving medications unattended and incorrectly recording doses of lorazepam and oxycodone. Discrepancies were found between medication cards, controlled drug records, and the MAR, with some doses not documented or signed out as required. These actions resulted in inaccurate records and a lack of proper accountability for controlled substances.
The facility failed to maintain proper sanitation practices in the kitchen and neighborhood kitchenettes, with expired sanitizer test strips and inconsistent dishwasher temperature logs. Additionally, a CNA was observed handling a resident's food with bare hands, contrary to policy. These deficiencies increased the risk of foodborne illnesses for residents.
The facility failed to ensure proper oversight in the food and nutrition services department, as the dietary director was unaware of nursing home kitchen regulations and no food service audits were conducted. The consultant dietitian's visits were undocumented, and the dietary director's responsibilities, including policy development and kitchen maintenance, were not fulfilled. This lack of oversight increased the risk of foodborne illnesses for residents.
The facility failed to maintain privacy and obtain consent for audio and video monitoring devices in residents' rooms. Observations revealed that 13 residents had monitoring devices without proper signage or consent, compromising privacy. Several residents were unaware of the devices, and their EMRs lacked documentation of consent or care plan updates. Staff were not adequately informed about the devices, and the facility's privacy policy did not address their use.
The facility failed to implement an effective grievance process, compromising residents' rights to file grievances and have them addressed. Issues included lack of documentation, investigation, and follow-up on grievances, as well as outdated policies and no formal tracking system. Residents reported unresolved concerns about food quality and missing personal items, while staff interviews revealed inconsistencies in handling grievances.
The facility failed to accurately code MDS assessments for two residents using seat belts in their wheelchairs. One resident, with intact cognition, used a seat belt daily by choice, while the other, moderately cognitively impaired, rarely used it. Observations and interviews revealed discrepancies in MDS coding, with the director of nursing confirming the seat belts were coded as restraints, despite stating they were not used as such.
A CNA suspected of being intoxicated was allowed to work a weekend shift without thorough investigation by the facility. Despite staff reports of strange behavior and the smell of alcohol, the CNA continued working until termination the following Monday. The facility's failure to enforce its policies on alcohol use and conduct a timely investigation represents a deficiency.
Failure to Protect Residents from Verbal Abuse and Neglect by CNA/CMA
Penalty
Summary
The facility failed to protect multiple residents from verbal abuse and neglect by a certified nurse aide/certified medication aide (CNA/CMA). The incident involved the CNA/CMA withholding fluids from residents during meals as a form of punishment for making a mess or for concerns that they would not eat if given drinks. Additionally, the CNA/CMA denied a resident's repeated requests for coffee, yelled at residents, and attempted to force-feed residents by shoving large bites of food into their mouths while yelling at them to eat. These actions caused distress and agitation among the residents, particularly those with significant memory and cognitive decline residing in a secured memory care unit. The report details that the CNA/CMA also scolded a resident for wanting to change her clothes frequently, attributing it to creating extra work and laundry for staff. Staff interviews and record reviews confirmed that these behaviors were observed and reported by another CNA/CMA, and additional staff corroborated the allegations. The affected residents included those with cognitive impairments who were particularly vulnerable to such treatment, and the incidents occurred in a specialized memory care neighborhood designed to provide a structured and supportive environment. Prior to the incident being reported, there were no documented concerns or disciplinary actions related to the CNA/CMA's care or treatment of residents, aside from previous medication administration errors. The deficiency was substantiated through staff interviews and review of the facility's records, which confirmed that the residents were subjected to verbal abuse and neglect by the CNA/CMA during the provision of care.
Failure to Follow Safety Protocols During Bathing and Transfers Resulting in Resident Injuries
Penalty
Summary
Certified nursing assistants (CNAs) failed to follow established safety protocols during resident bathing and transfers, resulting in serious injuries to multiple residents. In two separate incidents, CNAs removed the whirlpool bath chair safety belt before the residents were ready to be transferred, leaving the residents unsecured. In one case, a CNA turned away from a resident after removing the safety belt to retrieve nail clippers, and the resident fell forward out of the bath chair, sustaining a pelvic fracture. In another case, a CNA removed the safety belt to dry a resident and turned away, leading to the resident falling out of the chair and suffering multiple fractures, including to the spine, pelvis, and tibia. Both residents required hospitalization for their injuries. Additionally, a CNA failed to follow the care plan for a resident requiring transfer with a mechanical total lift and assistance from two staff members. Instead, the CNA transferred the resident alone and used the incorrect lift device, contrary to the resident's care plan and facility policy. This resulted in the resident sustaining an acute fracture of the proximal tibia in her lower left leg. The injury was discovered later when a bruise was noted, and subsequent assessment and imaging confirmed the fracture. The resident was under hospice care at the time of the incident. Interviews and observations confirmed that staff were aware of the facility's policies requiring the use of safety belts during bathing and the need for two staff members during mechanical lift transfers. Documentation showed that the involved CNAs had previously received training on these procedures. Despite this, the protocols were not followed, directly leading to the residents' injuries during routine care activities.
Failure to Ensure Use of Wheelchair Foot Pedals Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, traumatic subdural hemorrhage, and moderate cognitive impairment fell from her wheelchair and sustained a laceration to her forehead that required sutures. The incident took place when the resident was being transported in her wheelchair without the required foot pedals in place, contrary to facility policy. The absence of the foot pedals caused the resident to fall forward out of the wheelchair, resulting in injury. Record review showed that the resident had a care plan identifying her as being at risk for falls, with multiple falls reported in the previous six months, including one that led to her current admission. On the day of the incident, staff responded to a call for help and found the resident on the floor, bleeding from her forehead. The injury could not be controlled with pressure, and the resident was transported to the emergency department, where she received sutures before returning to the facility. Interviews with staff revealed that the use of wheelchair foot pedals was expected and outlined in facility policy, which required pedals to be used unless otherwise care planned. However, at the time of the incident, the pedals were not attached to the resident's wheelchair. Staff acknowledged awareness of the importance of using foot pedals, and the director of nursing confirmed that no formal monitoring mechanism was in place to ensure compliance with this requirement.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A cognitively impaired resident residing in a secured memory care unit, who was dependent on staff for activities of daily living and known to be resistive to care, was subjected to verbal and physical abuse by a certified nursing assistant (CNA). The CNA became frustrated while assisting the resident with undressing, aggressively removed the resident's arm from his sweatshirt, and attempted to pry the shirt from his hands, causing the resident to verbally express pain. The incident was witnessed by another staff member, who reported discomfort with the CNA's actions and observed a change in the CNA's demeanor upon realizing she was being watched. The resident had severe cognitive impairment and was unable to be interviewed about the incident. In a separate incident, another cognitively impaired resident who required total staff assistance for toileting and repositioning was left on a bedpan for an extended period of time by a CNA. The resident was unable to reposition herself and was found with linear, slow-to-blanch marks on her buttock, consistent with prolonged pressure from a bedpan. Documentation and staff interviews confirmed that the resident had been placed on the bedpan during the night shift and was not removed until discovered by day shift staff several hours later. The resident's care plan required frequent repositioning and total assistance with toileting, which was not provided as required. Both incidents involved residents with significant cognitive impairment and dependency on staff for care. In the first case, the resident's care plan included specific interventions for resistance to care, such as reassurance and re-approaching after a short interval, which were not followed. In the second case, the failure to remove the resident from the bedpan in a timely manner resulted in a skin injury. The events were substantiated through staff interviews, record reviews, and direct observation, demonstrating failures to protect residents from abuse and neglect.
Failure to Accurately Document and Account for Controlled Medications
Penalty
Summary
A deficiency occurred when a nurse failed to correctly document the administration of controlled medications for a resident. Specifically, the nurse left controlled medications unattended on top of a medication cart and incorrectly signed out three doses of lorazepam on the controlled drug record, while the actual medication card count did not match the documentation. Additionally, the nurse signed out doses of oxycodone on the medication administration record (MAR) but did not document the administration of lorazepam in the MAR, and a scheduled lorazepam dose was documented at a different time. There were also discrepancies in the narcotic count sheets for both lorazepam and oxycodone, with mismatched counts between the medication cards and the controlled drug records. Further review revealed that another nurse administered a dose of oxycodone but failed to sign it out on the controlled drug record. During shift changes and narcotic counts, discrepancies were noted, and requests to correct the narcotic records were not immediately addressed. The nurse responsible for the errors admitted to incorrectly signing out doses and not documenting medication administration in the MAR. These actions and inactions led to inaccurate records and discrepancies in the accountability of controlled substances for the resident.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper sanitation practices in the main kitchen and neighborhood kitchenettes, leading to potential risks of foodborne illnesses for residents. Observations revealed that staff were unable to verify the chemical sanitation levels required for cleaning kitchen surfaces, as the sanitizer test strips were expired and not used. Additionally, there was no system in place to document the testing of sanitizer solutions, and the dishwasher temperatures were not consistently recorded, with some rinse cycles failing to meet the manufacturer's required minimum of 180 degrees Fahrenheit. In the neighborhood kitchenettes, the dishwashers were not consistently reaching the required rinse temperature of 180 degrees Fahrenheit, as specified by the manufacturer's manual. Maintenance staff were responsible for overseeing the dishwashers but did not keep logs of temperature checks, and the dishwashers were only monitored about once every three weeks. This lack of consistent monitoring and documentation increased the risk of unsanitary dishware being used for resident meals. Furthermore, a hospice CNA was observed assisting a resident with eating a sandwich using bare hands, contrary to the facility's policy that required the use of gloves or utensils when handling ready-to-serve foods. The CNA later acknowledged the mistake and received additional training. The facility's director of nursing confirmed that the CNA should have worn gloves, highlighting a lapse in adherence to food handling protocols.
Deficiency in Food and Nutrition Services Oversight
Penalty
Summary
The facility failed to ensure that the dietitian and dietary director effectively carried out the functions of the food and nutrition services department. This failure was identified through observation, interviews, record reviews, and job description reviews. The dietary director, who had been in her position for two months, was not aware of the regulations applicable to nursing home kitchens and had not seen the necessary policies until the survey week. Additionally, there were no food service-related audits conducted since she started. The consultant registered dietitian visited weekly but did not record these visits, although documentation was made in residents' medical records. The dietary director's position description outlined responsibilities such as consulting with the dietitian, maintaining a clean kitchen environment, and developing policies in compliance with food service regulations. However, these responsibilities were not fulfilled, as evidenced by the lack of oversight in cleaning, sanitization, and record-keeping in the main kitchen and four kitchenettes. The contract for registered dietitian services was not signed by the current facility administrator, and the maintenance director's position description did not include oversight of the kitchenettes or monitoring of dishwasher temperatures. This lack of oversight increased the potential risk of foodborne illnesses for residents receiving meals from these areas.
Failure to Maintain Privacy and Obtain Consent for Monitoring Devices
Penalty
Summary
The deficiency report highlights the failure of the provider to maintain privacy and obtain consent for the use of audio and video monitoring devices in residents' rooms. Observations and interviews revealed that 13 residents had monitoring devices in their rooms, but there was no signage indicating their presence, and consent was not obtained for six of these residents. The devices were used for monitoring purposes, such as fall prevention, but the lack of consent and signage compromised residents' privacy. Several residents were unable to identify the monitoring devices in their rooms, and there was no documentation in their electronic medical records (EMR) indicating that consent had been obtained or that care plans had been updated to reflect the use of these devices. For instance, resident 13's EMR lacked documentation of consent, and the care plan was not updated. Similarly, resident 106 had an audio device in their room without consent or care plan updates, and the device was later removed without explanation. The report also notes that the facility's staff, including newly hired employees, were not adequately informed about the presence and use of these monitoring devices. Interviews with staff members revealed a lack of awareness and training regarding the devices, and the facility's privacy policy did not specifically address the use of monitoring devices. The absence of a formal consent process and the failure to post notices about the monitoring devices contributed to the deficiency in maintaining residents' privacy and confidentiality.
Failure to Implement Effective Grievance Process
Penalty
Summary
The facility failed to implement an effective grievance process, which compromised the residents' right to file grievances and have them addressed appropriately. The provider did not ensure that all written grievance decisions included essential details such as the date the grievance was received, a summary of the grievance, steps taken to investigate, findings, conclusions, and any corrective actions. Additionally, the facility did not maintain grievance documentation for the required period of three years, nor did it make prompt efforts to resolve grievances or keep residents informed of progress. Interviews with residents and staff revealed multiple instances where grievances were not documented or followed up on. Resident 20 expressed ongoing concerns about the quality of food, which were voiced to staff, at resident council meetings, and during care plan conferences, yet remained unaddressed. Similarly, resident 41's husband reported a missing bag of personal items and concerns about the quality of fish served, but these issues were not formally documented or resolved. Staff interviews indicated a lack of clarity and consistency in handling grievances, with some staff not filling out grievance forms for reported concerns. The facility's grievance policy was outdated, and there was no formal grievance tracking system in place. The social services director was unaware of the updated grievance policy and continued to use an outdated form. The life enrichment director documented resident concerns during council meetings but did not fill out grievance forms or receive consistent responses from department directors. The administrator confirmed the absence of a grievance log and formal grievances, indicating a systemic failure to document and address resident grievances effectively.
Inaccurate MDS Coding for Wheelchair Seat Belts
Penalty
Summary
The provider failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents who used seat belts in their wheelchairs. Resident 23, who had intact cognition, used a seat belt on her electric wheelchair by choice and could independently apply and remove it. However, her MDS inaccurately coded the trunk restraint as not used, despite an edit note indicating daily use of the seat belt. Her care plan and restraint assessment confirmed her ability to manage the seat belt independently and her preference for its use for safety. Resident 32, who was moderately cognitively impaired, had a seat belt for wheelchair positioning but rarely used it. Observations showed the seat belt was not fastened, and the resident was unsure of its purpose or her ability to use it. Her MDS inaccurately coded the trunk restraint as not used, with an edit note stating she could remove it herself, although she rarely did. The director of nursing confirmed the seat belts were coded as restraints on the MDS, despite stating they were not used as restraints.
Failure to Investigate Alleged Intoxication of CNA
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a certified nursing assistant (CNA) suspected of being intoxicated while on duty. The incident occurred when staff reported that the CNA was acting strangely and smelled of alcohol during her shift. Despite these concerns, the CNA was allowed to continue working the following weekend without any follow-up investigation by the administration. The police were contacted, but they did not conduct a breathalyzer test as they did not find sufficient evidence of intoxication. The Director of Nursing (DON) was informed of the situation but did not take immediate action to investigate further or remove the CNA from the schedule. The CNA was eventually terminated on the following Monday after a container smelling of alcohol was found in the staff break room. However, the facility's failure to act promptly and investigate thoroughly left residents at risk during the weekend when the CNA continued to work. Interviews with other staff members revealed that they were unaware of any alcohol use in the facility, and the CNA in question had not been seen consuming alcohol. The facility's employee handbook outlines strict policies against working under the influence of alcohol, but these policies were not effectively enforced in this instance. The lack of immediate and thorough investigation into the allegations of intoxication represents a deficiency in the facility's handling of the situation.
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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 Brandon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avera Prince Of Peace | 9.2 mi | — | 2 | 0 |
| Palisade Healthcare Center | 9.3 mi | — | 5 | 1 |
| Good Samaritan Society Sioux Falls Center | 9.7 mi | — | 4 | 0 |
| Tuff Memorial Home | 10.3 mi | — | 0 | 0 |
| Dow Rummel Village | 10.4 mi | — | 6 | 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 August 2026) and official state health department websites.