Bethany Home Brandon: Unsafe Lift Transfer Violation - SD
The nursing assistant, identified in inspection records as CNA M, had been trained on the facility's lift procedures just two months before the incident. On July 15, 2025, during orientation, she received education on what the facility calls its "limited lift agreement." Three days later, on July 18, she signed a floor training checklist confirming she had received proper instruction on both the mechanical total lift and the stand aid.
The facility's own written policy is direct: at least two nursing assistants are required to safely move a resident with a mechanical lift. On September 18, 2025, that did not happen.
Federal inspectors classified the violation under F689, which covers accidents and unsafe conditions. The level of harm was recorded as actual harm, not potential, not theoretical. A small number of residents were affected.
What the inspection report does not describe is what that harm looked like. It does not name the resident. It does not describe an injury, a fall, or a medical consequence. The finding of actual harm stands in the record without a face attached to it.
Bethany Home moved quickly after the incident. On September 25, 2025, the facility put corrective actions in place. By the time inspectors arrived on October 21, they found that the facility had worked through its quality assurance process, delivered education to all nursing care staff on safe resident transfers with both the mechanical total lift and the stand aid, and conducted follow-up audits. Staff interviews confirmed that employees understood what they had been taught. Observations of resident transfers and bathing showed no further concerns.
Inspectors concluded the facility had reached substantial compliance. The violation was recorded as past noncompliance, meaning the deficient practice had ended before the inspection date.
That sequence, a trained employee violating a clear two-person policy, actual harm resulting, and a facility correcting course before inspectors arrived, is a common pattern in nursing home enforcement. The correction is real. So is the harm that preceded it.
CNA M had been on the job for less than a week when she signed that training checklist in July. The incident happened roughly two months into her employment. Whether she was working alone because of a staffing shortage, a miscommunication, or a lapse in judgment, the inspection report does not say.
The facility's mechanical lift policy existed precisely because this kind of transfer carries risk. Mechanical lifts move residents who cannot bear their own weight. A sling malfunction, a positioning error, or a sudden shift in a resident's body can send a person to the floor or into equipment. Two staff members are required not as a formality but because one person cannot simultaneously manage the lift controls, monitor the resident's position, and respond to an emergency.
CNA M knew that. She had signed her name to it.
Bethany Home is a long-term care facility serving the Brandon area. The complaint inspection that surfaced this violation was not a routine survey. Someone reported a concern, and inspectors came to investigate. The report does not identify who filed the complaint or what prompted it.
The resident who was moved that day in September, the one whose transfer triggered a federal finding of actual harm, is identified in the inspection record only by the absence of their name.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bethany Home - Brandon from 2025-10-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 8, 2026 · Our methodology
Bethany Home - Brandon in BRANDON, SD was cited for violations during a health inspection on October 21, 2025.
The nursing assistant, identified in inspection records as CNA M, had been trained on the facility's lift procedures just two months before the incident.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.