Bethany on the Lake LLC
1020 Lark Street, Alexandria, MN 56308 · Douglas County · (320) 762-1567
83 certified beds, about 80 residents a day · For profit - Corporation · Medicare and Medicaid since 1987
CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
2 of 5
Staffing
5 of 5
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 245434 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on August 13, 2025, inspectors cited 2 health deficiencies (the Minnesota average is 7.1, the national average 9.2).
Of 10 health citations since April 2023, 2 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists 1 fine totaling $19,330 in the last three years; the largest was $19,330, and the latest is dated March 26, 2026.
Nurses and nurse aides worked 3.81 hours per resident per day, against 4.19 across Minnesota and 3.86 nationally. Registered nurses accounted for 0.86 of those hours.
40.4% of nursing staff left within the year CMS measured (Minnesota average 42.2%).
CMS links it to Monarch Healthcare Management, an affiliated group of 45 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
104/23
306/24
112/24
101/25
208/25
203/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 10 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
1I
Potential for more than minimal harm
5D
1E
1F
Potential for minimal harm
0A
0B
1C
March 26, 2026Complaint inspection · 2 citations
- I Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and document review the facility failed to protect 1 of 3 residents (R1) reviewed for abuse, from mental abuse when nursing assistant (NA)-A ridiculed, yelled with intent to intimidate, and threatened R1 with physical abuse, to be sent to a locked unit, and for staff to be unwilling to provide cares to R1 in the future. R1's actual response and the use of the reasonable person concept identified serious psychosocial harm to R1 when she exhibited crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The IJ began on 3/11/26 at 8:30 p.m., when NA-A was witnessed to make derogatory aggressive toned statements in the presence of R1 and two other staff. [...]
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and documents review, the facility failed to report an allegation of abuse to the State Agency (SA) within two hours for 1 of 1 resident (R1) who was witnessed being verbally abused by a staff member. Findings Include: Facility Vulnerable Adult Maltreatment Report filed with State Agency (SA) dated 3/12/26 at 5:15 p.m., identified estimated date and time of most recent occurrence: 3/11/26 at 8:30 p.m., in resident [R1's] room. Description of incident: It was reported by nursing assistant (NA) she witnessed verbal aggressive tone and language towards resident by alleged perpetrator (AP) when NA and AP were getting resident ready for bed last evening. NA stated there were no changes with the resident behavior, no signs of injury mentally or physically resulting from the incident. Resident feels safe in facility. Allegations: abuse emotional or mental. [...]
August 13, 2025Standard inspection · 2 citations
- E Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and document review, the facility failed to ensure an environment was free of accident hazards, related to hot water temperatures in 8 of 8 resident rooms (114, 2117, 2208.2210, 2211, 2214, 2228, 2234), tested for safe water temperatures. This deficient practice had the potential to affect all 8 residents who used water from the water faucets in the affected area.
- C Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observation, interview and document review, the facility failed to ensure all three years of survey results were readily accessible for residents or visitors. This deficient practice had the potential to affect all 78 residents currently residing in the facility.
January 10, 2025Complaint inspection · 1 citation
- J Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview and document review, the facility failed to provide adequate supervision to prevent an elopement for 1 of 3 resident (R1) reviewed for supervision. R1 was assessed at risk for elopement and left the facility in the dark, freezing temperatures, and located outside approximately 25 minutes later. The immediate jeopardy began on 1/6/25, at 6:44 a.m. when R1 set off roam alert, exited the facility through the south door, in the dark in below zero temperature with her walker, and went missing. At 7:10 a.m. approximately two blocks away from the facility R1 was located. The administrator and DON were notified of the immediate jeopardy on 1/10/25 at 1:30 p.m. The facility immediately implemented corrective action and was corrected on 1/7/25, prior to survey and was issued at past noncompliance.
December 12, 2024Complaint inspection · 1 citation
- D Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on interview and document review the facility failed to ensure an appropriate facility-initiated discharge for 1 of 3 residents (R1) reviewed who admitted to the facility, was told to discharge due to a sexual abuse charge and was re-hospitalized .
June 5, 2024Standard inspection · 3 citations
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect oxygen usage and hospice status for 1 of 1 resident (R28) reviewed for hospice services.
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and document review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours to address the individualized needs for 1 of 2 residents (R174) who was recently admitted .
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview and document review, the facility failed to follow standards of practice related to medication administration of an inhalation medication for 1 of 1 resident (R176) observed for medication administration.
April 27, 2023Standard inspection · 1 citation
- F Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observation, interview, and document review, the facility failed to provide maintenance services to ensure a clean and safe kitchen for 1 of 2 kitchenettes and the main kitchen observed during the kitchen tour. This deficient practice had the potential to affect all 76 residents currently residing in the facility and staff who worked in the kitchen.
Fire safety inspections
7 fire safety citations on file: 5 on August 13, 2025, 2 on June 5, 2024.
Every fire safety citation7 citations
- F Have approved installation, maintenance and testing program for fire alarm systems.
- D Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D Install properly constructed windows in hallway walls or doors.
- D Install smoke barrier doors that can resist smoke for at least 20 minutes.
- D To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- E Provide properly protected cooking facilities.
- D Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| March 26, 2026 | Fine | $19,330 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Minnesota | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.81 | 4.19 | 3.86 |
| Registered nurses | 0.86 | 1.06 | 0.69 |
| All nursing staff on weekends | 3.32 | 3.71 | 3.42 |
| Nurse aides | 1.72 | ||
| Licensed practical nurses | 1.23 | ||
| Nursing staff turnover (share who left in a year) | 40.4% | 42.2% | 45.8% |
| Registered nurse turnover | 25.0% | 38.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.23 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.01 on weekdays and 3.32 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 4.9% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.87 in April to June 2025 to 3.81 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.81 | 0.86 | 4.01 | 3.32 | 4.9% | 0 of 90 | 80 |
| Oct to Dec 2025 | 3.81 | 0.94 | 4.02 | 3.28 | 7.7% | 0 of 92 | 77 |
| Jul to Sep 2025 | 3.92 | 0.99 | 4.13 | 3.39 | 7.8% | 0 of 92 | 78 |
| Apr to Jun 2025 | 3.87 | 1.04 | 4.05 | 3.42 | 9.6% | 0 of 91 | 76 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Minnesota, Jan to Mar 2026 | 4.19 | 1.05 | 4.38 | 3.73 | 5.2% | 0.8% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Minnesota | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 12.6 | 18.2 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.1 | 1.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 4.2 | 2.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.7 | 4.0 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.3 | 1.9 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 15.0 | 20.5 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.3 | 5.2 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 13.4 | 17.1 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 24.7 | 23.5 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 22.2 | 14.8 | 12.0 |
Owners and operators
Legal business name: BETHANY ON THE LAKE LLC. CMS links this home to Monarch Healthcare Management, a group of 45 nursing homes averaging 2.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Jca Holdings LLC | 5% or greater direct ownership interest | Organization | 15% | 12/29/2017 |
| Nij LLC | 5% or greater direct ownership interest | Organization | 10% | 12/29/2017 |
| Spartan Healthcare LLC | 5% or greater direct ownership interest | Organization | 28% | 12/29/2017 |
| Wbs Holdings LLC | 5% or greater direct ownership interest | Organization | 19% | 12/29/2017 |
| Yazoma Holdings, LLC | 5% or greater direct ownership interest | Organization | 28% | 12/29/2017 |
| Halpert, Marc | 5% or greater indirect ownership interest | Individual | 28% | 12/29/2017 |
| Jaffa, Noam | 5% or greater indirect ownership interest | Individual | 10% | 12/29/2017 |
| Legum, Joshua | 5% or greater indirect ownership interest | Individual | 28% | 12/29/2017 |
| Stern, William | 5% or greater indirect ownership interest | Individual | 19% | 12/29/2017 |
| Legum, Joshua | Contracted managing employee | Individual | 12/29/2017 | |
| Jaffa, Noam | Corporate director | Individual | 12/29/2017 | |
| Halpert, Marc | Corporate officer | Individual | 12/29/2017 | |
| Stern, William | Corporate officer | Individual | 12/29/2017 | |
| Monarch Healthcare Operating V LLC | Operational/managerial control | Organization | 12/29/2017 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- When is the care plan meeting, and can family attend it?Inspectors cited 3 problems in this area, most recently on June 5, 2024: "Ensure each resident receives an accurate assessment."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 2 problems in this area, most recently on March 26, 2026: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 2 problems in this area, most recently on August 13, 2025: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 2 problems in this area, most recently on August 13, 2025: "Allow residents to easily view the nursing home's survey results and communicate with advocate agencies."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.32 hours per resident per day, below the Minnesota average of 3.71.
Other nursing homes nearby
- Knute Nelson Care Center Alexandria, 0.8 mi · 5 of 5 stars · 12 citations
- Galeon Osakis, 11 mi · 5 of 5 stars · 5 citations
- Glenwood Village Care Center Glenwood, 16.4 mi · 2 of 5 stars · 24 citations
- Evansville Care Center Evansville, 17.2 mi · 5 of 5 stars · 8 citations
- St. Williams Living Center Parkers Prairie, 19 mi · 5 of 5 stars · 10 citations
- Minnewaska Community Health Services Starbuck, 19.7 mi · 2 of 5 stars · 18 citations
- Cura of Sauk Centre Sauk Centre, 22.9 mi · 3 of 5 stars · 13 citations
- Barrett Care Center Inc Barrett, 24.1 mi · 5 of 5 stars · 7 citations
Minnesota contacts for a concern about a nursing home
These are the official offices in Minnesota. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Minnesota Department of Health, Health Regulation Division, the state agency that inspects nursing homes for CMS and takes complaints about care.
- State inspection reports: MDH Nursing and Boarding Care Home Survey and Complaint Inspection Findings, where Minnesota publishes its own records on licensed homes.
Common questions
- What is Bethany on the Lake LLC's Medicare star rating?
- CMS rates Bethany on the Lake LLC 3 out of 5 stars overall, with 2 for health inspections, 5 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Bethany on the Lake LLC get at its last inspection?
- 2 health deficiencies at the standard inspection on August 13, 2025. The Minnesota average is 7.1.
- Has Bethany on the Lake LLC been fined?
- Yes. CMS lists 1 fine totaling $19,330 in the last three years.
- Does Bethany on the Lake LLC accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Bethany on the Lake LLC?
- CMS lists 14 owners and managers, and links the home to Monarch Healthcare Management. Legal business name: BETHANY ON THE LAKE LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.