Bethany On The Lake LLC
1020 Lark Street, Alexandria, MN 56308
Bethany On The Lake LLC, a 83-bed for profit - corporation nursing facility in Alexandria, MN, holds a 5-star CMS overall rating - well above the 3.0-star national average, with nurse staffing above the national norm. 1 inspection finding reached the actual-harm or immediate-jeopardy level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 3207621567
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- 5 / 5
- Much above average · CMS overall · nat'l 3.0
- 3.92
- About average · nurse hrs/day · nat'l 3.89
- 8
- Inspection findings · 1 serious
- $0
- Federal penalties (0)
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 245434
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 83
- Residents
- 78
- In Hospital
- No
- County
- Douglas
- Last Inspection
- Aug 13, 2025
Staffing Data
How the 3.92 total nursing hours per resident-day are staffed:
- RN Hours
- 0.99 (nat'l avg: 0.68)
- LPN Hours
- 1.15
- CNA Hours
- 1.78
- Total Nursing Hours
- 3.92 (nat'l avg: 3.89)
- PT Hours
- 0.06
- Nursing Turnover
- 35.5%
- RN Turnover
- 15.0%
What the CMS Record Reveals About Bethany On The Lake LLC
Bethany On The Lake LLC operates 83 certified beds in Alexandria, MN with approximately 78 residents currently in care, and carries a CMS overall rating of 5 out of 5 stars (health inspection 4★ · staffing 5★ · quality 4★).
The inspection file contains 8 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. CMS has not levied any fines or payment denials against this facility. Reported nurse staffing runs 3.92 total hours per resident day (national average 3.89); RN hours specifically are 0.99 per resident day.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Bethany On The Lake LLC falls into a category where comparative context matters. Reported nursing turnover at this facility is 35.5%, within a range generally associated with stable care teams.
Why sub-scores and the CMS methodology matter
The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results, staffing levels, and quality measures. Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. The staffing metric in particular is the one most strongly tied to resident outcomes in peer-reviewed literature.
For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (8 most recent)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 3, 2025
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Category: Resident Rights Deficiencies
Corrected: Sep 3, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jan 7, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Dec 26, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 26, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 26, 2024
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 26, 2024
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: May 10, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 10.8% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.1% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 3.0% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 5.1% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 16.7% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.9% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 17.8% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.5% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 5.3% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 3.3% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 21.7% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 98.5% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 26.2% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 96.6% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 94.6% | No |
Penalty History
No penalties on record.
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Understanding Nursing Home Data
Frequently Asked Questions
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
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