Bethany On The Lake LLC
Open-data reference.
Bethany On The Lake LLC is a for profit - corporation facility in ALEXANDRIA, MN with 83 certified beds and a 5-star overall CMS rating. The facility has 8 deficiency records on file.
1020 LARK STREET, ALEXANDRIA, MN 56308
Phone: 3207621567
Overall Rating
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
- 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. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (4★), staffing levels (5★), and quality measures (4★). 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.
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. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 3.92 total nursing hours per resident day (national average 3.89), with RN coverage at 0.99 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
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. 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. Reported nursing turnover at this facility is 35.5%, within a range generally associated with stable care teams. 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 who lose too much weight | Long Stay | 5.3% | No |
| 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 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 experiencing one or more falls with major injury | Long Stay | 5.1% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 96.6% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.5% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 16.7% | Yes |
| 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 94.6% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 5.9% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 26.2% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 17.8% | Yes |
Penalty History
No penalties on record.
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County Health Data
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Frequently Asked Questions
What is the overall CMS rating for Bethany On The Lake LLC?
What are the staffing levels at Bethany On The Lake LLC?
How many beds does Bethany On The Lake LLC have?
Does Bethany On The Lake LLC have any deficiencies on record?
Has Bethany On The Lake LLC received any fines or penalties?
Who owns Bethany On The Lake LLC?
When was Bethany On The Lake LLC last inspected?
What quality measures are tracked for Bethany On The Lake LLC?
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.