Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethany On The Lake Llc during CMS and state inspections, most recent first.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
Hot water temperatures exceeded the required 105 to 115 degrees F range in multiple resident rooms, with measured temps ranging from 116.6 to 119.4 degrees F. Residents reported the water was very hot, and the DOM verified the readings were above the allowed limit. The facility had recently received a new hot water heater and was still adjusting temperatures.
Survey results were not fully accessible for residents or visitors. A binder posted near the nurse's desk contained the most recent survey, but it did not include several prior abbreviated surveys. The administrator confirmed the missing surveys had been completed and were not in the binder, and stated all surveys should have been available for review.
A resident with dementia and a history of elopement risk exited a facility unsupervised, despite being on a roam alert system. The resident was found 25 minutes later, two blocks away, in freezing temperatures. Staff failed to respond promptly to the door alarm, and the alarm was turned off before the resident was located, contributing to the delay in finding the resident.
A resident with significant medical needs, including paraplegia and a stage IV pressure ulcer, was inappropriately discharged from a facility due to a pending sexual abuse charge. The discharge decision was made without providing a proper notice or discussing the risks and benefits with the resident. Despite requiring skilled nursing care, the resident was sent home with home care services, leading to re-hospitalization shortly after due to issues with his wound vac.
A resident with COPD and on hospice care was not accurately coded in the MDS for oxygen therapy and hospice status. Despite documented needs for continuous oxygen and hospice services, the MDS failed to reflect these treatments. The DON acknowledged the oversight, noting the resident's inconsistent use of oxygen.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with COPD, who required assistance with transfers and oxygen therapy. The care plan, initiated late, lacked interventions for skin breakdown, toileting, and oxygen use. This deficiency was confirmed by nursing staff and the DON, despite the facility's policy requiring timely care plan development.
A resident with COPD was not instructed to rinse her mouth after using an Advair Diskus inhaler, contrary to medication orders and facility policy. The LPN was unaware of the requirement, and the resident was not consistently reminded to rinse, posing a risk of infection. Both the pharmacy consultant and DON highlighted the importance of this practice.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Late Reporting of Verbal Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse to the State Agency (SA) within the required two-hour timeframe after suspicion of abuse was formed. On the evening in question, a nursing assistant (NA-A) was assisting a cognitively impaired resident (R1) with evening cares when multiple staff observed and later reported that NA-A used a loud, stern, and verbally aggressive tone toward the resident. Statements attributed to NA-A included telling the resident to stop crying and that she was acting like a two-year-old, threatening that if the resident hit her again she would hit the resident back, saying the resident was in trouble and might be sent to a locked unit, and stating that nobody would want to work with a “crybaby.” Staff present perceived these interactions as verbally abusive and threatening. R1, who had severely impaired cognition, dementia, Alzheimer’s disease, depression, anxiety, and a psychotic disorder, was crying, distraught, and had just ended a phone call with her son during which she expressed a desire to leave the facility. R1’s admission MDS and care plan documented significant cognitive impairment, mood disturbance, and dependence on staff for transfers, toileting, and mobility, with use of a mechanical stand lift (EZ stand). Her care plan directed staff to allow time for communication, provide a consistent environment, monitor and respond to unmet needs, and monitor mood and behaviors, including for a psychotic disorder with delusions. The facility’s abuse and vulnerable adult policy defined abuse to include verbal and mental abuse and required that suspected abuse be reported to the Office of Health Facility Complaints (OHFC) not later than two hours after forming the suspicion, with immediate steps to protect residents, including immediate suspension of staff alleged to have abused a resident. Despite this, after NA-B and NA-C witnessed and described NA-A’s loud, stern, and threatening statements to R1, they reported their concerns that evening to the on-duty LPN (LPN-A), who acknowledged the conduct as verbal abuse but did not initiate immediate reporting or protective actions as required by policy. Instead of contacting the DON, administrator, or manager on call immediately, LPN-A told the NAs she would speak to the nurse manager (RN-A) the next day. The trained medication assistant (TMA) was also informed that evening and understood that the DON should be called within two hours so the incident could be reported to the SA, but she did not make the report herself and left it to LPN-A. NA-A remained on duty and continued working on the unit until the end of her shift, with unsupervised contact with other residents. The DON and RN-A were not notified until the following day in the early afternoon, at which time the facility submitted the vulnerable adult maltreatment report to the SA, documenting the most recent occurrence as the prior evening. Facility leadership, including the DON and administrator, later confirmed that the facility’s abuse reporting policy, including the two-hour reporting requirement for suspected abuse, was not followed and that the allegation of verbal abuse was reported late to the SA. Title: Late Reporting of Verbal Abuse Allegation to State Agency ShortSummary: A resident with severe cognitive impairment, dementia, depression, anxiety, and a psychotic disorder was observed crying and distraught during evening cares while an NA used a loud, stern, and verbally aggressive tone, including calling the resident a crybaby, comparing her to a two-year-old, threatening to hit her back if struck, and referencing placement in a locked unit. Two NAs and a TMA recognized the conduct as inappropriate and reported it that evening to an LPN, who acknowledged it as verbal abuse but did not immediately notify the DON, administrator, or manager on call as required by facility policy. The NA alleged to have committed the verbal abuse remained on duty with continued resident contact until the end of the shift, and the DON and nurse manager were not informed until the following day, when the incident was finally reported to the State Agency, outside the required two-hour reporting window.
Hot Water Temperatures Exceeded Safe Range in Resident Rooms
Penalty
Summary
The facility failed to ensure an environment free of accident hazards related to hot water temperatures in 8 resident rooms, including rooms 114, 2117, 2208, 2210, 2211, 2214, 2228, and 2234. Minnesota Administrative Rules require hot water at sinks and bathing fixtures to be maintained between 105 and 115 degrees Fahrenheit, but during screening the water in resident rooms 2210 and 2215 felt very warm after running for one minute. Residents reported the water was too hot, with one resident stating the bathroom water was pretty hot and another stating he could not leave his hands under the faucet for long because the water got too hot. During observation, the Director of Maintenance measured water temperatures in resident rooms and verified they were above 115 degrees Fahrenheit. Recorded temperatures included 118.7, 117.6, 116.6, 117.5, 117.8, 119.4, and 117.6 degrees Fahrenheit. The Director of Maintenance stated resident hot water temperatures were to be maintained between 105 and 115 degrees Fahrenheit and that the facility had recently gotten a new hot water heater and was still working on adjusting the water temperatures. The Administrator later verified the required temperature range and stated the hot water heater had been turned down and maintenance was checking water temperatures. The facility policy also stated domestic hot water should be kept within 105 and 115 degrees Fahrenheit to prevent scalding of residents.
Survey Results Not Fully Posted
Penalty
Summary
The facility failed to ensure that all three years of survey results were readily accessible for residents or visitors. During an observation on 8/12/2025 at 11:47 AM, the survey results were found in a white binder posted on the wall by the nurse's desk on the second floor, but the most recent survey included was a standard abbreviated survey dated 1/10/25. The binder did not include survey results for abbreviated surveys completed on 7/3/24, 9/16/24, and 12/24/24. During an interview on 08/12/2025 at 11:55 a.m., the administrator confirmed that other surveys had been completed and were not included in the binder. The administrator stated that all surveys should have been included so residents, visitors, and staff could review them, and later indicated by e-mail on 8/14/25 at 8:13 a.m. that the facility did not have a policy and would default to the State Operations Manual.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was assessed at risk for elopement. The resident, who had a history of dementia and was using a roam alert system, exited the facility through the south door in the early morning hours. The resident was found approximately 25 minutes later, two blocks away from the facility, in below-zero temperatures. The staff did not respond promptly to the door alarm, and the alarm was turned off before the resident was located, which contributed to the delay in finding the resident. The resident had a history of cognitive impairment, as indicated by a SLUMS score of 9 out of 30, suggesting major neurocognitive disorder. The resident's care plan identified her as at risk for elopement and required the use of a wander/elopement alarm daily. Despite these precautions, the resident was able to leave the facility unsupervised. The resident's elopement risk evaluation and care plan included interventions such as redirecting her from exits and monitoring the wander guard for proper functioning, but these measures were not effectively implemented on the day of the incident. Interviews with staff revealed that there was a lack of immediate response to the door alarm, and the facility's policy for handling such alarms was not followed. Staff were expected to respond to the alarm immediately, search both inside and outside the facility, and leave the alarm on until the resident was found. However, the alarm was cleared prematurely, and the search for the resident was not initiated promptly, resulting in the resident being outside in freezing temperatures for an extended period.
Removal Plan
- Began investigation
- Reviewed policy and procedures
- Placed a roam alert on R1's right ankle
- Initiated staff education
- Provided a memo to staff identifying the wanderguard or Roam Alert system requires an emergency response when it is alarming
- Conducted audits and drills with staff
- Tested all current roam alerts for functional use
- Updated R1's plan of care
- Provided corrective action and education regarding missing resident and elopement to RN
- Created a missing resident check list and elopement binder that identified residents in the facility at risk for elopement with roam alerts
- Ongoing staff education and audits will be provided
Inappropriate Facility-Initiated Discharge Due to Legal Issues
Penalty
Summary
The facility failed to ensure an appropriate facility-initiated discharge for a resident who was admitted with significant medical needs, including paraplegia, muscle weakness, and a stage IV pressure ulcer. The resident required skilled nursing care, including physical and occupational therapy, and was dependent on staff for various activities of daily living. Despite these needs, the facility discharged the resident due to a pending sexual abuse charge, without providing a proper discharge notice or discussing the risks and benefits of the discharge with the resident. Interviews with facility staff and the resident's health plan care coordinator revealed that the decision to discharge was influenced by the resident's legal issues, rather than his medical needs. The social services director and the administrator were involved in the decision-making process, consulting with corporate leadership and local law enforcement, but failed to document these consultations or provide the resident with a written discharge notice. The resident was discharged to his home with home care services arranged for wound care, but the discharge was not aligned with the resident's care goals and preferences. The resident's family member and other involved parties expressed concerns about the safety and appropriateness of the discharge, noting that the resident was re-hospitalized shortly after due to issues with his wound vac. The facility's policy on transfer or discharge notice for facility-initiated transfers was not followed, as the resident did not receive a written notice or an explanation of his right to appeal the discharge decision.
Inaccurate MDS Coding for Hospice and Oxygen Therapy
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect oxygen usage and hospice status for a resident reviewed for hospice services. The resident, who had a diagnosis of chronic obstructive pulmonary disease (COPD) and was dependent on supplemental oxygen, was admitted to the facility on hospice care. Despite this, the MDS did not indicate the resident's use of oxygen therapy or hospice care, as required by the Centers for Medicare and Medicaid (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. The resident's care plan and medical records clearly documented the need for hospice care and continuous oxygen therapy, with orders for oxygen at two liters per minute. Interviews with facility staff, including the Director of Nursing (DON), confirmed that the resident was admitted on hospice and had orders for oxygen. The DON, who was also the MDS coordinator, acknowledged that the MDS should have been marked for hospice and that the omission of oxygen therapy was due to the resident not wearing oxygen consistently. However, the expectation was for staff to accurately complete the resident assessment, which was not met in this case.
Failure to Develop Timely Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours for a resident who was recently admitted with chronic obstructive pulmonary disease (COPD). The resident required staff assistance for transfers and was on two liters of oxygen via nasal cannula. However, the baseline care plan, initiated three days after admission, did not include interventions for preventing skin breakdown, toileting, or oxygen therapy. This delay and omission were confirmed by both a nursing assistant and a registered nurse, who acknowledged the care plan's deficiencies and the failure to meet the 48-hour requirement. The Director of Nursing (DON) also verified that the baseline care plan lacked necessary components and was not completed within the required timeframe. The facility's policy, revised in January 2022, mandates that a baseline care plan be developed within 48 hours of admission to address the resident's immediate needs. Despite this policy, the care plan for the resident in question was incomplete and delayed, leaving staff without clear guidance on how to care for the resident effectively.
Failure to Instruct Resident on Proper Inhaler Use
Penalty
Summary
The facility failed to adhere to professional standards of practice regarding the administration of an inhalation medication for a resident with COPD, asthma, and end-stage renal disease. The resident, who had intact cognition, was observed receiving an Advair Diskus inhaler without being instructed to rinse her mouth afterward, as required by the medication order. The resident confirmed that she was not aware of the need to rinse her mouth after using the inhaler and stated that staff only occasionally reminded her to do so. The LPN involved admitted to not instructing the resident to rinse her mouth and was unaware of the order's instructions. Both the pharmacy consultant and the director of nursing emphasized the importance of rinsing the mouth after using a steroid inhaler to prevent infections such as thrush. The facility's policy on oral inhalation administration also required staff to provide water and instruct residents to rinse their mouths after using steroid inhalers. This oversight in medication administration was identified as a deficiency in the facility's adherence to professional standards of care.
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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 Alexandria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Knute Nelson Care Center | 0.8 mi | ★★★★★ | 7 | 0 |
| Galeon | 11 mi | ★★★★★ | 7 | 0 |
| Glenwood Village Care Center | 16.4 mi | ★★★★★ | 2 | 1 |
| Evansville Care Center | 17.2 mi | ★★★★★ | 5 | 0 |
| St Williams Living Center | 19 mi | ★★★★★ | 5 | 0 |
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