Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BETHANY ON THE LAKE LLC
ALEXANDRIA, MN · 83 certified beds · Last Life Safety survey August 13, 2025
CMS Certification Number 245434 · first certified February 1987
Ownership
Operated by MONARCH HEALTHCARE MANAGEMENT · For profit - Corporation
- Ownership changed December 29, 2017 (change of ownership)from ECUMEN
Position within MN
7 citations — more than 19% of the 338 certified nursing homes in MN. Compared within MN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 1. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: July 2026 to October 2026. This facility’s last Life Safety survey was August 2025. Facilities in MN are typically surveyed 11–14 months after the last one (median 13), measured over 613 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 7 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in MN, and nationally. Surveyors differ markedly between states, so the MN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 7 |
| Median facility in MN | 12 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| April 27, 2023 | 0 |
| June 5, 2024 | 2 |
| August 13, 2025 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2025-08-13 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-08-13 |
| K-0364 | Install properly constructed windows in hallway walls or doors. | 1 | 2025-08-13 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-06-05 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2025-08-13 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2025-08-13 |
What the citations cover
- Smoke Deficiencies 6
- Miscellaneous Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 13, 2025 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (September 30, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (September 5, 2025) |
| K-0364 | Install properly constructed windows in hallway walls or doors. | Deficient, Provider has date of correction (September 5, 2025) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (September 5, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (September 5, 2025) |
June 5, 2024 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 25, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 25, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.