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 September 23, 2026
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
12 citations — more than 50% of the 337 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 on file averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens September 2027 — about 10 months from now. This facility’s last Life Safety survey was September 2026. Facilities in MN are typically surveyed 11–14 months after the last one (median 13), measured over 641 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 about three years in Virginia. 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 12 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 | 12 |
| Median facility in MN | 12 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 5, 2024 | 2 |
| August 13, 2025 | 5 |
| September 23, 2026 | 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. | 3 | 2026-09-23 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2026-09-23 |
| K-0364 | Install properly constructed windows in hallway walls or doors. | 1 | 2025-08-13 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-08-13 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2026-09-23 |
| 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-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2026-09-23 |
What the citations cover
- Smoke Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Egress Deficiencies 2
- Miscellaneous Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Egress Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 23, 2026 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0226 | Have horizontal exits used in accordance with safety requirements. | Deficient, Provider has plan of correction (October 6, 2026) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has plan of correction (October 6, 2026) |
| 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 plan of correction (October 6, 2026) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has plan of correction (October 6, 2026) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has plan of correction (October 6, 2026) |
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 October 1, 2026. Surveys conducted in the last few months may not appear yet.