01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-08-13 | 4 | 2025-08-13 | 5 |
| Cycle 2 | 2024-06-05 | 5 | 2024-06-05 | 2 |
| Cycle 3 | 2023-04-27 | 1 | 2023-04-27 | 0 |
CMS CCN 2454342026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Bethany On The Lake Llc
1020 Lark Street · Alexandria, MN 56308 · Douglas County
Certified beds83CMS provider file
Recent citation rows17current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
17 rows in the current release
2 rows carry G–L scope/severity codes; 1 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-26 · HEALTHF0600Severity I · widespread actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Past Non-Compliance · 2026-03-13 · complaint2026-03-26 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2026-04-15 · complaint2025-08-13 · HEALTHF0577Severity C · widespread; potential for minimal harm
Resident Rights Deficiencies
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Correction field: Deficient, Provider has date of correction · 2025-09-032025-08-13 · HEALTHF0689Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-09-032025-08-13 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-09-302025-08-13 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-09-052025-08-13 · FIREK0364Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install properly constructed windows in hallway walls or doors.
Correction field: Deficient, Provider has date of correction · 2025-09-052025-08-13 · FIREK0374Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has date of correction · 2025-09-052025-08-13 · FIREK0761Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2025-09-052025-01-10 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Past Non-Compliance · 2025-01-07 · complaint2024-12-12 · HEALTHF0622Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-12-26 · complaint2024-06-05 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2024-06-262024-06-05 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2024-06-262024-06-05 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2024-06-262024-06-05 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2024-06-252024-06-05 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-06-252023-04-27 · HEALTHF0921Severity F · widespread; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2023-05-1003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2026-03-26 | Fine | $19,330 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- JCA HOLDINGS LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST15% · since 12/29/2017
- NIJ LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST10% · since 12/29/2017
- SPARTAN HEALTHCARE LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST28% · since 12/29/2017
- WBS HOLDINGS LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST19% · since 12/29/2017
- YAZOMA HOLDINGS, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST28% · since 12/29/2017
- HALPERT, MARCIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST28% · since 12/29/2017
- JAFFA, NOAMIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST10% · since 12/29/2017
- LEGUM, JOSHUAIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST28% · since 12/29/2017
- STERN, WILLIAMIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST19% · since 12/29/2017
- LEGUM, JOSHUAIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 12/29/2017
- JAFFA, NOAMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 12/29/2017
- HALPERT, MARCIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/29/2017
- STERN, WILLIAMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/29/2017
- MONARCH HEALTHCARE OPERATING V LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/29/2017
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.81per resident day
RN hours0.86per resident day
Weekend nurse hours3.32per resident day
Staff turnover40.4%CMS reported field
06 / LOCAL RECORDS
Open the Alexandria ledger →