Bethany on the Lake LLC

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a standard inspection.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS has cited this home for F0689 3 times since 2025.

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CMS lists this as a standard inspection.

• Citation K0921. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that testing and maintenance of electrical equipment is performed.

  CMS lists it as corrected on October 6, 2026.

• Citation K0226. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have horizontal exits used in accordance with safety requirements.

  CMS lists it as corrected on October 6, 2026.

• Citation K0291. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on October 6, 2026.

• Citation K0321. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on October 6, 2026.

  CMS has cited this home for K0321 3 times since 2024.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on October 6, 2026.

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• Star rating

  The CMS overall star rating changed from 5 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 2 of 5.

• CMS abuse icon

  CMS added its abuse icon to this home.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

Severity I is the second-highest of CMS's four levels. It means a resident was harmed.

53 of 337 Minnesota homes (16%) got a citation at the actual harm level in 2026.

• Citation F0600. Severity I: actual harm, widespread.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on March 13, 2026.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on April 15, 2026.

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CMS fine of $19,330 on March 26, 2026.

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• Star rating

  The CMS overall star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a standard inspection.

• Citation F0689. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on September 3, 2025.

• Citation F0577. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

  CMS lists it as corrected on September 3, 2025.

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CMS lists this as a standard inspection.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on September 5, 2025.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on September 30, 2025.

• Citation K0364. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install properly constructed windows in hallway walls or doors.

  CMS lists it as corrected on September 5, 2025.

• Citation K0374. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install smoke barrier doors that can resist smoke for at least 20 minutes.

  CMS lists it as corrected on September 5, 2025.

• Citation K0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: To conduct inspection, testing and maintenance of fire doors by qualified individuals.

  CMS lists it as corrected on September 5, 2025.

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• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS overall star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 5 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

74 of 337 Minnesota homes (22%) got a citation at the immediate jeopardy level in 2025.

• Citation F0689. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on January 7, 2025.

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CMS lists this as a complaint inspection.

• Citation F0622. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on December 26, 2024.

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• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

CMS lists this as a standard inspection.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on June 26, 2024.

• Citation F0655. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  CMS lists it as corrected on June 26, 2024.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on June 26, 2024.

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CMS lists this as a standard inspection.

• Citation K0324. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on June 25, 2024.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on June 25, 2024.

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• Star rating

  The CMS staffing star rating changed from 4 of 5 to 5 of 5.