Cycle 1
Health 2025-08-13 · Fire 2025-08-13
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Alexandria, MN
Bethany On The Lake LLC
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1020 Lark Street, Alexandria, MN
(320) 762-1567
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
83
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Monarch Healthcare Management
Operator or chain grouping
Approved since
1987-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
45 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.99
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
1.78
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.92
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
2.14
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.17
CMS adjusted RN staffing hours
Adjusted total hours
4.63
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,195
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
45.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9988
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.87
Baseline 18.61% · Performance 19.64% · Measure score 3.87 · Achievement 3.87 · Improvement 0
Healthcare-associated infections
2.79
Baseline 5.79% · Performance 7.00% · Measure score 2.79 · Achievement 2.79 · Improvement 0
Total nurse turnover
7.90
Performance 31.39% · Measure score 7.90 · Achievement 7.90 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.66
Baseline 4.57 hours · Performance 4.12 hours · Measure score 3.66 · Achievement 3.66 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.84% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 163 · Observed rate 7.36% · Lower 95% interval 7.57% |
| Discharge to community | 64.34% |
50.57%
13.8 pts better
|
Better than the National Rate · Eligible stays 152 · Observed rate 68.42% · Lower 95% interval 57.54% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.17% |
95.27%
2.9 pts better
|
Numerator 107 · Denominator 109 |
| Falls with major injury | 1.83% |
0.77%
1.1 pts worse
|
Numerator 2 · Denominator 109 |
| Discharge self-care score | 70.73% |
53.69%
17 pts better
|
Numerator 58 · Denominator 82 |
| Discharge mobility score | 81.71% |
50.94%
30.8 pts better
|
Numerator 67 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 1.83% |
2.29%
0.5 pts better
|
Numerator 2 · Denominator 109 · Adjusted rate 2.98% |
| Healthcare-associated infections requiring hospitalization | 7% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 5.32% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 0.62% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 161 |
| Staff flu vaccination coverage | 15.09% |
42%
26.9 pts worse
|
Numerator 24 · Denominator 159 |
| Discharge function score | 78.05% |
56.45%
21.6 pts better
|
Numerator 64 · Denominator 82 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 33 · Denominator 33 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 65 · Denominator 65 |
| Resident COVID-19 vaccinations up to date | 20% |
25.2%
5.2 pts worse
|
Numerator 10 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.3%
2.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
96.1%
2.4 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.9%
1.2 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 5.1% · Q3 3.3% · Q4 4.9% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
4.3%
1 pts better
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.9% · Q3 3.5% · Q4 5.3% · 4Q avg 3.3% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
4.1%
1.2 pts worse
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 8.3% · Q3 4.2% · Q4 4.1% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.7% |
12.4%
9.3 pts worse
|
19.6%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 18.4% · Q3 22.4% · Q4 26.5% · 4Q avg 21.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.8% |
17.5%
0.3 pts worse
|
16.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 21.1% · Q3 17.1% · Q4 17.1% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.7% |
22.5%
5.8 pts better
|
16.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 18.2% · Q3 14.0% · Q4 21.1% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.8% |
18.6%
7.8 pts better
|
14.9%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 6.7% · Q3 10.4% · Q4 15.2% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
2.3%
1.2 pts better
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.0% · Q4 1.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
2.6%
0.4 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 8.5% · Q4 1.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.2% |
24.8%
1.4 pts worse
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.3% · Q2 19.3% · Q3 23.6% · Q4 26.6% · 4Q avg 26.2% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
5.4%
0.5 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 5.6% · Q3 6.0% · Q4 5.3% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
88.6%
8 pts better
|
81.7%
14.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 99.2% · Q3 95.8% · Q4 95.5% · 4Q avg 96.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.4% |
14.0%
5.4 pts worse
|
12.0%
7.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.4% · Observed 18.0% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.9%
1.4 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
82.7%
11.9 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
23.1%
0.9 pts worse
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 18.0% · Expected 17.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-05 · Fire 2024-06-05
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-04-27 · Fire 2023-04-27
1 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-09-30
D · Potential for more than minimal harm
2025-08-13
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-08-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-05
E · Potential for more than minimal harm
2024-06-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-06-25
D · Potential for more than minimal harm
2024-06-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-06-25
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-03
C · Minimal harm
2025-08-13
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-09-03
J · Immediate jeopardy
2025-01-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-07
D · Potential for more than minimal harm
2024-12-12
F622 · Resident Rights Deficiencies
Health
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.
Corrected 2024-12-26
D · Potential for more than minimal harm
2024-06-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-06-05
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-06-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-06-26
F · Potential for more than minimal harm
2023-04-27
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-05-10
Penalties and ownership
What sits behind the stars
Ownership
Halpert, Marc
5% Or Greater Indirect Ownership Interest · Individual
Legum, Joshua
5% Or Greater Indirect Ownership Interest · Individual
Spartan Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Yazoma Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Stern, William
5% Or Greater Indirect Ownership Interest · Individual
Wbs Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Arem, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Jca Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Jaffa, Noam
5% Or Greater Indirect Ownership Interest · Individual
Nij LLC
5% Or Greater Direct Ownership Interest · Organization
Halpert, Marc
Corporate Officer · Individual
Jaffa, Noam
Corporate Director · Individual
Legum, Joshua
Contracted Managing Employee · Individual
Monarch Healthcare Operating V LLC
Operational/Managerial Control · Organization
Stern, William
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Knute Nelson Care Center
Alexandria, MN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Galeon
Osakis, MN
5-star overall rating with 5-star inspections with 7 fire-safety deficiencies in the latest cycle
#3
Glenwood Village Care Center
Glenwood, MN
1-star overall rating with 1-star inspections with $15,592 in total fines with 18 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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