Bethany on the Lake LLC

In the surveyor’s words

From the most serious findings on record at Bethany on the Lake LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 10, 2025

  Based on observation, interview and document review, the facility failed to provide adequate supervision to prevent an elopement for 1 of 3 resident (R1) reviewed for supervision. R1 was assessed at risk for elopement and left the facility in the dark, freezing temperatures, and located outside approximately 25 minutes later. The immediate jeopardy began on 1/6/25, at 6:44 a.m. when R1 set off roam alert, exited the facility through the south door, in the dark in below zero temperature with her walker, and went missing. At 7:10 a.m. approximately two blocks away from the facility R1 was located. The administrator and DON were notified of the immediate jeopardy on 1/10/25 at 1:30 p.m. […]

• Actual harm, widespreadF600Mar 26, 2026

  Based on interview and document review the facility failed to protect 1 of 3 residents (R1) reviewed for abuse, from mental abuse when nursing assistant (NA)-A ridiculed, yelled with intent to intimidate, and threatened R1 with physical abuse, to be sent to a locked unit, and for staff to be unwilling to provide cares to R1 in the future. R1's actual response and the use of the reasonable person concept identified serious psychosocial harm to R1 when she exhibited crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The IJ began on 3/11/26 at 8:30 p.m., when NA-A was witnessed to make derogatory aggressive toned statements in the presence of R1 and two other staff. […]

• No harm, potential for more than minimal, widespreadF921Apr 27, 2023

  Based on observation, interview, and document review, the facility failed to provide maintenance services to ensure a clean and safe kitchen for 1 of 2 kitchenettes and the main kitchen observed during the kitchen tour. This deficient practice had the potential to affect all 76 residents currently residing in the facility and staff who worked in the kitchen. Findings include: During the initial tour of the kitchen on 4/24/23, at 6:32 p.m. with the dietary cook (DC)-A the following was observed: The three compartment sink located in the back kitchen area had a heavy build up of white/green lime scale on the inside of the sink half way up the sidewalls of the third sink area and all around the faucet area. […]

• No harm, potential for more than minimal, widespreadF812Sep 30, 2021

  Based on observation, interview and document review, the facility failed to provide proper preparation and tracking of food temperatures in order to provide nourishing foods in a safe manner to prevent the potential for food-borne illness. This had the potential to affect all 72 residents who ate food prepared by the facility kitchen. Findings include: During an observation on 9/27/21, at 5:18 p.m. culinary services (CS)-B pushed a cart into the kitchenette with four large pans of pizza and additional special diet hot foods which were covered with aluminum foil. During an observation on 9/27/21, at 5:25 p.m. […]

• No harm, potential for more than minimal, patternF689Aug 13, 2025

  Based on observation, interview and document review, the facility failed to ensure an environment was free of accident hazards, related to hot water temperatures in 8 of 8 resident rooms (114, 2117, 2208.2210, 2211, 2214, 2228, 2234), tested for safe water temperatures. This deficient practice had the potential to affect all 8 residents who used water from the water faucets in the affected area.Findings include: According to Minnesota Administrative Rules 4658.1365 Subp.7. Hot water supplied to sinks and bathing fixtures must be maintained within a temperature range of 105 degrees Fahrenheit to 115 degrees Fahrenheit at the fixtures. […]