Bethany On The Lake Llc
Bethany On The Lake LLC in ALEXANDRIA, MN — inspection on March 26, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
suggested. NA-A re-entered R1's room five minutes later and assisted NA-C with the EZ Stand to
went to the nurse's station and informed LPN-A what they heard NA-A say to R1, the tone of her voice
like that before. We made it very clear to LPN-A, NA-A yelled at R1 and threatened to hit her. NA-C stated she felt this was verbal abuse, threatening to hit a resident and yelled at them to stop crying.
LPN-A did not appear to take the allegation seriously, was told it needed to be reported to someone, LPN-A stated she would talk to RN-A the next day and planned on coming into facility in the morning and would talk to the DON. TMA told NA-C, the DON should be called right away. NA-C trusted LPN-A would take care of it. At 9:30 p.m., NA-A continued to work on the floor. At 10:30 p.m., both NA-C and NA-A clocked out for the night and walked out of the facility together. NA-A stated to NA-C, I will most likely be fired.
Prior to this incident, NA-C stated she had witnessed N-A snap at another resident and thought she was just having a bad day. NA-C stated she told NA-A she should not snap at residents, and did not report the incident. NA-A seemed grumpy as time went on. NA-C recalled another occurrence when a resident requested help and NA-A was short with her, tone of her voice stern and loud as NA-A told resident, We'll be right there.During interview on 3/25/26 at 12:41 p.m., LPN-A stated R1 had episodes of behaviors such as resistive to cares, refusals, occasionally cried, verbal with staff telling them to stop talking and to go away. LPN-A was unsure what made them worse, but R1 was not easily redirected. LPN-A stated it was brought to her attention on 3/11/26, between 8:00 p.m. to 8:30 p.m., by NA-B and NA-C concerns of inappropriate interactions between NA-A and R1. NA-A threatened R1, if she hit NA-A, NA-A would hit her back. LPN-A informed both NA's she would talk to nurse manager, RN-A, the next day. LPN-A felt like it was verbal abuse. LPN-A stated according to facility policy, an allegation of abuse was to be reported within two hours, and she thought it was 24 hours due to no injury.
The facility policy was not followed. DON called her the next day on 3/12/26 at 2:20 p.m., and informed her NA-A should have been removed from the floor to prevent any further danger to any other residents.
After LPN-A found out about the incident, she observed R1 in her room and made sure she was safe in her recliner, eyes were open. R1 acknowledged LPN-A by replying, hi, but did not say anything else. LPN-A did not ask R1 any questions. NA-A remained working on the floor after the allegation of abuse was made until 10:30 p.m.
LPN-A left the facility at 9:00 p.m. that day, her shift had ended. LPN- A stated she had previously worked with NA-A and only concern she had was NA-A seemed stressed out at times and frazzled, not enough time to do things, and issues with her home life.
During an interview on 3/25/26 at 1:40 p.m., NA-D stated R1 had behaviors but not every day. R1 wandered all over the building in her wheelchair and occasionally cried. NA-D stated R1's behaviors increased when she was rushed, approached in a demanding tone of voice such as get up now, and did not like to be hurried. NA-D stated on 3/12/26, she arrived at work for the day shift and R1 was already up for the day. R1 sat at the nurse's station.
This was not typical for R1.
After breakfast R1 had increased behaviors: pinching, hitting, crying. NA-D stated R1 had not displayed those types of behaviors when she worked with her prior to this day.
She was informed by RN-A about the incident that happened one day ago. NA-D felt this made sense, why R1 was acting out, it was obvious something was bothering her. NA-D charted no behaviors early that morning around 9:18 a.m., noted the change in behaviors after that, and reported the concerns to LPN-B.
During an interview on 3/25/26 at 2:04 p.m., LPN-B stated R1 lacked short term memory and had dementia. LPN-B stated approximately two weeks ago she noticed R1's behaviors had increased. On 3/12/26, LPN-B tried to administer R1's medications. R1 refused medications and water. LPN-B stated it appeared R1 was going to through the cup of water at LPN-B.
This was an off day for R1, usually happy. R1 seemed irritated. R1 entered another resident's room with family visiting, this was unusual behavior for her. R1 called staff assholes and said t
245434 03/26/2026
Bethany on the Lake LLC 1020 Lark Street Alexandria, MN 56308
was anything wrong at the time and planned to inform floor manager, RN-A the following day. LPN-A
notify either the DON or himself immediately on 3/11/26.
Staff were expected to always protect the
reported to the SA the next day.
Administrator stated staff had been educated if they hear, see or know of abuse to immediately protect all residents.
The alleged perpetrator should have been immediately removed, and either call DON or himself if needed for direction or assistance.
Administrator stated he felt the residents were always safe, a staff made a mistake of words they used, resident safety was not in jeopardy at that time.Facility policy Abuse Prohibition/Vulnerable Adult dated 11/2025, identified guidelines for prevention of maltreatment of vulnerable adults in healthcare centers.
Purpose: protect residents against abuse by anyone, to promptly report, document, and investigate all incidents of alleged or suspected abuse/neglect and determine probable cause of unknown injuries and identify and remedy any potentially abusive situations.
All staff are responsible for reporting any situation that is considered abuse or neglect along with injuries of unknown origin (including suspicious bruises, skin tears, or other injuries). A supervisor will be notified immediately and will assess the situation to determine if any emergency treatment or action is required.
Immediately, upon learning of the incident, staff will take necessary steps to protect residents from possible subsequent incidents of misconduct or injury while the matter is being investigated.
The nurse will take the following actions to mitigate any potential for further abuse: a. If this is staff to resident alleged or suspected abuse, the staff person will be immediately suspended until the investigation is completed and human resources (HR) will be notified.
Notification to the facility administrator will occur immediately for any incidents of resident abuse, alleged or suspected abuse, injury of unknown origin, neglect, financial exploitation, or involuntary seclusion. If the administrator is absent or unavailable, staff will follow the chain of command for notification.
Abuse is defined as the willful (as used in definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm) infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
Instances of abuse of all residents, irrespective of any mental or physical condition can cause physical harm, pain or mental anguish and include verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.
Suspected abuse shall be reported to OHFC online reporting process not later than 2 hours after forming the suspicion of abuse.