Lakeshore Rehabilitation Center LLC
Waseca, Minnesota · CCN 245388
15 surveys since 2011. The first finding at harm level was recorded in 2016.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 75
- Surveys
- 15
- Harm or worse
- 2
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 52
- Ownership
- For profit - Corporation
- Chain
- MONARCH HEALTHCARE MANAGEMENT
- County
- Waseca · rural
- Medicare-certified since
- 1986
CMS ratings
- Overall
- 2
- Health inspection
- 2
- Staffing
- 4
- Quality measures
- 3
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.
Weighted by harm level, against 55 for-profit facilities with fewer than 66 beds in Minnesota.
Last survey on record
Jul 16, 2026
116 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.32 | 3.62 |
| Registered-nurse hours per resident day | 0.91 | — |
| Annual nurse turnover | 46.3% | 50.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
No fines, payment denials or special-focus designation on the current CMS record.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D1350.0% | E415.4% | F726.9% |
| No harm, potential for minimal | A— | B— | C27.7% |
Most frequently cited here
In CMS’s current monthly file.
- F8123×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F5542×
Allow residents to self-administer drugs if determined clinically appropriate.
- F6772×
Provide care and assistance to perform activities of daily living for any resident who is unable.
- F6842×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F8672×
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
In the surveyor’s words
From the most serious findings on record at Lakeshore Rehabilitation Center LLC, in the surveyor’s own words.
- No harm, potential for more than minimal, widespreadF725Jul 16, 2026
Based on interview and document review, the facility failed to provide sufficient nursing staff to ensure 13 of 13 residents (R7, R4, R13, R31, R45, R35, R37, R42, R29, R35, R8, R24, R33), reviewed for sufficient staffing, received care and assistance in a timely manner. The lack of sufficient staff had the potential to affect all 42 residents who resided in the facility. Findings include: Refer to F676: Based on interview, observation, and document review, the facility failed to provide the necessary assistance with activities of daily living (ADL) to maintain ral hygiene for 1 of 2 residents (R42) reviewed for ADL assistance. […]
- No harm, potential for more than minimal, widespreadF838Jul 16, 2026
Based on interview and document review, the facility failed to ensure the Facility Assessment included information on staffing levels needed for specific shifts. This deficient practice had the potential to affect all 42 residents who resided in the facility.Findings include:Review of Facility assessment dated 6/2026, indicated the following:Section 3. Facility resources needed to provide competent support and care for our resident population every day and during emergencies:3.2 & 3.3. Direct Care Staffing Plan: To ensure an adequate amount of staff at Lakeshore Rehabilitation Center at all times, the resident population, case mix index (CMI), and census if taken into account daily to determine sufficient staffing needs. […]
- No harm, potential for more than minimal, widespreadF865Jul 16, 2026
Based on interview and record review, the quality assurance and performance improvement (QAPI) committee failed to identify resident call light wait time concerns prior to survey, nor make a good faith attempt to correct the deficiency. This deficient practice had the potential to affect all 42 residents residing in the facility. Findings include: QAPI meeting minutes dated 3/31/25, indicated, Call lights tend to be #1 issue. Call light response times had not been included/mentioned again in the subsequent six QAPI meeting minutes. […]
- No harm, potential for more than minimal, widespreadF867Jul 16, 2026
Based on interview and document review, the facility failed to develop and implement action plans, measure the success of actions and track performance, conduct a performance improvement project (PIP), and regularly review, analyze, and act on data collected. This deficient practice had the potential to affect all 42 residents residing in the facility. Findings include:Due to numerous sufficient staffing and long call light wait time concerns expressed by residents, family members and staff, QAPI (quality assurance and performance improvement) meeting minutes were reviewed.QAPI meeting minutes from March 2025 through June 2026, indicated the following:3/31/25 - Minutes lacked substance. No actions or resolutions. Identified under grievances: call lights tend to be #1 issue. […]
- No harm, potential for more than minimal, widespreadF812Mar 27, 2025
Based on observation, interview, and document review, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in 1 of 1 walk-in freezers, failed to ensure food stored in the refrigerators and dry storage were labeled, dated and discarded properly. This deficient practice had the potential to affect all 48 residents, staff and visitors who received food from facility kitchen. Findings include: Freezer During the initial kitchen tour on [DATE] at 12:50 p.m., a walk-in commercial freezer had a cooling fan mounted to the top of the unit which had visible ice built up on numerous places along the unit. […]
Read 22 findings in full →The most serious and the most recent: 22 of 75 on record.
Every survey on record
FindingsAt actual harm or above
- Jul 16, 2026Standard and complaint13 findings
- Mar 27, 2025Standard5 findings
- May 30, 2024Standard5 findings
- Jun 7, 2023Standard3 findings
- Jun 24, 2021Standard5 findings
- May 31, 2019Standard3 findings · 1 harm
- Mar 8, 2018Standard6 findings
- Jun 23, 2017Standard4 findings
Show the 7 earlier surveys
- Jul 21, 2016Standard4 findings · 1 harm
- Apr 18, 2016Complaint3 findings
- Sep 17, 2015Standard4 findings
- Jul 24, 2014Standard6 findings
- Sep 12, 2013—8 findings
- Jun 7, 2012—2 findings
- May 26, 2011—4 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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