Above average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Minnetonka Shores during CMS and state inspections, most recent first.
Failure to Notify Provider of Weight Change: A resident with severe cognitive impairment, HF, dementia, and anxiety had a 5-lb weight gain over 1 day, but the record showed no evidence that the NP was notified as ordered. The administrator and DON confirmed the provider was not updated, and the DON stated staff should have notified the provider and documented the communication.
Failure to Provide Pneumococcal Vaccination After Consent: A resident with severe cognitive impairment and diagnoses including HTN, BPH, and non-Alzheimer’s dementia had a physician order and signed consent for pneumococcal vaccination, but the medical record lacked evidence the vaccine was given. The DON confirmed the vaccination had not been provided and stated the expectation was for it to be completed upon admission, with follow-up in 2-4 weeks if delayed.
The facility did not ensure accurate documentation of a resident's advanced directives in the electronic medical record (EMR) and physician orders. A resident, R158, had completed an updated Physician's Orders For Life Sustaining Treatment (POLST) indicating a Do Not Resuscitate (DNR) status. However, the EMR and physician orders still showed full code status. Staff members, including LPNs and RNs, relied on the EMR banner for code status information, leading to potential confusion and incorrect actions in the event of a medical emergency. This discrepancy could result in actions contrary to the resident's wishes during a cardiac arrest.
During a kitchen observation, a facility did not adhere to food safety guidelines for thawing raw chicken, risking cross-contamination. Cook-A was seen thawing frozen chicken in a sink with cloudy water and no running water. After handling the chicken with gloved hands, Cook-A washed hands for only 10 seconds, not meeting the required 20 seconds with soap and water. These actions were inconsistent with the facility's policies on Proper Thawing of Frozen Foods and Handwashing.
A medication cart on the third floor was left unlocked and unattended multiple times by an RN, allowing unauthorized access by residents, visitors, and unlicensed staff. Both the clinical coordinator and the DON confirmed that the cart should have been locked when unattended.
A facility failed to follow proper PPE protocol for a resident on contact precautions due to an MRSA infection. An LPN was observed performing wound care with inadequate PPE, increasing the risk of spreading the infection. The facility's policy required long sleeve gowns with cuffs, which was not adhered to, potentially affecting all residents, staff, and visitors.
The facility failed to ensure that two residents were offered and/or provided the pneumococcal vaccine series as recommended by the CDC. Both residents' records lacked evidence of shared clinical decision-making with the physician for PCV20 at least 5 years after the last pneumococcal dose, despite being eligible.
The facility failed to ensure the required staffing information was posted daily, affecting all 57 residents, staff, and visitors. The administrator and DON acknowledged the failure to complete and post the staffing information daily, as required by the facility's Nurse Hours Posting Policy.
Failure to Notify Provider of Significant Weight Change
Penalty
Summary
The facility failed to update the provider about a resident’s weight change according to the physician order for daily weights and notification of the NP if the resident gained 3 pounds in one day or 5 pounds in one week. The resident had severe cognitive impairment and diagnoses including heart failure, non-Alzheimer’s dementia, and anxiety. The record showed the resident weighed 171.2 pounds on 5/17/26 and 174.2 pounds on 5/18/26, a 5-pound increase, followed by a weight of 170.6 pounds on 5/19/26. The medical record lacked evidence that the provider was ever updated about the weight changes per the order. During the survey, the administrator confirmed the facility did not update the provider of the noted weight changes. The DON also confirmed the provider was not updated and stated staff would have been expected to notify the provider and document the communication in the resident’s chart. The facility’s Communication and Notification policy stated staff will notify the practitioner when there is a significant change in clinical condition or any other significant change in status from the plan of care.
Failure to Provide Pneumococcal Vaccination After Consent
Penalty
Summary
The facility failed to ensure that 1 of 5 residents reviewed for immunizations, R13, was offered, educated, and/or provided the pneumococcal vaccination series as recommended by the CDC. R13’s annual MDS indicated severe cognitive impairment and diagnoses of hypertension, benign prostatic hypertrophy, and non-Alzheimer’s dementia. The resident’s order summary included a physician order dated 5/27/26 stating the resident may receive pneumococcal vaccinations if not already received, and the resident’s pneumococcal vaccination consent form was signed the same day, showing consent to receive the vaccination. The resident’s Minnesota Immunization Information Connection report showed prior receipt of Pneumo-PCV13 on 8/29/17 and Pneumo-PPSV23 on 10/1/17, but the medical record lacked evidence that a vaccination was provided after the consent was signed. On 7/22/26, the DON, who was working as the infection preventionist, confirmed the vaccination had not been provided. The DON stated the expectation was that vaccinations should have been provided upon admission, and also stated the family had wanted to wait until R13 was doing better, but the facility should have followed up in 2-4 weeks after admission. The facility’s Pneumococcal Vaccination Policy stated each resident’s pneumococcal immunization status would be determined upon admission or soon thereafter and the vaccination date documented in the medical record.
Inconsistent Documentation of Advanced Directives in EMR and Physician Orders
Penalty
Summary
The facility failed to ensure accurate documentation of resident advanced directives in the electronic medical record (EMR) and physician orders, leading to a deficiency in following the resident's wishes in the event of a cardiac arrest for one of the residents reviewed. Despite the resident, R158, completing an updated Physician's Orders For Life Sustaining Treatment (POLST) to change code status to Do Not Resuscitate (DNR), the EMR and physician orders still indicated full code status. This discrepancy was identified when staff members checked the EMR banner for code status, leading to potential confusion and incorrect actions in the event of a medical emergency. Multiple staff members, including licensed practical nurses and registered nurses, acknowledged relying on the EMR banner for code status information. However, there was inconsistency in documentation, as the most recent POLST for R158 clearly indicated a DNR status while the EMR and physician orders reflected full code status. Despite R158's explicit wishes to be DNR and not receive CPR, the facility's failure to accurately document and update the code status in the EMR and physician orders created a situation where chest compressions would have been initiated if a cardiac arrest occurred, potentially going against the resident's wishes.
Improper Thawing and Handwashing Procedures Observed in Kitchen
Penalty
Summary
During a kitchen observation, it was noted that the facility failed to follow food safety guidelines in thawing raw chicken, potentially leading to cross-contamination. Cook-A was observed thawing raw, frozen chicken in a sink filled with cloudy water, with no water running over the chicken. Cook-A proceeded to handle the chicken with gloved hands, separating the pieces under running water, and then washed hands for only about 10 seconds, not following proper handwashing procedures. The Dietary Manager later corrected Cook-A on the appropriate thawing method for chicken and the proper handwashing technique, emphasizing the need for at least 20 seconds of handwashing with soap and water. The deficiency was further highlighted by the facility's policies on Proper Thawing of Frozen Foods and Handwashing, which were not followed during the observed incident.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure all medications and biologicals were locked in compartments accessible only to authorized personnel. During continuous observation, a medication cart on the third floor was left unlocked and unattended by RN-C multiple times, allowing residents, visitors, and unlicensed staff to walk by the unattended cart. The clinical coordinator, RN-A, eventually locked the cart when RN-C was not present. Both RN-C and RN-A acknowledged that the cart should have been locked when unattended. The director of nursing (DON) confirmed that staff were expected to lock medication carts when not in sight to prevent diversion and ensure safety. The facility's policy indicated that only authorized personnel should have access to medications, and medication storage areas should be locked when unattended.
Failure to Follow Proper PPE Protocol for Resident on Contact Precautions
Penalty
Summary
The facility failed to follow proper use of personal protective equipment (PPE) for a resident (R1) who was on contact precautions due to a methicillin-resistant Staphylococcus aureus (MRSA) infection in the right foot. The resident's wound culture lab collected on 4/2/24 indicated the presence of MRSA, necessitating contact precautions. Despite this, an LPN was observed on 4/24/24 at 7:13 a.m. performing wound care on R1 while wearing a short sleeve, fabric gown and disposable gloves, which did not meet the required criteria for contact precautions. The LPN's actions created an opportunity for splashing while cleansing the wound, increasing the risk of spreading the infection. The facility's infection preventionist and a registered nurse confirmed that the proper protocol was to wear a long sleeve gown with cuffs and gloves when providing care to a resident on contact precautions, which was not followed in this instance. The facility's undated Infection Prevention and Control Manual included instructions that a clean, non-sterile gown with long sleeves should be worn for direct care or when contact with secretions or excretions is expected. The failure to adhere to this policy was confirmed during interviews with the infection preventionist and a registered nurse, who both stated that long sleeve gowns with cuffs were necessary to protect clothing and skin from potential contamination. This deficiency had the potential to affect all 57 residents, staff, and visitors in the facility.
Failure to Ensure Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that two residents were offered and/or provided the pneumococcal vaccine series as recommended by the CDC. Resident 1, aged 90, with diagnoses including severe protein-calorie malnutrition, immunodeficiency, and type 2 diabetes, had no proof in their electronic medical record (EMR) of being offered the PCV20 vaccine. Additionally, Resident 1's care plan indicated a potential for infection related to their medical history and use of immuno-suppressant medication, but lacked evidence of shared clinical decision-making with the physician for PCV20 at least 5 years after the last pneumococcal dose. Resident 17, aged 80, with diagnoses including morbid obesity, unspecified asthma, and type 2 diabetes, had a signed pneumococcal vaccination consent form, but the section on shared clinical decision-making was not filled out. The resident's order summary report included an order stating the resident may receive pneumococcal vaccinations if not already received, but there was no evidence of shared clinical decision-making with the physician for PCV20 at least 5 years after the last pneumococcal dose. The Director of Nursing confirmed these deficiencies during an interview.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure the required staffing information was posted daily, affecting all 57 residents, staff, and visitors who may wish to view this information. During a review of the staff posting documentation from 3/24/24 through 4/25/24, it was found that the facility did not provide evidence of staff postings for nine specific dates. The administrator acknowledged the failure to complete and post the staffing information daily. The staffing coordinator and the director of nursing confirmed that staffing information needed to be posted and updated daily, as per the facility's Nurse Hours Posting Policy, last modified in October 2022.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Estates At Excelsior Llc | 4.7 mi | ★★★★★ | 20 | 3 |
| Haven Homes Of Maple Plain | 4.9 mi | ★★★★★ | 4 | 0 |
| Folkestone | 6.8 mi | ★★★★★ | 3 | 0 |
| Hope Springs At Minnetonka | 7.1 mi | ★★★★★ | 13 | 0 |
| Good Samaritan Society - Waconia And Westview Acre | 9.8 mi | ★★★★★ | 23 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.