Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeshore Rehabilitation Center Llc during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain proper storage of frozen and refrigerated foods, with significant ice buildup in the walk-in freezer and multiple opened food items in coolers and storage areas lacking required labels and dates. Staff and administration confirmed these deficiencies, and some food items were found to be expired or spoiled, contrary to facility policy.
A resident with multiple chronic conditions and requiring significant assistance with daily living was allowed to self-administer nebulizer treatments without a documented assessment or physician order. Staff set up the nebulizer and left the resident to complete the treatment alone, despite facility policy requiring an interdisciplinary assessment for self-administration. Staff interviews confirmed the absence of the required assessment and order in the resident's record.
A resident requiring substantial assistance with ADLs, including personal hygiene, was observed over several days with significant facial hair growth and expressed a desire to be shaved. Despite staff awareness of the need to assist with shaving and the facility's policy on person-centered care, no staff provided the necessary assistance, and the resident's care plan lacked documentation of shaving preferences.
The facility's QAPI committee did not identify or address ongoing freezer maintenance issues, including persistent ice buildup, despite repeated citations in past surveys for similar food storage and sanitation concerns. Interviews revealed that the dietary manager was aware of the problem, but the administrator was not, and QAPI meeting minutes showed no evidence of monitoring or corrective action for the freezer deficiency.
The facility failed to properly store frozen food in a walk-in freezer due to significant ice buildup, risking cross-contamination and foodborne illness. The director of culinary services confirmed ongoing issues with ice buildup, and the facility's policy lacked guidance on addressing this problem.
The facility failed to assess residents for suitability to be assisted by paid feeding assistants (PFAs) and did not ensure supervision by a nurse during meals. Six residents with cognitive impairments and swallowing difficulties were not formally assessed for PFA assistance, and staff were unaware of which residents could be assisted. The facility's policy required interdisciplinary assessments, but this was not followed, leading to unsupervised feeding assistance.
The facility failed to offer and provide recommended pneumococcal vaccinations to four residents, as per CDC guidelines. Despite having a policy to offer vaccinations, the facility did not ensure shared clinical decision-making or document the provision of newer PCV15/20 vaccines. Interviews with the DON and RNC confirmed the oversight, affecting residents with various medical conditions.
A resident experienced a breach of privacy when a nursing assistant entered her room without knocking, despite her preference for privacy. Another resident faced a prolonged wait for her meal, highlighting issues with the facility's dining service. The facility's policies on resident dignity and dining audits were not effectively implemented, leading to ongoing resident concerns.
A resident on hospice care complained of constipation, but the facility failed to comprehensively assess and develop a proactive bowel management program. Initial assessments were incomplete, and the care plan lacked interventions beyond toileting assistance. Despite the resident's preference for dietary interventions, the facility relied on laxatives, which the resident disliked. Staff interviews revealed lapses in communication and documentation, and the facility lacked a policy on bowel management programs.
Improper Food Storage and Labeling in Kitchen and Freezer
Penalty
Summary
Surveyors observed that the facility failed to properly store frozen food items in the walk-in freezer, resulting in significant ice buildup on the ceiling, walls, floor, and shelving. Cardboard food boxes were found to be soft, mushy, and covered in ice, with one box partially melted into a mound of ice on the floor. The cooling fan in the freezer was not functioning properly, and maintenance had only recently attempted repairs. The culinary services director acknowledged that the ice buildup had been an ongoing issue and could lead to food contamination, freezer burn, or food spoilage. The administrator was unaware of the current ice buildup, despite it being a concern during the last annual survey. Additionally, the facility did not ensure that food items stored in refrigerators and dry storage were properly labeled, dated, or discarded as required. Multiple opened food items, including salsa, hot dogs, cottage cheese, egg salad, lettuce, sliced cheeses, and sour cream, were found without labels or dates, and some were expired or spoiled. Staff interviews confirmed that the expectation was to label and date all opened food items, but this was not consistently followed. Facility policies required proper labeling, dating, and storage of food, but these procedures were not adhered to during the survey.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was comprehensively assessed for self-administration of medications, as required by policy. The resident, who had intact cognition but required substantial to maximal assistance with all activities of daily living, including personal hygiene, was observed self-administering nebulizer treatments without a documented assessment or physician order permitting self-administration. Staff interviews confirmed that the resident's electronic health record did not contain an order for self-administration, and the director of nursing acknowledged that no assessment had been completed for this purpose. Observations showed the resident independently using the nebulizer in her room, with staff setting up the medication and equipment but leaving the resident alone to complete the treatment. Staff reported that they would return after 10-15 minutes to check on the resident and turn off the machine. Additionally, nursing assistants noted that the resident sometimes required assistance to properly position the nebulizer mask. The facility's policy required an interdisciplinary team assessment to determine if self-administration was clinically appropriate and safe, but this process was not followed for the resident in question.
Failure to Provide Assistance with Facial Hair Removal
Penalty
Summary
A resident with intact cognition and diagnoses including diabetes mellitus and arthritis was identified as requiring substantial to maximal assistance with activities of daily living (ADLs), specifically personal hygiene. The resident's care plan did not document shaving preferences. Over several days of observation, the resident was noted to have approximately one inch of white facial hair on the chin, and the resident expressed a desire to be shaved, stating that staff had assisted with shaving in the past. Multiple staff interviews revealed that nursing assistants and an LPN were aware of the need to assist residents with shaving when facial hair was noticed, but none had provided this care to the resident in question. The DON confirmed that staff are expected to shave residents' facial hair, especially for women, and that razors are available for use. The facility's ADL policy emphasized person-centered care and honoring resident preferences, but this was not reflected in the care provided to the resident, resulting in a failure to assist with facial hair removal.
Failure of QAPI Committee to Address Ongoing Freezer Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) committee identified, investigated, analyzed, and responded to ongoing freezer maintenance issues, specifically the prevention of ice buildup. Despite the facility's QAPI plan outlining a proactive approach to quality improvement and a process for addressing high-risk or problem-prone areas, the committee did not address or monitor recurring concerns related to freezer maintenance. The deficiency was noted during interviews and document reviews, which revealed that the QAPI committee had not discussed or tracked the freezer issue, even though similar deficiencies had been cited in the last three recertification surveys. These previous citations included failures to properly label and store food, sanitize equipment, and prevent cross-contamination in the kitchen and freezer areas. During interviews, the dietary manager acknowledged that the freezer fan had been blocked and that ice buildup had persisted for several weeks, potentially affecting food quality. The administrator was unaware of the current ice buildup and confirmed that the issue had been identified in the past, with previous corrective actions not sustained. Review of QAPI meeting minutes showed no documentation of the freezer issue, and there was no evidence of ongoing monitoring or follow-up on the previously identified deficiency.
Improper Storage of Frozen Food Due to Ice Buildup
Penalty
Summary
The facility failed to ensure proper storage of frozen food items in their main production kitchen's walk-in freezer, which posed a risk of cross-contamination and potential foodborne illness. During an inspection, it was observed that the freezer had significant ice buildup on the cooling fan, ceiling, back wall, floor, and metallic shelving. Food items, including an opened box of salmon and an unopened box of cod, were stored in this environment. The salmon box was open, with fillets exposed and covered in ice, while the cod box was sealed but had wet spots and loose tape. The temperature inside the freezer was recorded at -8 degrees Fahrenheit. The director of culinary services confirmed the ongoing issue with ice buildup, stating that maintenance had chiseled the ice out multiple times over the past seven months. Despite these efforts, the ice buildup persisted, and the salmon was discarded due to contamination concerns. The facility's policy on refrigerator and freezer maintenance lacked specific guidance on addressing repeated ice buildup, contributing to the deficiency.
Failure to Assess and Supervise Feeding Assistance
Penalty
Summary
The facility failed to ensure that residents were properly assessed for their suitability to be assisted by paid feeding assistants (PFAs) during meals. This deficiency was observed in six residents, all of whom had varying degrees of cognitive impairment and required assistance with activities of daily living, including eating. The facility did not conduct assessments to determine if these residents, some of whom had conditions like dysphagia, were appropriate candidates for assistance by PFAs. The care plans and clinical nutrition evaluations for these residents lacked documentation of such assessments, and there was no mention of the residents' ability to be assisted by PFAs. Additionally, the facility did not ensure that PFAs were supervised by a nurse while assisting residents with meals. Observations revealed that activity department staff, who had completed the PFA training, were assisting residents without the presence of a nurse. Interviews with staff confirmed that there was no formal list of residents who could be assisted by PFAs, and the staff were under the impression that they could assist any resident needing help with eating. The director of nursing acknowledged the lack of formal assessments and supervision, stating that they relied on informal knowledge of residents' needs. The facility's policy on paid feeding assistants required an interdisciplinary team assessment to determine residents' eligibility for feeding assistance, but this was not adhered to. The director of nursing and other staff members confirmed that there was no formal assessment process in place, and the facility did not maintain a list of residents who could be assisted by PFAs. This lack of formal assessment and supervision posed a risk to residents, particularly those with swallowing difficulties or other complex feeding needs.
Failure to Provide Recommended Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that recommended pneumococcal vaccinations, as outlined by the CDC, were offered and/or provided in a timely manner to four out of five residents reviewed for immunizations. The CDC's guidelines for pneumococcal vaccine timing for adults, dated March 2023, recommend shared clinical decision-making between the resident and healthcare provider to determine if the PCV20 vaccine is appropriate. However, the facility did not adhere to these guidelines, as evidenced by the lack of documentation and shared decision-making for residents R3, R2, R8, and R24. Resident R3, with moderate cognitive impairment and medical conditions such as heart failure and diabetes mellitus, had received the PPSV23 vaccine in 1997 but had no record of receiving the newer PCV15/20 vaccines. Similarly, resident R2, with intact cognition and conditions including diabetes mellitus and heart failure, received the PPSV23 vaccine in 2005 but lacked evidence of subsequent pneumococcal vaccinations. Both residents did not recall being offered the newer vaccines, and their medical records lacked evidence of shared clinical decision-making regarding these vaccinations. Resident R8, with moderate cognitive impairment and conditions like anemia and chronic kidney disease, had received the PPSV23 in 2009 and PCV13 in 2017 but not the newer PCV15/20 vaccines. Resident R24, with intact cognition, had received the PPSV23 in 2000 and PCV13 in 2017, also without evidence of being offered the newer vaccines. Interviews with the DON and RNC confirmed that the facility had not provided the newer pneumococcal vaccinations to these residents, despite being aware of CDC recommendations. The facility's pneumococcal policy, dated February 2024, stated that vaccinations would be offered to all residents, but this was not followed in practice for the identified residents.
Deficiencies in Resident Privacy and Dining Experience
Penalty
Summary
The facility failed to maintain a dignified and personal space for a resident, identified as R8, when a nursing assistant entered the resident's room without knocking or waiting for a response. R8, who had moderate cognitive impairment, expressed a preference for privacy and for staff to knock before entering. Despite this, the nursing assistant entered the room abruptly during an interview with a surveyor, claiming to have knocked, although R8 and other residents had previously commented on staff not always knocking. The Director of Nursing was unaware of such issues but emphasized the importance of knocking to respect residents' dignity and privacy. In another incident, the facility failed to provide a dignified dining experience for a resident, identified as R29, who waited an extended period for her meal while her tablemates were served and finished eating. R29, who was cognitively intact and independent with eating, had ordered a grilled cheese sandwich from the always available menu, which was delayed due to a cooking issue. The dietary aide and certified dietary manager acknowledged the delay, with the latter stating that meals should be served within 30-40 minutes. Despite efforts to improve meal service times, residents continued to express concerns about long wait times during resident council meetings. The facility's policy on dining room audits required regular checks to ensure residents' needs were met and that dining was a pleasant experience. However, the policy did not seem to be effectively implemented, as evidenced by the ongoing complaints about meal wait times. The administrator acknowledged the issue and mentioned plans to have items from the always available menu prepared in advance, but residents continued to experience delays, impacting their dining experience and sense of dignity.
Failure to Implement Proactive Bowel Management Program
Penalty
Summary
The facility failed to comprehensively assess and develop interventions for a proactive bowel management program for a resident (R31) who complained of constipation. Upon admission, R31 was identified as having intact cognition and was continent of bowel, but the initial assessments lacked a thorough evaluation of bowel patterns and preferences. The bowel evaluation conducted was incomplete, with sections left blank and no individualized treatment plan documented. Despite R31's complaints of constipation and her preference for dietary interventions like prunes and graham crackers, the facility did not engage with her to develop a proactive management plan, instead opting for laxatives which she disliked. R31's care plan, which included hospice enrollment for heart failure and a lung mass, did not adequately address her bowel management needs. The care plan only listed a single intervention of assistance with toileting, lacking any comprehensive strategies to manage her bowel movements. Progress notes from hospice visits indicated potential constipation concerns due to narcotic use, but there was no follow-up or re-evaluation of R31's bowel management needs by the facility after a certain date. The facility's documentation did not reflect any proactive measures or reassessment of R31's bowel management program, despite hospice's observations and R31's own input. Interviews with staff revealed a lack of communication and documentation regarding R31's bowel management. Nursing staff acknowledged lapses in creating daily listings for bowel interventions and noted that comprehensive bowel evaluations were considered the responsibility of hospice. The Director of Nursing admitted that the facility's assessments were more focused on incontinence rather than proactive bowel management. The facility did not have a policy on bowel management programs, and there was no evidence of a comprehensive assessment or management plan to address R31's constipation and promote her comfort.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 51 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waseca
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whispering Creek | 9.9 mi | ★★★★★ | 5 | 0 |
| Benedictine Living Community Owatonna | 11.5 mi | ★★★★★ | 6 | 0 |
| New Richland Care Center | 12.7 mi | ★★★★★ | 2 | 0 |
| The Emeralds At Faribault Llc | 19.4 mi | ★★★★★ | 3 | 0 |
| Oaklawn Care & Rehabilitation Center | 24 mi | ★★★★★ | 2 | 0 |
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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 July 2026) and official state health department websites.