Below 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 Lakeshore Rehabilitation Center Llc during CMS and state inspections, most recent first.
A facility failed to provide enough nursing staff to meet resident needs, resulting in prolonged call light waits, delayed toileting, bathing, ambulation, and oral care for multiple residents. Residents with conditions including CHF, stroke, fractures, Alzheimer’s disease, Parkinson’s disease, diabetes, and mobility impairment reported waiting 30 minutes to more than 1 hour for help, and staff described chronic shortages, agency no-shows, and poor communication between NAs and nurses that delayed care and left some baths and ADLs incomplete.
The facility failed to ensure its Facility Assessment included staffing levels needed for specific shifts. The assessment stated the IDT reviewed daily census, admissions, discharges, resident population, and CMI to determine staffing needs, and that the DON, nurse management, charge nurse, and unit nurse determined assignments, but it did not include day, evening, or night staffing levels or how staffing would be adjusted with changes in census. The administrator stated she provided the current version to the SA, said she would not include shift-specific staffing because staffing fluctuates, later stated the staffing information had been accidentally deleted, and confirmed the facility did not use the daily census template as directed or have a specific algorithm for determining staffing levels.
QAPI committee failed to identify and address resident call light wait time concerns, despite meeting minutes noting call lights were the #1 issue. The concern was not documented in subsequent QAPI meetings, and the administrator stated there was no documentation showing follow-up, audit results, or staff feedback related to the issue. The VPO said the facility’s QAPI process should include data analysis, root cause review, action planning, and monitoring, but the administrator acknowledged the issue had not been on her radar and staff had not been informed or asked for input.
QAPI failed to document analysis, action plans, or outcomes for key quality concerns, including staffing and long call light wait times. Meeting minutes were often missing or lacked substance, and a grievance noting call lights as the #1 issue was not followed by documented review. The administrator also admitted the 2026 PIP on unplanned wt loss relied only on dietician data and did not include a root cause analysis or other relevant data such as diet orders, food preferences, resident eating observations, family input, or supplement use.
Resident council concerns were not addressed or documented for the residents who attended meetings. Minutes showed issues with wheelchair maintenance, a leaking toilet, missing socks, meal delays, food quality and temperature, and long call light response times, but there was no follow-up or explanation of resolution. Residents stated they did not receive answers about staffing and call light concerns, and the AA who facilitated meetings said she could not find evidence of replies and did not know a formal written response was required.
A facility failed to maintain a clean, comfortable, and homelike environment in the East and [NAME] hallways. Observations showed dark stains, worn-through carpet, frayed and separated seams, and carpet backing visible in multiple areas. An LPN, EVS manager, MD, and the administrator all acknowledged the carpet was old, not secure, and had remained stained despite repeated cleaning. In the East hallway bath tub room, surveyors also observed stained, cracked, broken, and sagging ceiling tiles, which the MD and administrator confirmed were damaged.
A resident’s MDS discharge assessment was coded as an unplanned discharge even though the discharge was planned. The resident had improved after a CVA with left-sided weakness and vision deficit, was independent with ADLs and ambulation, had a provider discharge order, received discharge instructions and medication review, and left home with the daughter; staff interviews confirmed the discharge had been planned over several days and was not AMA.
A resident with a right ankle fracture and limited mobility required staff help with oral hygiene, including obtaining toothbrush supplies and water and emptying the cup after brushing. Although the care plan and facility policy called for daily ADL support, documentation did not show oral care was completed every day, and the resident reported that staff sometimes said they were too busy or delayed assistance for long periods. Staff interviews confirmed missed or delayed oral care support and long call light response times.
Failure to provide oral care for a dependent resident. A resident with fractured vertebrae, a fractured R radius, and a fractured R humerus required staff assistance for oral hygiene, including care of an upper denture and lower partial. The resident and family member reported staff were not cleaning the dentures, and an NA admitted oral care had not been provided and later still had not been done because it had been busy. The DON stated oral care was the responsibility of NAs and expected at least twice daily, while documentation showed limited entries that reflected needed care rather than completed oral care.
Failure to Follow Bowel Movement Protocol: A resident with fractures and limited mobility went six days without a documented BM despite PRN laxative orders and standing bowel protocol orders for escalating treatment after 2 and 3 days without a BM. An LPN learned the resident had lower abdominal pressure and had not had a BM for a while, the RN later gave a suppository after PRN medication had no effect, and the DON acknowledged staff had not been monitoring and addressing the resident’s BMs per the standing orders.
Failure to follow walking programs for two residents. One resident with osteoarthritis, diabetes, weakness, and obesity and another resident with CHF, diabetes, weakness, fall history, and obesity were both ordered to ambulate 1-2 times daily with staff assistance, but records showed inconsistent or unsupported documentation of ambulation. PT instructions were not fully reflected in the care plan or Kardex for one resident, the POC system was not set up for the other, NAs said workload prevented all walks from being completed, and nurses documented ambulation based on what NAs told them rather than direct observation.
Damaged Shower Chair Used in Bath Room: A shower chair in the east hallway bath room had a black vinyl cushion with multiple tears, cracks, and openings, with exposed underlying material. NA-A confirmed the chair was used for residents and said a towel was placed on it before use. An LPN, MD, administrator, and DON all acknowledged the cushion was damaged and stated it presented an infection control concern.
The facility failed to keep the daily staffing posting current when staffing changed. The posting in the main entrance area was observed with an outdated date, and an LPN was seen replacing the page. Review of the staffing schedule showed extra NAs were added to help with missed baths, but the posting was not updated to reflect the added staff. The DON and administrator both confirmed the postings were not updated to match the actual staffing levels.
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.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to ensure timely care and assistance for 13 of 13 residents reviewed for staffing concerns. The report states that residents experienced prolonged waits for call light response, missed or delayed ADL care, and delays in toileting, bathing, ambulation, and oral care. Multiple residents and family members reported waiting 30 minutes to 1 1/2 hours for staff response, and call light logs showed repeated response times over 30 minutes, with some exceeding 60, 80, 100, 130, and 150 minutes. Several residents described how the delays affected their daily care. One resident with orthopedic aftercare for a hip fracture, intact cognition, and dependence for many ADLs said the facility was chronically short-handed and that he used his call light for brief changes and getting in and out of bed, but often waited a long time. Another resident with congestive heart failure and intact cognition said staff took a long time to answer her call light every day. A dependent resident with fractures and multiple trauma had family report that the call light was sometimes not in reach and that the resident had to yell for help or pound on furniture to get attention. Other residents with heart failure, diabetes, stroke, Alzheimer’s disease, Parkinson’s disease, and mobility limitations reported long waits for toileting, bathing, and other assistance, and some said they missed baths because staff were unavailable. The report also documents that residents and staff repeatedly raised concerns about staffing levels and communication problems. During resident council, residents said staffing was a big concern, call lights were answered too slowly, and baths were rescheduled or missed. Staff stated the south unit had fewer nursing assistants than before, that agency staff often did not report, and that there were times when only one NA was available for a unit. Staff also reported that the facility did not provide walkie-talkies, forcing them to search room-to-room for coworkers or nurses, which delayed resident care. The DON and administrator acknowledged lengthy call light response times, staffing shortages, and that the facility did not routinely monitor call light response times facility-wide. The report further states that staffing decisions were based on census and PPD, but staff and leadership described ongoing delays in care, missed baths, delayed morning care, and incomplete ambulation and oral care.
Facility Assessment Missing Shift-Based Staffing Levels
Penalty
Summary
The facility failed to ensure its Facility Assessment included information on staffing levels needed for specific shifts. Review of the Facility Assessment dated 6/2026 showed the direct care staffing plan stated the interdisciplinary team reviewed the daily census template, admissions, discharges, resident population, and case mix index to determine staffing needs, and that staff assignments were determined by the DON, nurse management, charge nurse, and unit nurse in that order of hierarchy. However, the assessment did not include staffing levels for specific shifts such as day, evening, and night, or how staffing would be adjusted based on changes to the resident population. During interview, the administrator stated she provided the state agency the correct and most current version of the assessment and said she would not include specific staffing requirements for each shift because staffing fluctuates so much. On a later interview, she stated she was aware specific staffing data should be in the Facility Assessment and said she must have accidentally deleted the staffing information. She also stated the facility did not use the daily census template to review staffing needs as directed in the assessment, although the IDT did discuss census daily, and that the facility did not have a specific algorithm to determine needed staffing levels and would refer to the Facility Assessment to determine staff needed to meet residents' needs. A document titled Staffing Levels Per Patient Day (PPD) Compliant, undated, indicated staffing levels were based on resident census numbers.
QAPI Committee Failed to Address Call Light Response Time Concerns
Penalty
Summary
The facility’s QAPI committee failed to identify resident call light wait time concerns before survey and did not make a good faith attempt to correct the deficiency. QAPI meeting minutes dated 3/31/25 stated that call lights tended to be the #1 issue, but call light response times were not included or mentioned again in the next six QAPI meeting minutes. The deficiency had the potential to affect all 42 residents residing in the facility. During interviews, the administrator stated she assumed the QAPI committee had followed up on call light wait time concerns, completed an audit, and determined it was not an issue, but there was no documentation to support that. The vice president of operations stated the organization uses a standardized QAPI meeting format and that facilities are expected to analyze data, discuss findings, review audit results, perform root cause analyses, develop action plans, and monitor the effectiveness of interventions. The administrator later stated the long call light response times found during survey had not been on her radar and admitted there had been no staff meetings where QAPI activities were communicated to employees or where employees were asked for feedback about resident care concerns.
QAPI Program Failed to Document Analysis and Follow-Through on Quality Issues
Penalty
Summary
The facility failed to develop and implement action plans, measure the success of actions, track performance, conduct a performance improvement project (PIP), and regularly review, analyze, and act on collected data. This deficient practice was identified during review of QAPI meeting minutes and interviews, and it had the potential to affect all 42 residents in the facility. Concerns raised by residents, family members, and staff included sufficient staffing and long call light wait times, but the QAPI minutes from March 2025 through June 2026 were incomplete or lacked substance, with several meetings having no documentation at all and others not showing actions or resolutions. The QAPI minutes from 3/31/25 noted that call lights were the number one grievance, but the issue was not mentioned again in the record. During interviews, the administrator stated the discussions were mostly verbal and admitted the minutes did not reflect those discussions. The administrator also stated she assumed follow-up had been done regarding call light wait times, including an audit, but there was no documentation to support it. For the 2026 PIP, the administrator identified unplanned weight loss, but admitted only weight loss information from the dietician had been used and that no root cause analysis had been completed. The administrator further acknowledged that other relevant data, such as diet orders, food preferences, observations of residents eating, family involvement, supplements, and audits, had not been included. The VPO stated he was not aware of specific quality indicator concerns at the facility and described the type of analysis and documentation he would expect for call light concerns, including trends, patterns, root cause analysis, and identified interventions.
Resident Council Concerns Were Not Addressed or Documented
Penalty
Summary
The facility failed to ensure resident concerns raised during resident council meetings were addressed and that residents were notified of any resolution or ongoing measures. Review of resident council minutes from 7/6/26, 6/10/26, 3/26/26, and 3/11/26 showed concerns about wheelchair maintenance, a leaking toilet, missing socks, mealtime service delays, food quality and temperature, and long call light response times, but the minutes did not include follow-up, explanations of how or when the concerns would be addressed, or whether they were ever addressed. This affected all 9 residents who attended resident council, including residents with concerns about delayed call light response and other facility issues. Interviews confirmed that residents did not receive responses to their concerns. R29, whose quarterly MDS showed intact cognition, use of a walker and wheelchair, partial assistance with toileting, bathing, and transfers, and diagnoses of heart failure and high blood pressure, stated she had raised staffing and call light concerns but never received an answer about whether they were addressed. R35, whose quarterly MDS showed intact cognition, wheelchair use, dependence with toilet use, substantial assistance with bathing and transfers, and diagnoses of heart failure and kidney insufficiency, stated she was unaware of any follow-up or solutions. The activities assistant who facilitated the meetings stated she could not find evidence of replies to resident council concerns and was not aware that a formal written response was required, while the administrator stated she would expect leadership responses and was unaware the concerns were not being addressed or documented.
Unsafe and Unhomelike Hallway Carpeting and Damaged Ceiling Tiles
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in the East and [NAME] hallways. Observation of the East hallway identified multiple dark stains on the carpeting, worn and soiled carpet, fraying seams, and areas where the carpet was worn through with the backing visible. Staff acknowledged the carpet was stained, frayed, not securely attached at the seams, and had been shampooed and scrubbed multiple times without improvement because the carpeting was old. The environmental services manager stated requests for replacement flooring had been ongoing for an extended period and described the condition as embarrassing and unfair to residents. The maintenance director and administrator confirmed the carpeting was not secure, frayed, and could be tripped on, and stated replacement had been discussed but no replacement date had been established. The administrator acknowledged residents would not be expected to live with frayed carpeting or holes in the carpet because it is not a homelike environment. In the East hallway bath tub room, observation identified a ceiling tile with a large brown discolored area around the sprinkler head, an adjacent tile with additional discoloration, and other ceiling tiles that were cracked, broken, and sagging. The maintenance director confirmed the ceiling tile was stained and busted, and the administrator stated the stained and cracked ceiling tiles would be expected to be replaced.
MDS Discharge Coded Incorrectly as Unplanned
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident by coding the discharge as an unplanned discharge when the discharge was planned. The resident had been admitted after a CVA with left-sided weakness and left-sided vision deficit, and the record showed the resident had improved to the point of being independent with oral hygiene, toileting hygiene, dressing, personal hygiene, transfers, and walking, with modified independence for daily decision making. The discharge instructions documented that the resident was discharged home at the resident’s request, with the resident and daughter informed of the medication instructions and other discharge information. The record also showed a provider note stating the resident could be discharged home with current medications and treatment plan, a notice of transfer or discharge stating the discharge was appropriate because the resident’s health had improved sufficiently, and nursing documentation showing the resident packed belongings, awaited pickup, reviewed discharge medications, and left by private vehicle with the daughter. Staff interviews confirmed the discharge planning had occurred over several days, a provider discharge order had been obtained, the resident did not leave AMA, and the discharge was planned; however, the MDS coordinator coded it as unexpected because the exact day of discharge was finalized only shortly before the resident left.
Failure to Provide Daily Oral Care Assistance
Penalty
Summary
The facility failed to provide the necessary assistance with activities of daily living to maintain oral hygiene for one resident who was reviewed for ADL assistance. The resident’s MDS indicated she was cognitively intact, had no rejection of care, and required supervision or touching assistance with oral hygiene. Her diagnoses included a displaced trimalleolar fracture of the right lower leg and a history of falling. The resident’s CAA noted a decline in mobility after hospitalization for a fall that resulted in a right ankle fracture, with PT and OT in progress and a plan to continue assistance with ADLs and follow therapy recommendations. The resident’s care plan identified altered mobility, that she did not walk, required assistance with movement in bed and in and out of bed, and needed set-up with personal hygiene. However, the task record for personal hygiene did not show daily set-up assistance with oral care. During observation and interviews, the resident stated she needed staff help to obtain her toothbrush, toothpaste, and water, and to empty the water after brushing her teeth. She stated she did not receive assistance with morning oral care every day and that when she requested help, staff sometimes told her they did not have time because they were assisting other residents. Staff interviews confirmed delays and missed assistance. A nursing assistant stated there were times staff did not have enough time to assist the resident with oral care supplies and that assistance could be delayed until about 1:00 p.m.; the same assistant acknowledged occasions when the resident was told staff were too busy. The social services director confirmed call light logs showed response times exceeding 25 minutes and that the resident had been moved to another hallway because of long response times. The DON stated staff were expected to provide daily assistance with tooth brushing and document the care, but the documentation did not show oral care was completed daily. The facility policy stated residents would receive the care and services needed to ensure ADL abilities do not diminish, including oral care.
Failure to Provide Oral Care for a Dependent Resident
Penalty
Summary
The facility failed to provide oral care to a resident who was dependent on staff for most ADLs, including oral hygiene. The resident had diagnoses of fractured vertebrae, a fractured right radius, and a fractured right humerus, and the admission MDS indicated intact cognition, clear speech, and that the resident could understand and be understood. The care plan identified self-care deficits related to impaired mobility and right arm fractures and stated staff would assist with dental hygiene for the resident's upper denture and lower partial. During interviews, the resident and a family member stated staff had not been cleaning the resident's dentures, and the family member reported finding food and white material on them when removed for cleaning. A nursing assistant acknowledged not providing oral care that morning and stated it probably should have been done when the resident was sitting up earlier. Later the same day, the resident and family member again stated the dentures and teeth had not yet been cleaned, and the nursing assistant stated she still had not done it because it had been busy. The DON stated oral care was the responsibility of NAs and expected it to be done at least twice a day. Review of the point-of-care documentation showed only 12 checkmarks in 15 days and 30 opportunities for oral care, reflecting the level of care needed rather than whether oral care had actually been completed.
Failure to Follow Bowel Movement Protocol
Penalty
Summary
The facility failed to implement the bowel movement protocol for a resident with diagnoses of fractured vertebrae, fracture of the right radius, and fracture of the right humerus. The resident’s admission MDS indicated intact cognition, clear speech, and dependence on staff for most ADLs, with no walking. Physician orders included senna as needed for constipation and standing bowel protocol orders for Milk of Magnesia if no BM for two days, Dulcolax suppository if no BM for three days, and Fleet’s or tap water enema if constipation continued. The care plan identified altered elimination related to mobility limitations and indicated the resident would move bowels every three days or greater. The resident’s bowel movement task list showed no documented BM from 7/9/26 through the morning of 7/14/26, a period of six days. During observation, the LPN spoke with the resident, who reported pressure in the lower abdomen and stated she had not had a BM for a while; the LPN then checked the EMR and saw the last documented BM had been six days earlier and was unaware of the facility’s BM protocol or standing orders. The NA stated BMs were documented in the EMR but admitted documentation could be forgotten or not completed. The RN later stated the resident had no results from the PRN medication given the prior day and then administered a suppository, after which the resident had a BM. The RN also acknowledged staff had not been monitoring the resident’s BMs and addressing them per the standing orders, and the DON stated it was not okay for a resident to go six days without a BM and that by day three the resident should have received a suppository per standing orders.
Failure to Follow Walking Programs for Two Residents
Penalty
Summary
The facility failed to maintain, restore, or improve the functional ability of 2 residents by not ensuring they were walked according to PT instructions and physician orders. One resident had diagnoses including generalized osteoarthritis, diabetes, generalized muscle weakness, and obesity, used a walker and wheelchair, and had orders to be walked two times daily with staff. PT also instructed that the resident ambulate one to two times a day with a front wheeled walker and one staff member. Although the care plan, Kardex, and orders reflected the walking program, documentation in point-of-care records showed the resident was walked only 9 times out of 56 opportunities over 28 days. The second resident had diagnoses including CHF, diabetes, generalized muscle weakness, history of falling, and obesity, used a walker and wheelchair, and had orders to ambulate one to two times per day with assistance of one to manage oxygen tubing. PT instructed ambulation one to two times daily with a front wheeled walker and assistance of one. The care plan referenced altered mobility and following PT instructions, but the PT walking recommendations were not included in the care plan, the Kardex did not include the ambulation recommendations, and the point-of-care system had not been set up for NAs to document ambulation. Nursing documentation showed the resident was walked 27 times out of 30 opportunities over 15 days, but there was no NA documentation supporting those entries. Interviews showed the residents were sitting in wheelchairs with walkers off to the side and stated they had not been walking as much as before, though they wanted to walk to stay strong and mobile. PT staff stated therapy alert forms were given to the DON and NAs. NAs stated residents were on walking lists but were not always walked because staff were busy and workload was heavy, and one NA said residents only got walked once a day. Nurses stated they documented ambulation on the TAR based on what NAs told them, even when they did not personally observe it. The DON stated she did not monitor whether residents were walked according to PT recommendations or monitor the documentation, and acknowledged that R29 had not been walked according to the PT recommendation, physician order, care plan, and Kardex.
Damaged Shower Chair Used in Bath Room
Penalty
Summary
The facility failed to maintain reusable resident care equipment in a condition that could be effectively cleaned and disinfected when it continued to use a bathtub chair with a torn and cracked cushion surface in the east hallway bath room. Observation of the bath tub room on the east hallway showed the shower chair seat had a black vinyl cushion with multiple tears, cracks, and openings throughout the seating surface, with portions of the vinyl missing and the underlying light-colored cushion material exposed. During interviews, NA-A stated the bathtub room was used for residents and confirmed the cracked shower chair was used, adding that a towel was placed on the chair before residents used it. LPN-A stated the bathtub chair cushion was cracked and had openings and said it could be an infection control issue. MD-A confirmed the cushion was cracked and damaged and said it would be expected to be replaced, while the administrator observed the chair and confirmed it should not be in that condition due to infection control concerns. The DON, also the infection preventionist, stated the shower chair was not expected to have cracked cushions and said the damaged cushion could present an infection control problem.
Daily Staffing Posting Not Kept Current
Penalty
Summary
The facility failed to ensure the posted nursing hours were updated when staffing levels changed. During an observation and interview on 3/14/26 at 10:45 a.m., the daily staffing hours were posted in the main entrance area for residents and visitors to see, but the posting was still dated 3/13/26. LPN-A was observed removing the 3/13/26 page and inserting the new daily staffing hours for 3/14/26. Review of the posted staffing hours showed different staffing patterns for 3/13/25 and 3/14/26, and review of facility schedules dated 7/13/26 and 7/14/26 showed additional NAs were scheduled on each day to assist with baths missed on the weekend. On 7/13/26, an additional NA was scheduled from 10:30 a.m. to 2:30 p.m., and on 7/14/26, an additional NA was scheduled from 11:00 a.m. to 2:30 p.m., but the daily staffing posting was not updated to reflect these changes. The DON stated she had added extra staff to assist with making up baths from the weekend and expected the daily staff posting to be updated when staffing changed. The administrator stated it was the TMA's responsibility to update the posting in real time and confirmed the postings were not updated on either day. A policy on daily staff postings was requested but not received.
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.
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What surveyors actually found near you
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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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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 Fairbault Llc | 19.4 mi | ★★★★★ | 15 | 0 |
| Oaklawn Health Care, Llc | 24 mi | ★★★★★ | 11 | 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 October 2026) and official state health department websites.