Cycle 1
Health 2025-03-27 · Fire 2025-03-27
5 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Waseca, MN
Lakeshore Rehabilitation Center LLC
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
108 8th Street Northwest, Waseca, MN
(507) 835-2800
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
52
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Monarch Healthcare Management
Operator or chain grouping
Approved since
1986-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
45 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.07
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.36
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.11
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.94
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.18
CMS adjusted RN staffing hours
Adjusted total hours
3.90
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
63%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,594
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.85
Composite VBP score used to determine payment impact.
Payment multiplier
1.0027
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.84
Performance 18.72% · Measure score 5.84 · Achievement 5.84 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.82
Performance 6.69% · Measure score 3.82 · Achievement 3.82 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.69
Baseline 100.00% · Performance 45.95% · Measure score 6.69 · Achievement 4.34 · Improvement 6.69
Adjusted total nurse staffing
3.19
Baseline 5.07 hours · Performance 3.98 hours · Measure score 3.19 · Achievement 3.19 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.22% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 1.82% · Lower 95% interval 5.73% |
| Discharge to community | 53.64% |
50.57%
3.1 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 53.19% · Lower 95% interval 40.58% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 42 · Denominator 42 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 42 |
| Discharge self-care score | 27.27% |
53.69%
26.4 pts worse
|
Numerator 9 · Denominator 33 |
| Discharge mobility score | 36.36% |
50.94%
14.6 pts worse
|
Numerator 12 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 2.38% |
2.29%
0.1 pts worse
|
Numerator 1 · Denominator 42 · Adjusted rate 2.34% |
| Healthcare-associated infections requiring hospitalization | 6.69% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 3.13% · Lower 95% interval 3.96% |
| Staff COVID-19 vaccination coverage | 5.8% |
8.2%
2.4 pts worse
|
Numerator 4 · Denominator 69 |
| Staff flu vaccination coverage | 58.16% |
42%
16.2 pts better
|
Numerator 57 · Denominator 98 |
| Discharge function score | 42.42% |
56.45%
14 pts worse
|
Numerator 14 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 42.86% |
25.2%
17.7 pts better
|
Numerator 9 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
97.3%
2 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.3% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.9%
1.5 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 5.9% · Q3 2.6% · Q4 5.4% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
4.3%
0.6 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 3.3% · Q3 2.6% · Q4 5.9% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
4.1%
3.4 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.9% |
12.4%
3.5 pts better
|
19.6%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 6.1% · Q3 8.6% · Q4 6.1% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.5% |
17.5%
4 pts worse
|
16.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 22.2% · Q3 17.9% · Q4 20.7% · 4Q avg 21.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.4% |
22.5%
10.1 pts better
|
16.3%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 19.6% · Q4 7.7% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
18.6%
5.4 pts better
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 19.4% · Q3 12.5% · Q4 12.1% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
2.3%
1.7 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.6%
1.9 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.6% |
24.8%
2.8 pts worse
|
19.8%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.6% · Q2 39.4% · Q3 14.3% · Q4 19.9% · 4Q avg 27.6% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
5.4%
3.1 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.8% · Q3 4.2% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
88.6%
6.5 pts better
|
81.7%
13.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 95.2% · Q3 92.1% · Q4 97.9% · 4Q avg 95.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.9% |
14.0%
4.9 pts worse
|
12.0%
6.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 16.7% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.8% |
1.9%
2.9 pts worse
|
1.6%
3.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 8.7% · Q4 7.1% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.7% |
82.7%
10 pts better
|
79.7%
13 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
23.1%
0.6 pts better
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 20.0% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-30 · Fire 2024-05-30
5 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2023-06-07 · Fire 2023-06-07
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-01
F · Potential for more than minimal harm
2025-03-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-01
E · Potential for more than minimal harm
2024-05-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-08-22
E · Potential for more than minimal harm
2024-05-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-30
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-08-22
D · Potential for more than minimal harm
2024-05-30
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-02
C · Minimal harm
2024-05-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-02
F · Potential for more than minimal harm
2023-06-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-06-07
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-18
F · Potential for more than minimal harm
2023-06-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-06-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-06-07
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-08-01
C · Minimal harm
2023-06-07
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-08-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-03-27
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-03-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-01
D · Potential for more than minimal harm
2025-03-27
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-05-01
C · Minimal harm
2025-03-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-05-01
F · Potential for more than minimal harm
2024-05-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-05-30
F811 · Nutrition and Dietary Deficiencies
Health
Ensure that residents are assessed for appropriateness for a feeding assistant program, receive services as per their plan of care, and feeding assistants are trained and supervised.
Corrected 2024-07-02
E · Potential for more than minimal harm
2024-05-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-05-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-02
F · Potential for more than minimal harm
2023-06-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-07
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-07
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-08-01
Penalties and ownership
What sits behind the stars
Ownership
Halpert, Marc
5% Or Greater Indirect Ownership Interest · Individual
Legum, Joshua
5% Or Greater Indirect Ownership Interest · Individual
Spartan Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Yazoma Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Stern, William
5% Or Greater Indirect Ownership Interest · Individual
Wbs Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Jaffa, Noam
5% Or Greater Indirect Ownership Interest · Individual
Nij LLC
5% Or Greater Direct Ownership Interest · Organization
Halpert, Marc
Operational/Managerial Control · Individual
Halpert, Marc
Corporate Officer · Individual
Jaffa, Noam
Corporate Director · Individual
Legum, Joshua
Contracted Managing Employee · Individual
Stern, William
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Whispering Creek
Janesville, MN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Benedictine Living Community Owatonna
Owatonna, MN
2-star overall rating with 2-star inspections with $36,638 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
New Richland Care Center
New Richland, MN
1-star overall rating with 1-star inspections with $122,605 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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