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
Staffing
Hours and turnover
RN hours / resident day
1.07
Registered nurse staffing
LPN hours / resident day
0.36
Licensed practical nurse staffing
Aide hours / resident day
2.11
Nurse aide staffing
Weekend hours
3.26
Weekend nurse staffing
RN turnover
43%
Annual RN turnover
Total nurse turnover
63%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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