Cycle 1
Health 2025-06-26 · Fire 2025-06-26
8 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Baudette, MN
Lakewood Care Center
4-star overall rating with 3-star inspections with $8,421 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
600 Main Avenue South, Baudette, MN
(218) 634-3401
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
32
Certified beds
Average residents
25
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Commonspirit Health
Operator or chain grouping
Approved since
1991-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.70
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
3.06
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.78
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
4.23
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.45
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
0.86
CMS adjusted RN staffing hours
Adjusted total hours
5.89
CMS adjusted total nurse staffing hours
Case-mix index
1.11
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
216
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
77.53
Composite VBP score used to determine payment impact.
Payment multiplier
1.0252
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.51
Baseline 16.00% · Performance 41.18% · Measure score 5.51 · Achievement 5.51 · Improvement 0
Adjusted total nurse staffing
10
Performance 6.17 hours · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 6.49% |
8.2%
1.7 pts worse
|
Numerator 5 · Denominator 77 |
| Staff flu vaccination coverage | 57.05% |
42%
15 pts better
|
Numerator 85 · Denominator 149 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
97.3%
0.5 pts worse
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.5% · Q3 95.7% · Q4 95.8% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.0% |
96.1%
4.1 pts worse
|
95.5%
3.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.9%
1.7 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
4.3%
2 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 4.8% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
4.1%
3.2 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 5.0% · Q4 8.7% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.3% |
12.4%
4.9 pts worse
|
19.6%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 20.0% · Q4 21.7% · 4Q avg 17.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.1% |
17.5%
9.4 pts better
|
16.7%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.1% · 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 | 18.9% |
22.5%
3.6 pts better
|
16.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.5% |
18.6%
7.9 pts worse
|
14.9%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 15.0% · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.8% |
2.3%
2.5 pts worse
|
1.0%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 5.2% · Q3 0.0% · Q4 4.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.4% |
24.8%
5.4 pts better
|
19.8%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 4.4% · Q3 28.6% · Q4 8.3% · 4Q avg 19.4% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
5.4%
5.4 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.2% |
88.6%
7.4 pts worse
|
81.7%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 81.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-11 · Fire 2024-09-11
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2023-08-02 · Fire 2023-08-02
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-26
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-06-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-06-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-25
F · Potential for more than minimal harm
2024-09-11
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2024-09-23
F · Potential for more than minimal harm
2024-09-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-09-11
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 2024-09-23
D · Potential for more than minimal harm
2024-09-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-09-23
F · Potential for more than minimal harm
2023-08-02
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-08-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-08-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-08-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-26
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-06-26
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-06-26
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-06-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-06-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-06-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-06-26
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-06-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-25
D · Potential for more than minimal harm
2024-11-20
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-01-08
G · Actual harm
2024-09-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-29
E · Potential for more than minimal harm
2024-09-11
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 2024-10-29
D · Potential for more than minimal harm
2024-09-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-09-11
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-10-29
E · Potential for more than minimal harm
2023-08-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-09-12
D · Potential for more than minimal harm
2023-08-02
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-02
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-10-02
D · Potential for more than minimal harm
2023-08-02
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-10-02
J · Immediate jeopardy
2023-05-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-20
D · Potential for more than minimal harm
2023-05-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-20
Penalties and ownership
What sits behind the stars
$0
2024-09-11
Payment Denial
Payment Denial · denial start 2024-10-02 · 98 days
98 day denial
$8,421
2023-05-24
Fine
Fine · fine $8,421
Fine
Ownership
Commonspirit Health
5% Or Greater Direct Ownership Interest · Organization
Austad, James
Corporate Director · Individual
Burton, Bruce
Corporate Director · Individual
Drop, Jeffrey
Corporate Officer · Individual
Ebner, Bernice
Corporate Director · Individual
Lofton, Kevin
Corporate Officer · Individual
Nylander, Brad
Corporate Director · Individual
Olson, Crystal
Corporate Director · Individual
Quo, Justin
Corporate Director · Individual
Schmidt, Brent
Corporate Officer · Individual
Schmidt, Brent
W-2 Managing Employee · Individual
Stampohar, Jeffry
Corporate Officer · Individual
Stampohar, Jeffry
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Warroad Care Center
Warroad, MN
1-star overall rating with 1-star inspections with abuse icon flag with $359,330 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Littlefork Care Center
Littlefork, MN
1-star overall rating with 1-star inspections with $179,075 in total fines with 14 recent health deficiencies
#3
Good Samaritan Society - International Falls
International Falls, MN
4-star overall rating with 3-star inspections with $8,190 in total fines with 3 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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