Cycle 1
Health 2026-02-19 · Fire 2026-02-19
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Staples, MN
Lakewood Health System
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
401 Prairie Avenue Northeast, Staples, MN
(218) 894-1515
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
87
Certified beds
Average residents
81
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1987-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.89
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.80
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
4.23
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
3.34
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.98
CMS adjusted RN staffing hours
Adjusted total hours
4.62
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,851
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.56
Composite VBP score used to determine payment impact.
Payment multiplier
1.0083
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.38
Performance 20.33% · Measure score 2.38 · Achievement 2.38 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.45
Performance 6.21% · Measure score 5.45 · Achievement 5.45 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
6.10
Baseline 40.96% · Performance 38.74% · Measure score 6.10 · Achievement 6.10 · Improvement 0.88
Adjusted total nurse staffing
7.50
Baseline 4.61 hours · Performance 5.21 hours · Measure score 7.50 · Achievement 7.50 · Improvement 4.65
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.45% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 2% · Lower 95% interval 5.86% |
| Discharge to community | 50.52% |
50.57%
About the same
|
No Different than the National Rate · Eligible stays 51 · Observed rate 47.06% · Lower 95% interval 37.62% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 96.43% |
95.27%
1.2 pts better
|
Numerator 27 · Denominator 28 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 28 |
| Discharge self-care score | 20% |
53.69%
33.7 pts worse
|
Numerator 5 · Denominator 25 |
| Discharge mobility score | 36% |
50.94%
14.9 pts worse
|
Numerator 9 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 28 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.21% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 0% · Lower 95% interval 3.48% |
| Staff COVID-19 vaccination coverage | 1.67% |
8.2%
6.5 pts worse
|
Numerator 4 · Denominator 239 |
| Staff flu vaccination coverage | 76.13% |
42%
34.1 pts better
|
Numerator 185 · Denominator 243 |
| Discharge function score | 40% |
56.45%
16.5 pts worse
|
Numerator 10 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.0
0.5 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| 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 96.9% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
96.1%
1.2 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.9%
0.4 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 4.3% · Q3 5.5% · Q4 1.4% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
4.3%
3.9 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 2.9% |
4.1%
1.2 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.5% · Q3 2.7% · Q4 2.8% · 4Q avg 2.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.1% |
12.4%
2.3 pts better
|
19.6%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.5% · Q3 13.7% · Q4 11.1% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.8% |
17.5%
0.3 pts worse
|
16.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 16.4% · Q3 17.5% · Q4 20.6% · 4Q avg 17.8% · 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 | 17.1% |
22.5%
5.4 pts better
|
16.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 15.9% · Q3 18.3% · Q4 13.9% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.8% |
18.6%
4.8 pts better
|
14.9%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 9.4% · Q3 14.5% · Q4 8.6% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
2.3%
0.1 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.4% · Q3 1.5% · Q4 1.4% · 4Q avg 2.4% · 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 1.6% · Q2 0.0% · Q3 1.4% · 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 | 24.1% |
24.8%
0.7 pts better
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 36.0% · Q3 18.1% · Q4 20.0% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 0.8% |
5.4%
4.6 pts better
|
5.1%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 1.5% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
88.6%
8.1 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 98.2% · Q3 97.9% · Q4 95.3% · 4Q avg 96.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.1% |
14.0%
4.1 pts worse
|
12.0%
6.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.1% · Observed 17.2% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.9%
0.4 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.8% |
82.7%
4.1 pts better
|
79.7%
7.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.6% |
23.1%
10.5 pts better
|
23.9%
11.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.6% · Observed 10.3% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-04 · Fire 2024-12-04
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-11-08 · Fire 2023-11-08
5 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-02-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Not marked corrected
F · Potential for more than minimal harm
2024-12-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-12
E · Potential for more than minimal harm
2024-12-04
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-12-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-12
E · Potential for more than minimal harm
2023-11-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-02-19
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Not marked corrected
D · Potential for more than minimal harm
2026-02-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Not marked corrected
G · Actual harm
2024-07-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-05
E · Potential for more than minimal harm
2023-11-08
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-11-08
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-11-08
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-11-20
C · Minimal harm
2023-11-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-11-20
D · Potential for more than minimal harm
2023-08-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-09
Penalties and ownership
What sits behind the stars
Ownership
Albrecht, Christine
Operational/Managerial Control · Individual
Anderson, Brad
Operational/Managerial Control · Individual
Bauman, Alicia
Operational/Managerial Control · Individual
Bjerga, Judith
Corporate Director · Individual
Bjerga, Lisa
Operational/Managerial Control · Individual
Bjerga, Lisa
Corporate Officer · Individual
Brichacek, Amy
Corporate Director · Individual
Cichos, Jef
Corporate Director · Individual
Daniels, Melissa
W-2 Managing Employee · Individual
Dietrich, Linda
Corporate Director · Individual
Dobson, Kathleen
Operational/Managerial Control · Individual
Grove, Sara
Corporate Director · Individual
Haehnel, Billy
Corporate Director · Individual
Hansen, Lana
Corporate Director · Individual
Hoemberg, Beverly
Corporate Director · Individual
Jordahl, Stephanie
Corporate Director · Individual
Krause, Norman
Corporate Director · Individual
Kray, Ryan
Corporate Director · Individual
Leveille, Lindsay
Corporate Director · Individual
Lindow, Melissa
Operational/Managerial Control · Individual
Mcilravy, Curtis
Corporate Officer · Individual
Mueller, Robert
Corporate Director · Individual
Neisess, Corrine
Operational/Managerial Control · Individual
Nelson, Kevin
Corporate Director · Individual
Newton Rice, Lynn
Operational/Managerial Control · Individual
Peet, Susan
Corporate Director · Individual
Pottratz, Elizabeth
Corporate Director · Individual
Reycraft, Joseph
Operational/Managerial Control · Individual
Reycraft, Joseph
Corporate Officer · Individual
Roeder, James
Operational/Managerial Control · Individual
Schoeck, Kaitlyn
Corporate Director · Individual
Storbakken, Ronald
Corporate Director · Individual
Swenson, Wade
Corporate Director · Individual
Theurer, Mary
Corporate Officer · Individual
Wicht, Emil
Corporate Director · Individual
Wolhowe, Craig
Operational/Managerial Control · Individual
Wolhowe, Craig
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Fair Oaks Nursing & Rehab LLC
Wadena, MN
1-star overall rating with 1-star inspections with $10,062 in total fines with 18 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Central Todd County Care Center
Clarissa, MN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Long Prairie Health Care Center
Long Prairie, MN
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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