01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-04-03 | 0 | 2025-04-03 | 0 |
| Cycle 2 | 2024-04-25 | 6 | 2024-04-25 | 0 |
| Cycle 3 | 2023-08-24 | 3 | 2023-08-24 | 6 |
CMS CCN 2452102026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Lake Minnetonka Shores
4527 Shoreline Drive · Spring Park, MN 55384 · Hennepin County
Certified beds60CMS provider file
Recent citation rows15current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
15 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 0 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2024-04-25 · HEALTHF0578Severity J · isolated immediate jeopardy
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Correction field: Deficient, Provider has date of correction · 2024-05-172024-04-25 · HEALTHF0732Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2024-05-172024-04-25 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2024-05-172024-04-25 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-05-172024-04-25 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-05-172024-04-25 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2024-05-172023-08-24 · HEALTHF0583Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2023-09-282023-08-24 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2023-09-282023-08-24 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2023-09-282023-08-24 · FIREK0222Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Correction field: Deficient, Provider has date of correction · 2023-09-282023-08-24 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2023-09-282023-08-24 · FIREK0341Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Correction field: Deficient, Provider has date of correction · 2023-09-282023-08-24 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2023-09-282023-08-24 · FIREK0541Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Install properly constructed and protected linen or trash chutes.
Correction field: Deficient, Provider has date of correction · 2023-09-282023-08-24 · FIREK0901Severity C · widespread; potential for minimal harm
Electrical Deficiencies
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Correction field: Deficient, Provider has date of correction · 2023-09-2803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-04-25 | Fine | $8,827 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- PRESBYTERIAN HOMES HOUSING AND ASSISTED LIVING, INC.Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/14/2010
- NORTHEAST BANKOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 06/03/2014
- NORTHEAST BANKOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 06/03/2014
- FLETCHER, JONATHANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 02/01/2025
- MEYER, MARKIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/14/2010
- PEDERSON, MARKIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2023
- FLETCHER, JONATHANIndividual · CORPORATE OFFICERNOT APPLICABLE · since 02/01/2025
- MEYER, MARKIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/14/2010
- PHS MANAGEMENT, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/11/2011
- PRESBYTERIAN HOMES HOUSING AND ASSISTED LIVING, INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/14/2010
- MIELKE, JOHNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/29/2019
- SOKOLOSKI, SHAYLEEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/11/2019
- PHS MANAGEMENT, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 07/17/2025
- PRESBYTERIAN HOMES HOUSING AND ASSISTED LIVING, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 09/30/2025
- MIELKE, JOHNIndividual · ADP OF THE SNFNOT APPLICABLE · since 08/29/2019
- PETERSON, HEIDIIndividual · ADP OF THE SNFNOT APPLICABLE · since 01/12/2025
- SOKOLOSKI, SHAYLEEIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/11/2019
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.26per resident day
RN hours1.31per resident day
Weekend nurse hours3.99per resident day
Staff turnover29.1%CMS reported field
06 / LOCAL RECORDS
Open the Minnesota ledger →Other published facilities nearby
No second facility in the same city met the directory rule.