01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-03-27 | 5 | 2025-03-27 | 2 |
| Cycle 2 | 2024-05-30 | 5 | 2024-05-30 | 7 |
| Cycle 3 | 2023-06-07 | 3 | 2023-06-07 | 6 |
CMS CCN 2453882026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Lakeshore Rehabilitation Center Llc
108 8Th Street Northwest · Waseca, MN 56093 · Waseca County
Certified beds52CMS provider file
Recent citation rows28current CMS citation release
Penalty rows0current 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
28 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-03-27 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-03-27 · 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 · 2025-05-012025-03-27 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-03-27 · 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 · 2025-05-012025-03-27 · HEALTHF0867Severity C · widespread; potential for minimal harm
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-03-27 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-05-012025-03-27 · FIREK0374Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has date of correction · 2025-05-012024-05-30 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-07-022024-05-30 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-07-022024-05-30 · HEALTHF0811Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-07-022024-05-30 · 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 · 2024-07-022024-05-30 · HEALTHF0883Severity E · pattern; 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 · 2024-07-022024-05-30 · FIREK0211Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2024-07-022024-05-30 · FIREK0225Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Correction field: Deficient, Provider has date of correction · 2024-08-222024-05-30 · FIREK0226Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Have horizontal exits used in accordance with safety requirements.
Correction field: Deficient, Provider has date of correction · 2024-07-022024-05-30 · FIREK0291Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2024-07-022024-05-30 · FIREK0321Severity E · pattern; 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 · 2024-08-222024-05-30 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2024-07-022024-05-30 · FIREK0712Severity C · widespread; potential for minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2024-07-022023-06-07 · FIREE0039Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2023-08-012023-06-07 · FIREE0041Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Implement emergency and standby power systems.
Correction field: Deficient, Provider has date of correction · 2023-07-182023-06-07 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2023-08-012023-06-07 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2023-08-012023-06-07 · 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 · 2023-08-0103 / 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 |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- NIJ LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST14% · since 07/15/2022
- SPARTAN HEALTHCARE LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST32% · since 07/15/2022
- WBS HOLDINGS LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST22% · since 07/15/2022
- YAZOMA HOLDINGS, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST32% · since 07/15/2022
- HALPERT, MARCIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST32% · since 07/01/2022
- JAFFA, NOAMIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST14% · since 07/01/2022
- LEGUM, JOSHUAIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST32% · since 07/01/2022
- STERN, WILLIAMIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST22% · since 07/01/2022
- LEGUM, JOSHUAIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 07/01/2022
- JAFFA, NOAMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2022
- HALPERT, MARCIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2022
- STERN, WILLIAMIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/01/2022
- HALPERT, MARCIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2022
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 hours3.32per resident day
RN hours0.91per resident day
Weekend nurse hours3.02per resident day
Staff turnover46.3%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.