Lakeshore Inn Nursing Home

F-F812 for further details of the kitchen tour.

During an interview on [DATE REDACTED] at 10:23 a.m., dietary manager (DM) stated the fan in the freezer was blocked and was not working, however maintenance looked at it the day before and fixed the fan. DM stated the ice buildup has been there for several weeks. The DM stated ice buildup could be a concern as it could contaminate food, causing freezer burn on food or cause food to rot from mushy boxes the food is being stored in and said it was not appropriate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 245388 Department of Health & Human Services Printed: 09/03/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245388 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakeshore Rehabilitation Center LLC 108 8th Street Northwest Waseca, MN 56093

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 During an interview on [DATE REDACTED] at 12:30 p.m., the administrator stated she was not aware of ice buildup in the freezer and would expect the DM to have notified her. The administrator confirmed the concern was Level of Harm - Potential for identified during the last recertification and the plan of corrections was to replace the draping in the freezer. minimal harm The administrator confirmed the freezer did not currently have any draping and stated ice buildup was a problem because it could impact food quality and overall functionality of the freezer. The administrator stated Residents Affected - Many the QA team met monthly and explained the current facility's PIP's included various projects, with all current goals for them being met. The administrator stated the QA team included members from clinical care services, culinary, activities, maintenance, housekeeping, and administration. The QA focus may extend to any one of these service areas.

The administrator reviewed the QAPI meeting minutes and confirmed the committee did not identify any current or previous issues with the freezer. The administrator confirmed monitoring of the last years recertification was not performed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 245388