Lakewood Care Center
600 Main Avenue South, Baudette, MN 56623 · Lake Of Woods County · 32 certified beds · avg 28 residents/day · certified since Oct 1, 1991
Part of chain: COMMONSPIRIT HEALTH (18 facilities, chain avg rating 2.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Sep 11, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 29, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (20)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 26, 2025 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 20, 2024 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Sep 11, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 11, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 11, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Sep 11, 2024 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Sep 11, 2024 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Aug 2, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Aug 2, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Aug 2, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 2, 2023 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Aug 2, 2023 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Aug 2, 2023 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (5 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 6 | 0 | E |
| 2024 | 6 | 1 | G ▲ |
| 2025 | 8 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
0 fines totaling $0, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Sep 11, 2024 | Payment Denial | 98 days from Oct 2, 2024 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Minnesota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 6.07 | 4.83 | 3.95 | top 10% in Minnesota; top 4% in the U.S. |
| Registered Nurse hours | 1.23 | 1.22 | 0.69 | top 40% in Minnesota; top 9% in the U.S. |
| Weekend total nurse staffing | 5.37 | 4.27 | 3.50 | top 8% in Minnesota; top 4% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.66 | 0.69 | 0.48 | top 42% in Minnesota; top 18% in the U.S. |
| Total nursing staff turnover (%) | 37.0 | 42.2 | 45.8 | top 42% in Minnesota; top 29% in the U.S. |
| RN turnover (%) | 0.0 | 38.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.41, RN 0.89, weekend 3.90. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Commonspirit Health | Organization | 5% or Greater Direct Ownership Interest | 100% | 07/01/1996 |
| Austad, James | Individual | Corporate Director | NOT APPLICABLE | 07/01/2019 |
| Burton, Bruce | Individual | Corporate Director | NOT APPLICABLE | 07/01/2011 |
| Drop, Jeffrey | Individual | Corporate Officer | NOT APPLICABLE | 08/01/1994 |
| Ebner, Bernice | Individual | Corporate Director | NOT APPLICABLE | 07/01/2019 |
| Lofton, Kevin | Individual | Corporate Officer | NOT APPLICABLE | 02/01/2019 |
| Nylander, Bradley | Individual | Corporate Director | NOT APPLICABLE | 03/01/2017 |
| Olson, Crystal | Individual | Corporate Director | NOT APPLICABLE | 07/01/2019 |
| Quo, Justin | Individual | Corporate Director | NOT APPLICABLE | 12/01/2013 |
| Schmidt, Brent | Individual | W-2 Managing Employee | NOT APPLICABLE | 07/01/2015 |
| Schmidt, Brent | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2015 |
| Stampohar, Jeffry | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/15/2018 |
| Stampohar, Jeffry | Individual | Corporate Officer | NOT APPLICABLE | 01/15/2018 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
- "If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
- "How do you make sure resident assessments are completed and submitted to the state on time?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "How do you handle residents who need modified food textures, and how do you make those meals appetizing?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Warroad Care Center | 36.6 mi | Warroad, MN | ★☆☆☆☆ | 1/5 | abuse |
Compare this facility with the 1 closest →
Facility data as of CMS processing date 2026-08-01. CCN 245580.