Mayo Clinic Health System - Lake City
500 West Grant Street, Lake City, MN 55041 · Goodhue County · 90 certified beds · avg 60 residents/day · certified since Mar 20, 1978
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
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)
▲ Immediate jeopardy, one-off · Apr 20, 2026 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: May 15, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Apr 3, 2025 · 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: May 1, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 18, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
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: Dec 10, 2024 (Past Non-Compliance)
All citations in the current public record (22)
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 |
|---|---|---|
| Apr 20, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Apr 20, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Apr 20, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Apr 20, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Dec 4, 2025 | D · Potential for 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 |
| Jul 31, 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. |
| Apr 3, 2025 | ▲ 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 |
| Dec 18, 2024 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jun 13, 2024 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Jun 13, 2024 | 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 13, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jun 13, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jun 13, 2024 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Jun 13, 2024 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Jun 13, 2024 | 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. |
| Jun 13, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Jun 13, 2024 | B · Minimal risk, repeated | The facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. |
| Nov 6, 2023 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint |
| Nov 6, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Nov 6, 2023 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint |
| Nov 6, 2023 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · from a complaint |
| Nov 6, 2023 | D · Potential for harm, one-off | The facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (9 → 1).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | D |
| 2024 | 10 | 1 | G ▲ |
| 2025 | 3 | 1 | G ▲ |
| 2026 | 4 | 1 | J ▲ |
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)
2 fines totaling $145,117.
| Date | Type | Amount / length |
|---|---|---|
| Apr 20, 2026 | Fine | $112,978 |
| Apr 3, 2025 | Fine | $32,139 |
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) | 5.22 | 4.83 | 3.95 | top 29% in Minnesota; top 10% in the U.S. |
| Registered Nurse hours | 1.53 | 1.22 | 0.69 | top 19% in Minnesota; top 4% in the U.S. |
| Weekend total nurse staffing | 4.77 | 4.27 | 3.50 | top 23% in Minnesota; top 8% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.82 | 0.69 | 0.48 | top 25% in Minnesota; top 10% in the U.S. |
| Total nursing staff turnover (%) | 44.4 | 42.2 | 45.8 | bottom 38% in Minnesota; top 49% in the U.S. |
| RN turnover (%) | 20.0 | 38.6 | 42.9 | top 17% in Minnesota; top 13% in the U.S. |
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 4.70, RN 1.38, weekend 4.30. 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: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Alix, Jay | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/24/1998 |
| Anderson, Brett | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2024 |
| Anderson, Trent | Individual | Corporate Director | NOT APPLICABLE | 01/01/2025 |
| Anil, Gokhan | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2025 |
| Archer, Lisa | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2025 |
| Baicker, Katherine | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/28/1998 |
| Baker, Douglas | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/28/1998 |
| Bartlett, Brian | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2025 |
| Beahrs, Taylor | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2025 |
| Bilicic, George | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/28/1998 |
| Brown, Sally | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/28/1998 |
| Burns, Ursula | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/28/1998 |
| Caine, Natalie | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/28/1998 |
| Callstrom, Matthew | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/28/1998 |
| Comfere, Nneka | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/28/1998 |
| Dahlen, Dennis | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/28/1998 |
| Davis, Jed | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/28/1998 |
| Davis, Richard | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/28/1998 |
| Didehban, Roshanak | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/28/1998 |
| Dunn, Ajani | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/28/1998 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
- "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 |
|---|---|---|---|---|---|
| Plum City Care Ctr | 12.4 mi | Plum City, WI | ★★★★★ | 4/5 | |
| Gundersen St Elizabeth's Care Center | 12.8 mi | Wabasha, MN | ★★★★★ | 5/5 | |
| St Crispin Living Community | 12.8 mi | Red Wing, MN | ★★★★☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 245218.