Lakewood Health System
A critical access hospital in Staples, Minnesota 56479
49725 County Road 83, Staples, Minnesota 56479. (218) 894-1515.
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The short answer
Record last released by CMS on Oct 20, 2026.
- Not rated CMS’s overall rating
- 4of 5 patient survey rating
- 4 deficiencies cited in the last three years
- 37 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Apr 2, 2025: a complaint and standard inspection.
4 deficiencies cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
4 deficiencies in 1 month of the last 36. Last cited Apr 2025. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Apr 2, 2025: complaint and standard inspection1 deficiency
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Life Safety From Fire
The inspectors’ words, 141 words
“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 48583 Based on observation, interview and document review, the critical access hospital (CAH) was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital. Findings include: Please refer to the Life Safety Code inspection tags: K753.”
Apr 1, 2025: standard inspection3 deficiencies
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Initial Comments - Not A Deficiency Citation
The inspectors’ words, 392 words
“Bldg 02 FIRE SAFETY An annual Life Safety Code survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on April 1, 2025. At the time of this survey, Lakewood Health System was found NOT in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR, Subpart 483.70(a), Life Safety from Fire, and the 2012 edition of National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care and the 2012 edition of NFPA 99, Health Care Facilities Code. THE FACILITY’S POC WILL SERVE AS YOUR ALLEGATION OF COMPLIANCE UPON THE DEPARTMENT’S ACCEPTANCE. YOUR SIGNATURE AT THE BOTTOM OF THE FIRST PAGE OF THE CMS-2567 FORM WILL BE USED AS VERIFICATION OF COMPLIANCE. UPON RECEIPT OF AN ACCEPTABLE POC, AN ONSITE REVISIT OF YOUR FACILITY MAY BE CONDUCTED TO VALIDATE THAT SUBSTANTIAL COMPLIANCE WITH THE REGULATIONS HAS BEEN ATTAINED IN ACCORDANCE WITH YOUR VERIFICATION. PLEASE RETURN THE PLAN OF CORRECTION FOR THE FIRE SAFETY DEFICIENCIES (K-TAGS) TO: IF PARTICIPATING IN THE E-POC PROCESS, A PAPER COPY OF THE PLAN OF CORRECTION IS NOT REQUIRED. Healthcare Fire Inspections State Fire Marshal Division 445 Minnesota St., Suite 145 St. Paul, MN 55101-5145, OR By email to: FM.HC.Inspections@state.mn.us THE PLAN OF CORRECTION FOR EACH DEFICIENCY MUST INCLUDE ALL OF THE FOLLOWING INFORMATION: 1. A detailed description of the corrective action taken or planned to correct the deficiency. 2. Address the measures that will be put in place to ensure the deficiency does not reoccur. 3. Indicate how the facility plans to monitor future performance to ensure solutions are sustained. 4. Identify who is responsible for the corrective actions and monitoring of compliance. 5. The actual or proposed date for completion of the remedy. Lakewood Health Hospital was constructed in 2006. It has 3 stories and the construction type is II(222). It is fully sprinkled and has smoke detectors in patient rooms, corridors and all hazardous rooms and spaces open to the corridor and most offices. It is separated from the adjacent clinic by a 3 hour fire barrier. Each floor has a minimum of 2 smoke compartments separated by a smoke barrier. The Hospital has a capacity of 25 beds and had a census of 14 at the time of the survey. The requirement at 42 CFR, Subpart 482.623 (d) is NOT MET as evidenced by:”
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Initial Comments - Not A Deficiency Citation
The inspectors’ words, 163 words
“Bldg 05 FIRE SAFETY An annual Life Safety Code survey was conducted by the Minnesota Department of Public Safety, State Fire Marshal Division on April 01, 2025. At the time of this survey, Lakewood Health System (Emergency Department) was found in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR, Subpart 483.70(a), Life Safety from Fire, and the 2012 edition of National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 18 New Health Care and the 2012 edition of NFPA 99, Health Care Facilities Code. Lakewood Health Hospital Emergency Department was remodeled and added onto in 2017. The construction type is II(222). It is fully sprinkled with smoke detection in patient care areas and in the corridors. It is constructed as a suite with a one hour smoke barrier. The Hospital has a capacity of 25 beds and had a census of 15 at the time of the survey. The requirement at 42 CFR, Subpart 482.623 (d) is MET.”
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Combustible Decorations
The inspectors’ words, 249 words
“Combustible Decorations CFR(s): NFPA 101 Combustible Decorations Combustible decorations shall be prohibited unless one of the following is met: o Flame retardant or treated with approved fire-retardant coating that is listed and labeled for product. o Decorations meet NFPA 701. o Decorations exhibit heat release less than 100 kilowatts in accordance with NFPA 289. o Decorations, such as photographs, paintings and other art are attached to the walls, ceilings and non-fire-rated doors in accordance with 18.7.5.6(4) or 19.7.5.6(4). o The decorations in existing occupancies are in such limited quantities that a hazard of fire development or spread is not present. 19.7.5.6 This Standard is not met as evidenced by: 34764 Based on observation and interview, the facility did not restrict the use of flammable decorations, including candles, in accordance with the requirements of NFPA 101 Life Safety Code, 2012 edition, section 19.7.5.6. These deficient findings could have an isolated impact on the residents within the facility. Findings include: On 04/01/2025 at 09:19 AM, it was revealed by observation there were 134 candles with intact wood wicked candles in the gift shop, after meeting with the Maintenance Director and a guided tour was then made of the gift shop and they were told to remove them. The staff in the gift shop understood and said they would remove them and when this surveyor walked by again at approximately 11:30 AM they were still on display. An interview with the Maintenance Director verified these deficient findings at the time of discovery.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Apr 2, 2025 | Complaint and standard inspection | 1 deficiency cited |
| Apr 1, 2025 | Standard inspection | 3 deficiencies cited |
How do patients fare?
- CMS gives no overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “There are too few measures or measure groups reported to calculate a star rating or measure group score.”
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 2; safety of care, 0 better and 0 worse of 1; readmission, 0 better and 1 worse of 4.
- Patients rate it 4 of 5 in CMS’s patient survey (175 surveys completed, Oct 1, 2024 to Sep 30, 2025): 77% rated it 9 or 10 out of 10, and 77% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): C. diff infections, no different than national benchmark.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): pneumonia 14.1%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart failure 21.5%, pneumonia 18.2%, COPD 19.5%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate.
- Emergency department patients spent a median of 126 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 0% left before being seen.
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | Not rated |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 4 of 5 |
Is it certified, and in good standing?
- Medicare-certified critical access hospital since Mar 12, 2002.
- Ownership: voluntary non-profit - private.
- It is not accredited by a private organisation, so the state carries out its routine inspections for Medicare.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Voluntary non-profit - Private.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS’s HAC Reduction Program file has no result for it: the program covers general acute care hospitals Medicare pays under its inpatient prospective payment system.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 4 of 5.
- 82% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- 41 owners or officers are people: Melissa Beth Lindow (runs it (operational or managerial control)); Billy Joe Haehnel (corporate director); Joseph Thomas Reycraft (corporate officer); Joseph Thomas Reycraft (runs it (operational or managerial control)); Curtis Eugene Mcilravy (corporate officer); Curtis Eugene Mcilravy (corporate director); Ryan David Kray (corporate director); Robert Michael Mueller (corporate officer); Robert Michael Mueller (corporate director); Sara Jane Grove (corporate director); Craig Thomas Wolhowe (corporate officer); Craig Thomas Wolhowe (runs it (operational or managerial control)); Alicia Kay Bauman (runs it (operational or managerial control)); Mary Martha Theurer (corporate officer); Elizabeth Ann Pottratz (corporate director); Lisa Marie Bjerga (corporate officer); Lisa Marie Bjerga (runs it (operational or managerial control), 0%); Kaitlyn Rose Schoeck (corporate director); Lana Ellen Hansen (corporate officer); Ronald Alvin Storbakken (corporate director); Franz Harry Achermann (corporate director); Kathleen Marie Dobson (runs it (operational or managerial control)); James Alan Roeder (runs it (operational or managerial control)); Mary Ann Fitcher (corporate director); Brad Richard Anderson (runs it (operational or managerial control)); Amy Jo Brichacek (corporate director); Emil Paul Wicht (corporate director); Melissa Sue Daniels (managing employee (on the payroll)); Michael Lee Austin (runs it (operational or managerial control)); Norman Harold Krause (corporate director); Daniel John Douts (corporate director); Susan Kay Peet (corporate officer); Susan Kay Peet (corporate director); Wade Thomas Swenson (corporate director); Lindsay Rae Leveille (corporate director); Christine Sara Albrecht (runs it (operational or managerial control)); Sarah Ann Jennissen (corporate director); Beverly Jean Hoemberg (corporate director); Jef Richard Cichos (corporate officer); Jef Richard Cichos (corporate director); Sarah Jane Baumgartner (runs it (operational or managerial control)).
- CMS’s Provider of Services file records 2 changes of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
How does it compare nearby?
- Of the 2 hospitals CMS lists in Todd County, none has an overall star rating from CMS.
- CMS gives this hospital no overall star rating to compare.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| Centracare - Long Prairie Hospital | Not given |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.