Ecumen Lakeshore

Inspection findings

1. May 21, 2026 Fire Safety · 8 findings
   • Not serious Scope/severity F

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jul 2, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jul 2, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jul 2, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jul 24, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Jul 24, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected Jul 2, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jul 24, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Jul 24, 2026 · CMS fire safety

2. Aug 7, 2025 Health · 8 findings
   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Aug 29, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Sep 20, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 22, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Aug 22, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0541 Services Deficiencies

     Install properly constructed and protected linen or trash chutes.

     Corrected Aug 26, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Aug 28, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Aug 24, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0921 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure that testing and maintenance of electrical equipment is performed.

     Corrected Sep 9, 2025 · CMS fire safety

3. Jun 13, 2024 Health · 7 findings
   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jun 25, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jun 25, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 25, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jun 25, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0541 Services Deficiencies

     Install properly constructed and protected linen or trash chutes.

     Corrected Jun 25, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Jun 25, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Jun 25, 2024 · CMS fire safety

4. Aug 9, 2023 MDH complaint investigation · 1 finding
   • Severity not stated

     H52154124C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

5. Oct 19, 2022 MDH complaint investigation · 1 finding
   • Severity not stated

     H52155053C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

6. Aug 12, 2021 MDH complaint investigation · 3 findings
   • Severity not stated

     H5215062C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H5215063C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H5215065C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

7. Nov 8, 2020 MDH complaint investigation · 2 findings
   • Severity not stated

     H5215049C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

   • Severity not stated

     H5215050C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

8. Aug 27, 2020 MDH complaint investigation · 1 finding
   • Severity not stated

     H5215043C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

Owners and managers (as published by CMS)

• ALAM, MORSHED — corporate director, NOT APPLICABLE, since 09/30/2019
• ALAM, MORSHED — corporate officer, NOT APPLICABLE, since 09/30/2019
• ALAM, MORSHED — operational/managerial control, NOT APPLICABLE, since 09/30/2019
• CERVENKA, DEBBIE — corporate officer, NOT APPLICABLE, since 06/01/2015
• DADY, JAMES — corporate director, NOT APPLICABLE, since 06/01/2019
• KENDRICK, SHELLEY — w-2 managing employee, NOT APPLICABLE, since 01/18/2012
• KENDRICK, SHELLEY — corporate director, NOT APPLICABLE, since 01/18/2012
• KENDRICK, SHELLEY — corporate officer, NOT APPLICABLE, since 01/18/2012
• KENDRICK, SHELLEY — operational/managerial control, NOT APPLICABLE, since 01/18/2012
• KRO, LISA — corporate director, NOT APPLICABLE, since 06/01/2019
• ULVESTAD, NANCY — corporate director, NOT APPLICABLE, since 06/01/2019
• ECUMEN — 5% or greater direct ownership interest, 100%, since 06/14/1994