Lakehouse Healthcare & Rehabilitation: CPR Withheld - MN
The resident, identified in federal inspection records only as R1, was a full code, meaning he had explicitly chosen every available life-saving measure, including chest compressions, rescue breathing, and defibrillation. On the day he was found unresponsive and without a pulse, none of those measures were attempted. No CPR. No AED. No 911 call. Time of death was called, and that was the end of it.
Federal inspectors who reviewed the incident cited Lakehouse with an immediate jeopardy violation, the most serious classification available under Medicare's inspection system, indicating that the failure placed residents in immediate risk of serious harm or death.
The hospice registered nurse who had come to the facility that day to see R1 told inspectors she had been there because he was experiencing increased pain. When she assessed him, he was a little confused but could answer basic questions. She left his room to call his provider.
That was the last time R1 was conscious.
A licensed practical nurse, identified as LPN-A, came to find the hospice nurse and told her R1's breathing had changed. The two returned to his room together. He was not responding. He was not breathing. The hospice nurse checked for a pulse. LPN-A checked for breathing. There was neither. Time of death was called.
At no point did the hospice nurse check R1's code status. At no point did LPN-A leave the room to get a crash cart, an AED, or any other equipment. At no point did anyone dial 911.
The hospice nurse confirmed to inspectors that CPR had not been initiated.
The facility's director of nursing confirmed the same thing, and added that when she reviewed the incident, she found that R1's code status had not been checked when he was found unresponsive. She confirmed CPR had not been performed. She also confirmed, without apparent ambiguity, what should have happened: if a resident is found not responding and not breathing, a nurse checks the POLST, the standardized form documenting a patient's wishes for life-sustaining treatment. If the resident is full code, the nurse starts chest compressions, gives rescue breaths, uses the AED, and calls 911. If the resident is DNR, CPR is not started.
R1 was full code. None of the full-code steps were taken.
A registered nurse at the facility, RN-A, told inspectors there was no reason CPR would not be started on a resident who had elected full code status. She described how a nurse STAT page, the facility's code blue alert, was designed to summon all available nurses to a location with their equipment. Each nurse would bring what was needed based on where they were working, a crash cart stocked with CPR supplies, a vital signs machine, an AED. The system existed precisely for moments like the one in R1's room.
It was not used.
Three attempts were made to reach LPN-A for an interview. She did not return any of them.
The facility's own CPR policy, reviewed by inspectors, stated clearly that staff were to provide basic life support, including CPR, when a resident experienced cardiac arrest, in accordance with that resident's advance directives, unless the resident showed obvious signs of clinical death. Those signs, the director of nursing told inspectors, include rigor mortis, dependent lividity, decapitation, transection, or decomposition. She also noted that those signs take four to six hours to develop, and that staff would be checking on residents long before any of them appeared.
In other words, the policy contained no exception that applied to R1. He was full code. He had not been dead for hours. The only thing standing between him and the resuscitation he had asked for was the failure of the people in the room to check a piece of paper.
The inspection report does not say whether R1 was on hospice because he had a terminal diagnosis, or how long he had been a resident at Lakehouse, or whether his family was present that day, or what they were told. It does not say whether anyone has explained to them that their loved one's written wishes were not followed in the final minutes of his life.
What the report does say is that the facility moved quickly once the incident came to light. LPN-A was immediately suspended. The facility reached out to the hospice company. House-wide nursing education was launched, focused specifically on the requirement to check code status when a resident is found unresponsive, including residents who had elected hospice care. That education was completed before the inspection. Code blue drills began, covering scenarios involving full-code residents, DNR residents, and hospice residents alike.
Because those corrective actions were already in place by the time inspectors arrived, the immediate jeopardy was cited as past non-compliance rather than ongoing. The danger, in the facility's telling, had been addressed.
But the education that followed the incident only underscores how basic the failure was. Checking a resident's code status before deciding whether to start CPR is not an advanced clinical skill. It is not a judgment call requiring years of experience. It is the first step, the foundational step, the step that exists so that a person's documented wishes are honored rather than ignored in the moment that matters most.
RN-A put it plainly: there was no reason CPR would not be started on a resident who elected full code status.
And yet it wasn't.
The hospice nurse who was in the room had come that day because R1 was in pain. She assessed him, found him confused but responsive, and stepped out to make a phone call. When she came back, he was gone. She did not check his code status. She confirmed to inspectors that CPR was not initiated.
The inspection record does not describe what the room looked like in those minutes, or how long it took to call time of death, or who was standing there when it happened. It does not say whether anyone hesitated, or whether the decision not to act felt like a decision at all.
What it records is the outcome: a man who wanted to be saved was not.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakehouse Healthcare & Rehabilitation Center from 2025-09-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 5, 2026 · Our methodology
LAKEHOUSE HEALTHCARE & REHABILITATION CENTER in MINNEAPOLIS, MN was cited for violations during a health inspection on September 3, 2025.
On the day he was found unresponsive and without a pulse, none of those measures were attempted.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.