Lakehouse Healthcare: CPR Withheld from Full-Code Resident - MN
Federal inspectors classified the failure as immediate jeopardy, the most serious category of nursing home violation, meaning the lapse put residents at risk of serious harm or death.
The resident, identified in inspection records only as R1, had been showing signs of distress before he died. A licensed practical nurse, identified as LPN-A, had asked a house registered nurse, identified as HRN, to come to R1's room because his breathing had changed. When they arrived together, he was unresponsive. He had no pulse. He was not breathing.
Nobody started CPR.
HRN checked for a pulse. LPN-A checked for breathing. Finding neither, they called the time of death. According to the inspection report, HRN confirmed afterward that CPR had not been initiated. LPN-A did not leave the room until after death was declared. Neither nurse checked the resident's POLST, the physician-signed form that records whether a patient has chosen full-code status, meaning they want every resuscitation measure attempted, or DNR status, meaning they do not.
R1 had chosen full code.
The inspection report does not say how long it took from the moment LPN-A noticed the change in R1's breathing to the moment time of death was called. It does not say how old R1 was, or what had brought him to the facility. What it says is that a man who had made a legal, documented decision that he wanted to be kept alive was not given that chance.
A registered nurse at the facility, identified as RN-A, told inspectors exactly what should have happened. In an interview, RN-A said a STAT page, a facility-wide emergency alert, calls all nurses to respond to a specific location. Each nurse brings equipment based on their location: a crash cart with CPR supplies, a vital signs machine, an automated external defibrillator. If a resident is found unresponsive and not breathing, a nurse checks the POLST. If the resident is full code, CPR starts immediately. RN-A stated there was no reason CPR would not be started on a resident who had elected full code status.
No ambiguity there.
The director of nursing told inspectors the same thing. If a resident is not responding and not breathing, a nurse checks the code status on the POLST. Full code means chest compressions, rescue breathing, and the AED. Then 911. The director noted that the only reasons not to start CPR, listed in the facility's own written policy, are signs of obvious clinical death: rigor mortis, dependent lividity, decapitation, transection, or decomposition. The director added that those signs take four to six hours to develop, and that staff would be checking on residents long before that point was reached.
None of those conditions applied to R1 when LPN-A and HRN entered his room.
The facility's written CPR policy, reviewed by inspectors, instructed staff to provide basic life support, including CPR, in accordance with a resident's advance directives whenever a resident experienced a cardiac arrest and did not show obvious signs of clinical death.
The policy was clear. The training had apparently occurred. The equipment existed. The STAT page system existed. And still, when a man stopped breathing, the nurses in his room did not check what he had asked for, and did not do what his paperwork required them to do.
Inspectors attempted to reach LPN-A three times. LPN-A did not return the calls.
By the time inspectors arrived, the facility had already begun responding. LPN-A had been immediately suspended. The facility made contact with the hospice company involved in R1's care, a detail that raises its own question: the inspection report notes that house-wide nurse education started after the incident specifically included instruction on checking code status for residents who had elected hospice care. Hospice residents are typically comfort-focused and often carry DNR orders, but not always. A resident can be enrolled in hospice and still choose full-code status. The education was designed to make sure staff understood that distinction.
Code Blue drills began after the incident as well, the facility reported. The drills covered three scenarios: a full-code resident, a DNR resident, and a hospice resident. The point, apparently, was to make the distinction between those three categories automatic, something a nurse does not have to think through in a crisis but reaches for by reflex.
Because the facility had taken those corrective steps before inspectors arrived and could verify them through interviews and records, the immediate jeopardy was cited as past non-compliance. That designation means the danger no longer exists in its original form. It does not mean the violation didn't happen.
What happened was this: a man made a choice about his own death. He signed a form. The form was in his record. The nurses who came to his room when his breathing changed did not look at it. They did not start CPR. They called time of death.
The inspection report does not describe what R1's final hours looked like before LPN-A noticed the change in his breathing, or what the change sounded like, or how long HRN spent on the phone with the provider before returning to find him unresponsive. It does not describe what LPN-A said or did in the moments after time of death was called, or whether family had been notified before inspectors arrived, or whether anyone has since explained to R1's family what his POLST said and what was not done.
Those details are not in the record. What is in the record is enough.
A facility's CPR policy can be written correctly. Nurses can be trained. Equipment can be stocked on a crash cart and staged at every nursing station. A STAT page system can function exactly as designed. And a resident who wanted to live can still die without a single chest compression because, in the room where it mattered, nobody checked the form.
The drills have started now. The education is complete. LPN-A is suspended. The immediate jeopardy finding has been resolved on paper.
R1 is 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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
LAKEHOUSE HEALTHCARE & REHABILITATION CENTER in MINNEAPOLIS, MN was cited for violations during a health inspection on September 3, 2025.
The resident, identified in inspection records only as R1, had been showing signs of distress before he died.
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.