Lakehouse Healthcare: Pressure Ulcer Worsened Without Plan - MN
Not the floor nurse. Not the director of nursing. Not the regional nurse consultant. Nobody had a real answer.
The resident, identified in inspection records only as R2, had a history of moisture-associated skin damage under both breasts and on her buttocks. A wound nurse practitioner first evaluated her coccyx wound on July 30, 2025, describing it as superficial at that point, and put in orders for daily treatments, an air mattress, and a dietary consult for protein supplements. For two months the wound appeared to be improving. Then, on October 1, the nurse practitioner debrided the area and restaged it: stage 3 out of 4, meaning the wound had broken through the full thickness of the skin.
New dressing orders went in. The wound looked stable on October 8 and October 10.
Then it got worse. And kept getting worse. The nurse practitioner visited five times between October 15 and November 5 and documented deterioration at each one. During the October 15 and October 17 visits, she encouraged staff to limit R2's time in a wheelchair and keep her up only for meals. The dressing orders stayed the same throughout.
When a registered nurse changed R2's dressing on November 18, she described it as a stage 3 wound with moderate serosanguinous drainage. Asked how the turning and repositioning schedule had been determined, she said she didn't know, but that the nursing assistant taking care of R2 should know.
The nursing assistant, interviewed the same day, said staff were informed of repositioning schedules through their daily report sheets. Up for meals, otherwise in bed, turned every two to three hours.
That schedule had been written into R2's care plan back on July 28, before the wound ever reached stage 3. After it deteriorated in October, inspectors found no evidence the care plan had been updated, and no comprehensive assessment addressing whether the existing repositioning schedule was working.
A different registered nurse, interviewed November 14, said the schedules were individualized and that R2 was turned every two to three hours when in bed. She could not explain how that interval had been determined or whether anyone had evaluated whether it was actually relieving the pressure.
The director of nursing told inspectors on November 19 that R2 was on an alternating air mattress to help with pressure offloading, and that the interdisciplinary team met daily for quick wound updates and weekly for more detailed wound rounds. She could not explain how the two-to-three-hour repositioning schedule had been established or how the team was measuring whether its interventions were reducing pressure on the wound site.
The regional nurse consultant was more direct. She told inspectors that the facility did not use a tissue tolerance assessment, that such tools had "gone by the wayside years ago," and that there was no formalized process or tool for determining a resident's repositioning schedule. Decisions were based on the "clinical picture," she said, but which clinical factors were being weighed, and by whom, were not documented anywhere.
The wound nurse practitioner, who had been following R2 since July, told inspectors that the underlying cause of the pressure ulcer was pressure from lying on her back and from sitting in the wheelchair before the wound first developed in late July. She had been directing staff to limit wheelchair time for weeks. The wound kept deteriorating anyway.
A review of the facility's own policy on pressure ulcer monitoring and interventions found that it did not address how turning and repositioning programs should be developed, or require that they be grounded in a comprehensive assessment of the individual resident.
R2 had impaired decision-making and needed cues and supervision from staff for her daily care. She was not in a position to advocate for a different schedule or flag that the one she was on wasn't working. That job belonged to the clinical team. For at least five weeks, while her wound worsened at every visit, no one documented a reassessment of whether turning her every two to three hours was the right answer for her body, her wound, and her particular risk factors.
By the time inspectors arrived in mid-November, the wound had been deteriorating for a month and a half. The stage 3 ulcer was still there, still draining.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakehouse Healthcare & Rehabilitation Center from 2025-11-19 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: June 21, 2026 · Our methodology
LAKEHOUSE HEALTHCARE & REHABILITATION CENTER in MINNEAPOLIS, MN was cited for violations during a health inspection on November 19, 2025.
Not the regional nurse consultant.
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.