Lakehouse Healthcare & Rehabilitation Center

During interview on 7/31/24 at 1:42 p.m., nurse manager (RN-E) stated a doctor's order, and a

R184 didn't have a self administration order or an assessment. RN-E stated the assessment needed to be completed to establish if resident was able to safely administer his own medication.

A facility's self-administration of medications policy and procedure was requested but not received.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

During observation and interview with registered nurse (RN)-C on 7/31/24 at 7:44 a.m. in R134's room, RN-C stated, the floor is sticky here. It should be cleaned. We are to tell housekeeping.

The dark matter on floor appears to be food which means the floor was not cleaned recently.

During interview with RN-D on 7/31/24 at 7:52 a.m., in R134's room, RN-D stated, the floor is dirty here at the head of the bed. It looks like old food on the floor here and should be mopped up.

During interview with facility associate administrator (AA) on 7/31/24 at 10:09 a.m., AA stated, they [housekeepers] did not strip the floor before waxing it. I had to scrape it today and showed the contract team that it was waxed.

They should not have waxed the old floor anyways.

The old wax was never removed.

All the [memory care and third floor dining room floors] need to be waxed correctly. AA stated the same was true for R134's floor.

Facility policy on environmental cleaning and maintenance of floors was requested but not received.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

During interview with the director of social services (SW)-A on 8/1/24 at 11:16 a.m., SW-A stated they faxed a report to the ombudsman which listed discharges, hospitalizations, deaths, and other information from the EMR portal. SW-A reviewed the reports for 1/24 and 4/24 and verified they did not include hospitalizations for R60 or R27.

During interview with the director of social services (SW)-A on 8/1/24 at 11:26 a.m., SW-A stated the expectation of nursing staff was to fill out and provide the bed hold and transfer forms to residents prior to the transfer.

Also, SW-A stated if the transfer were emergent then the resident or guardian would be notified by phone to request a bed hold.

Regardless of whether the transfer or discharge were emergent, SW-A stated the expectation of staff to document the conversation or attempts in a progress note. SW-A reviewed R60's and R27's progress notes and stated, it is not mentioned in [the] progress notes and it should be.

During additional interview with SW-A on 8/1/24 at 12:12 p.m., SW-A and vice president of clinical operations (CO) noted a technical glitch between the EMR portal and the Admission/Discharge - To/From report. A ticket was submitted, and they would compare the portal and report until the report accurately pulled all needed information.

During interview on 8/1/24 at 2:25 p.m., administrator acknowledged the technology issue with the report faxed to the ombudsman and stated communication with the ombudsman was important and they did not lack communication with them.

Per email communication with the Office of Ombudsman for Long-Term Care on 8/2/24 at 8:17 a.m., the Ombudsman was not notified of R60's and R27's transfers or discharges.

The facility did not have a policy for notification of transfer to the ombudsman.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

During an interview on 7/31/24 at 8:43 a.m., the director of social services (SW)-A stated after reviewing R63's preadmission screening dated 10/12/23, she believed this was the final documented and indicated R63 did not require any additional screening. SW-A stated she would look into the issue and confirm that this was the final PASARR for R63.

During an interview on 8/1/24 at 8:27 a.m., the senior linkage line representative (SLL) stated she had reviewed the PAS that they had on file for R63 that said the PAS [PASARR] is not final until the lead agency sends the documentation to the nursing facility dated 10/12/23 and this was not the final PASARR. SLL stated the facility needed to reach out the lead agency, in this case Hennepin County.

SLL stated the lead agency would process the PAS and give the facility the final determination, what the document described was not the final PASARR.

During email communication on 8/5/24 at 12:47 p.m., administrator indicated the facility had a copy of R63's PASARR in the medical record and did not trigger for a level two PASARR assessment. On review the PASARR document provided was the same one dated 10/12/23 as described as above and did not contain the required final PASARR determination from the lead agency.

A policy regarding PASARR completion or maintenance was requested and not received.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

During an interview on 8/1/24 at 2:24 p.m., the director of nursing (DON) stated they had a massive turnover with the social work department and was aware of issues with care conference completion.

The DON stated the care conferences should have been completed quarterly, annually, and as needed.

The DON stated this was important to ensure communication was occurring between the facility and the resident, and to ensure the care plan included the resident's goals and wishes.

Facility policy regarding timing of care conferences was requested but not received.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

During observation and interview on 7/29/24 at 2:29 p.m., R383 was sitting on her bed dressed in a hospital gown, her hair was noticeable greasy and matted. R383 stated she had not had, or been offered, a shower since she got the facility.

During an interview on 7/31/23 at 11:38 a.m., licensed practical nurse (LPN)-F stated if he was made aware of a resident refusing a bath or shower, he would approach the resident and explain the benefits of accepting a shower but was not 100% sure what the facility policy or expectation was for refusal. LPN-F further stated he had never heard of R383 refusing cares and she was usually very easy to work with.

During a follow up observation and interview on 8/1/24 at 12:01 p.m., R383's hair continued to look greasy and matted and her finger and toenails were approximately 1/4 inch long with dark matter under the fingernails. R383 stated she had not refused a shower yesterday and a staff member had come to her room a few hours ago to ask her about a shower and offered to help her tomorrow with a shower.

During an interview on 8/1/24 at approximately 10:30 a.m., nurse manager and registered nurse (RN)-H stated it was expected for a resident to be offered a shower at least three times and to pass it on to the next shift if they continue to refuse, stating it would also be expected that the nurse be made aware. RN-H was unaware of R383 refusing any cares or showers. RN-H further stated it would be expected that toe and fingernails be trimmed and clean, even if a resident refused a shower.

During an interview on 8/1/24 the director of nursing (DON) stated it was expected that all residents are getting a shower or bath, stating I will make sure it gets done.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

the latest on the next shift, would transcribe, verify, and order any new medications from the

state it was important for R78 to receive his prescribed treatment to assist in healing his skin and not

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

interviewed. DON verified in-house audiology services were available, however, had not been

treatment (i.e., Debrox) could be started. RN-E verified R39's medical record lacked evidence the

anything. DON acknowledged the consultation order from April 2024, and stated they would look into it further. DON and RN-E both acknowledged hearing issues should be acted upon and, if needed, evaluated adding it was important because we don't want it to get worse.

On 7/31/24 at 7:55 a.m., DON was interviewed and verified the consult order had been transcribed into the medical record but not completed. DON stated they were going to reach out to the VA and get it scheduled. DON expressed the unit had a health unit coordinator (HUC) who resigned abruptly which could have contributed to the appointment being missed.

A facility policy on audiology services and hearing examinations was requested, however, none was received.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

During observations between on 7/30/24, at 09:41 a.m., R195 way lying in bed watching TV with their left leg hanging slightly off edge of bed. R195 was observed with a standard air mattress on their bed.

During subsequent observations on 7/31/24 and 8/1/24 R195 continued to be observed with a standard air mattress on their bed.

During interview on 7/31/24, at 01:58 p.m., registered nurse (RN)-G stated residents who have falls can have multiple interventions included a low bed, call don't fall signs, floor mats or a perimeter mattress. RN-G stated falls are reviewed daily by the interdisciplinary team (IDT) and interventions are determined by the team.

Furthermore, RN-G stated R195 had a physical device assessment on 7/25/24 and was determined R195 would benefit from a perimeter mattress. An order was received on 7/25/24 and a requisition should have been placed at that time. RN-G was unable to locate a request for the perimeter mattress and confirmed that R195 did not currently have a perimeter mattress in place.

During interview on 8/1/24. At 09:21a.m., director of nursing (DON) stated the IDT reviews resident falls daily and collaboratively plan for interventions to best meet each residents' individual needs.

DON stated if an order is received from a provider for a medical device to reduce falls, she would expect the device to be immediately put into place, or within 24 hours if device needed to come from an outside durable medical equipment company. DON stated she understood R195 had an order to use a perimeter mattress but confirmed it had not been implemented. DON stated it is important to implement interventions and physician orders to decrease the risk of falls and potential injuries to residents.

Facility policy Fall Mitigation Program dated April 1,2022 indicated each resident will be assessed for fall risk and will receive the care and services in accordance with their individualized level of risk to minimize the likelihood of falls.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

During interview on 8/01/24 at 11:39 a.m., licensed practical nurse (LPN)-C verified they are familiar with R69 and R131. LPN-C verified R69 has known chronic pain and rates it at an 8 out of 10 on a pain scale. LPN-C verified R131 has known chronic pain that is controlled with scheduled pain medication and currently not using any PRN pain medication. LPN-C verified any non-pharmacological interventions would be listed in the order section of the medical record and would be charted on.

LPN-C stated, on second floor we use oils and stuff to help with some behaviors and those are charted on, but we don't use them up here. LPN-C verified neither R131 or R69 are being offered or utilizing any non-pharmacological interventions to help manage their known chronic pain.

On 8/1/24 at 2:47 p.m., director of nursing (DON) stated, residents with pain should be offered non-pharmacological interventions such as repositioning, warm or cold packs and then the nurse is going to document whether or not it was effective or non-effective. DON verified non-pharmacological intervention would be found on the MAR/TAR (medication/treatment administration record).

A policy on use of non-pharmacological interventions for pain was requested but not provided.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

if an error or alarm activated.

Further, ADON stated they believed a user' manual for the device was in

A Trilogy 100 Ventilator Information and User Guide for Qualified Health Professionals manual, dated

details, and setting applications.

The manual outlined two types of ventilation circuits were available using the device, including active and passive, and how to set-up each one with the machine along with a red-colored exclamation point warning reading, Please check that circuit type if properly configured.

The manual outlined how to connect oxygen to the device along with humidified air.

The manual outlined how to review, set and monitor alarm parameters and indicated three types of alarms could trigger on the device including high-priority which, . require immediate response by the operator, the alarm mute button with flash red and the screen message will appear red. A graph showing multiple potential alarm reasons was included, along with corresponding staff-actions to resolve them.

A facility' policy on staff competency with medical device training was requested, however, none was received.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

During an interview on 8/1/24 at 12:35 p.m., the consulting pharmacist (PH) stated she had difficulty getting the facility/providers to fully respond to her recommendations for R164, so she had been reissuing them monthly since March.

The PH stated she sent recommendations to the facility once a month and would then follow up the next month to ensure the recommendations were completed.

The PH stated she had reviewed the response from the March recommendation and an appropriate diagnosis for antipsychotic use was not given, so she had reissued the recommendation.

The PH stated agitation was not an appropriate indication for antipsychotic use and would have expected a medical diagnosis such as schizophrenia, delusional disorder, or bipolar disorder.

The PH stated the facility had not established a duration of use for R164's as-needed lorazepam so she had reissued that recommendation monthly also.

The PH stated she had not had a conversation or further reached out to the provider, medical director, or other facility staff to explain the repeated recommendations to the facility staff.

During an interview on 8/1/24 at 2:28 p.m., the director of nursing (DON) stated nursing staff had reviewed the pharmacy recommendations, but there had been a misunderstanding regarding the requirement for a stop date for as-needed psychotropic medication, so it had not been addressed.

The DON stated agitation was not an appropriate indication for antipsychotic medication and the order should have been updated to include an appropriate indication before the start of the survey, but it had not been.

The DON stated she was unaware of the nursing staff or the provider reaching out to the pharmacist for clarification on recommendations.

A policy regarding pharmacist medication regimen reviews was requested and not received.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

During an interview on 8/1/24 at 10:29 a.m., nursing assistant (NA)-A stated he works with R164 frequently and had not noticed R164 being agitated or having any other behaviors when staff were not interacting with him. NA-A stated R164 was frequently sleeping during the day and only seemed to push staff when they were rolling him in bed and completing cares. R164 was observed sleeping in his wheelchair.

R164's Consultant Pharmacist Recommendation to Physician dated 6/25/24, indicated R164 received as-needed lorazepam.

The report indicated that as-needed psychotropic medications should have a 14-day stop date, unless a longer time frame is deemed appropriate by the physician.

The report indicated if the duration of use needed to be extended past 14 days, to provide a rationale for continuing use and a specific duration of therapy.

The provider responded on 7/29/24 to continue the as-needed lorazepam order due to its indication of use.

The response did not address the pharmacist's recommendation to include a specific duration of therapy.

R164's Consultant Pharmacist Recommendation to Physician dated 6/25/24, indicated R164 was receiving quetiapine for a diagnosis of agitation which is not considered an appropriate indication for antipsychotic use.

The report indicated if the antipsychotic use was to continue, to clarify the appropriate diagnosis.

The provider responded on 7/29/24 and indicated the diagnosis was resistant anxiety.

During an interview on 8/1/24 at 12:35 p.m., the consulting pharmacist (PH) stated she had difficulty getting the facility/providers to fully respond to her recommendations for R164, so she had been reissuing them monthly since March.

The PH stated she had reviewed the response from the March recommendation and an appropriate diagnosis for antipsychotic use was not given, so she had reissued the recommendation.

The PH stated agitation was not an appropriate indication for antipsychotic use and would have expected a medical diagnosis such as schizophrenia, delusional disorder, or bipolar disorder.

The PH stated the facility had not established a duration of use for R164's as-needed lorazepam so she had reissued that recommendation monthly also.

During an interview at 12:14 p.m., nurse practitioner (NP)-A confirmed a stop date had not been added to the as-needed lorazepam as she did not know it was necessary. NP-A stated it was unclear why R164 was using quetiapine, so on 7/29/24 she had updated the order to include an indication of resistant anxiety but was unable to specify what symptoms of resistant anxiety R164 had. NP-A stated the previous provider had talked with RR-C who was upset because R164 was not falling asleep at the same time every night and had requested the medication be continued so they had. NP-A stated, Maybe it [quetiapine] was more appropriate in the past and was unable to give an indication for current use.

During an interview on 8/1/24 at 2:28 p.m., the DON stated nursing staff had reviewed the pharmacy recommendations, but there had been a misunderstanding regarding the requirement for a stop date for as-needed psychotropic medication, so it had not been addressed.

The DON stated agitation was not an appropriate indication for antipsychotic medication use and the order should have been updated to include an appropriate indication before the start of the survey, but it had not been.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

During interview on 8/1/24 at 12:29 p.m., pharmacist (PH) stated it was not recommended to combine

scientific data to know how the medications interact or how they were absorbed when they are crushed and administered together. PH stated it was up to the providers to authorize the crushing of medications together and administering them via gastric tubes.

During interview on 8/1/24 at 2:55 p.m., director of nursing (DON) stated we have the responsibility to clarify the orders on admission. We need to have the right medication, the right dose, the right diagnosis, and the right frequency.

The nurse must ask those questions.

Some medications are prescribed for different reasons.

But is their patient taking the medication for seizures or what? Regarding the administration of medications via gastric tubes, DON stated a provider order is required to administer medications together because it could cause interactions.

Interactions could even be life threatening or have a negative outcome.

The order needs to come from the provider. DON stated It is 101 nursing, if you have 10 meds, you need 10 med cups, one for each medication. It is basic nursing.

Facility's policy titled Medication administration via Enteral Tube dated 4/1/22, indicated each medication will be administered separately.

Policy also indicated medications may be administered together with a provider's order.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

Based on observation and interview, the facility failed to ensure mediations were kept locked or under

medications on 3 of 5 resident floors.

Findings include: During observation and interview on 7/29/24 at 6:14 p.m., an unattended and unlocked medication cart was observed located along a knee-high wall facing the seventh floor dining room during mealtime.

Registered nurse (RN)-A returned to the medication cart and verified it was unlocked and, it should be locked to stop anyone from getting in.

During observation and interview on 7/31/24 at 1:10 p.m., an unattended and unlocked medication cart was observed located along a knee wall facing the fifth floor dining room with 12 seated residents in wheelchairs and walkers and two residents in wheelchairs rolling past the cart.

During interview with licensed practical nurse (LPN)-B stated he was responsible for the unlocked medication cart and stated, I should always lock the cart when I leave it.

Because the residents can get access to it.

During observation and interview on 8/1/24 7:54 a.m., an unattended and unlocked medication cart was observed located along a knee wall facing the fifth floor dining room with 12 seated residents in wheelchairs and walkers in the area. LPN-C stated he was responsible for the unlocked medication cart and stated, the med cart should be locked because it is regulation. [sic] keep others from getting into the cart and getting the meds.

During continuous observation on 8/1/24 from 11:30 a.m. to 11:47 a.m., an unattended and unlocked medication cart was observed on second floor in front of the nursing station until the DON walked by and locked the medication cart.

During interview with second floor nurse manager (RN)-H stated, leaving the cart unlocked [sic]concern because anybody can open it and take medications.

During interview with the third floor nurse manager RN-B on 8/1/24 at 7:58 a.m., stated, medication carts [sic] always lock before leaving the cart [sic] when leaving because we have residents here that can rummage through them and get access to them, and we do not want to have the risk of them getting into the carts and accessing the meds.

During interview with director of nursing (DON) on 8/1/24 at 9:02 a.m., DON stated, we teach nurses to keep the med carts locked once you are stepping away. No matter what. If you can't reach the cart, you must lock the cart.

Facility policy titled Medication Administration dated May 2024 identified, Medications are administered by licensed nurses, or other staff who are legally authorized to do so.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

referred for dental services.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

Fahrenheit. RD stated, this is not where we need it [food temps] to be and declined to offer surveyor

top of the counter and let them wait.

The meal trays would at least be warmer when served directly from the meal cart and not allowed to be sitting on the counter getting cold.

Resident council meeting minutes for February 16, 2024, identified, food is being brought to the floor in a timely manner however the aides on the floor aren't serving it right when it comes.

Resident Council Action form dated 6/13/24 provided to the DON identified, Residents expressed food isn't passed out right when the carts come up.

There was no implementation date or staff signature on the form.

Facility policy on food temperatures and timing of serving food was requested but not received.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

the poured milk which remained on the nurses' station ledge and NA-H stated, I skip it. NA-H left the

At 8:56 a.m., NA-H placed R39's tray in his room on the bedside dresser. R39 was not present in the

7/31/24, on the tray which had three items, including milk, listed on it with a star (i.e., *) next to them. NA-H reviewed the menu slip and verified the section labeled, Beverage Pref:, was left blank but expressed the starred items were the major things that they like. NA-H verified they didn't serve R39 any milk, despite it being starred on the slip, and expressed they served him the cranberry juice instead as, He [R39] doesn't like milk. NA-H reiterated, I'm used to them [residents] so I know. NA-H verified they had not asked or questioned R39 on what drinks he wanted with the breakfast meal that day. NA-H stated R39 would once in awhile complain about the drinks on his meal tray but they (NA-H) attributed such to just him changing his mind at times.

Further, NA-H stated the kitchen staff made and sent-up the white-colored menu slips for each meal.

When interviewed on 7/31/24 at 1:06 p.m., RN-E stated they believed the starred items on the menu slips were what they prefer but added, I could be wrong though. RN-E stated the staff were told to review the menu slips and ensure the diet served matches the diet listed but also staff were told to get to know your residents and what they like and don't like. RN-E stated the kitchen or dietary department had never, to their recall, explained to inform the staff what the starred items actually meant.

On 7/31/24 at 1:27 p.m., the kitchen supervisor (KS) was interviewed. KS explained the white-colored menu slips were made in the kitchen for each meal and sent up with the trays to the units adding the starred drink items were a preference, a beverage preference. KS stated the kitchen sends up the drinks and beverages to the units and the CNAs take it from there to pass them out. KS stated the starred items didn't necessarily mean they should be passed at each meal but verified the NA should be asking the resident which drinks or beverages they wanted for each meal. KS stated this was important to do for customer service and to ensure the resident is getting what they're wanting.

A facility policy on resident drink preferences with meals was requested, however, none was received.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

During interview with NA-F on 8/1/24 at 1:13 p.m., NA-F stated, we should be making sure the food is

cake needs to be covered also, which [it] wasn't when I was delivering those three trays.

Facility policy on covering food during transport and delivery was requested but not received.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

During observation on 7/31/24 at 11:55 a.m., R2 was observed to have a single page document in a plastic page protector hung on the door that indicated: Respiratory Precaution Room.

The sign had a person on it with PPE (proper protective equipment), it also included a stop sign on the sign with a picture of a hand along with the words: gown, N95, eye protection, one pair of gloves. At the bottom of the page, it indicated airborne infection isolation room: keep door closed if possible. To the left of the door was a three-drawer plastic bin to the left of the door which contained disposable gowns, N95 masks and face shields. On top of the plastic bin was hand sanitizer, disposable gloves, and disposable masks.

During observation on 7/31/24 at 11:55 a.m., housekeeper (HSK)-D was observed with a surgical mask on pushing their cleaning cart to the entrance of R2's. HSK-D was observed using hand sanitizer, grabbing a disposable gown from the bin, putting the gown on followed by a pair of disposable gloves. HSK-K then entered R2's room.

Upon exit of the room, HSK-D was observed to take off the gown and gloves and use hand-sanitizer but did not remove the surgical mask.

During continual observation, HSK-D was observed to move their cart down the hallway to an adjacent room with a sign on the door, Enhanced Barrier Precautions.

During the same continual observation, HSK-D was observed to use hand sanitizer, put on gloves and then a gown to enter the room, while continuing to wear the same surgical mask worn in R2's room.

During interview at 7/31/24 at 12:09 p.m., HSK-D verified that they just completed cleaning R2's room. HSK-D verified they did not wear a N95 or a face shield. HSK-D stated, I can't breathe with those masks on. HSK-D stated, I changed my blue mask though, I carry them in my pocket. HSK-D verified PPE is to be worn to stop the spread of diseases. HSK-D verified that R2 was on precautions for COVID.

During interview on 8/01/24 at 11:05 a.m., registered nurse (RN)-F verified R2 had COVID. RN-F stated that any staff needs to have full attire on when they enter COVID rooms, or any rooms PPE is needed in. RN-F verified that all staff get training on proper PPE use.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

to having poor breathing adding, I would take it yesterday.

subsequent recommended pneumococcal vaccinations (i.e., PCV15/20) were discussed, offered or

On 8/1/24 at 1:03 p.m., the assistant director of nursing (ADON) and regional nurse consultant (RNC) were interviewed. ADON explained themselves, along with RNC, were helping to manage and oversee the facility' infection control program since the previous infection preventionist (IP) had abruptly resigned a few months prior. ADON verified they had reviewed R158 and R17's respective medical records, and explained the PointClickCare information was the most current, including with data pulled from the MIIC (Minnesota Immunization Information Connection). ADON verified neither R158 or R17 had their respective, eligible doses offered or provided prior to the survey to their knowledge and expressed they had been, so far, unable to locate any documentation to demonstrate otherwise but would provide it, if located. ADON explained the previous IP apparently had been offering the vaccinations but not giving them. RNC stated, in hindsight, a quality assurance (QA) project should have likely been started for immunizations but had not been. RNC and ADON both verified they were going to review a 'whole house' audit now and get the immunizations offered, as needed, moving forward adding, It's in the process. ADON stated it was important to ensure vaccinations were offered and, if accepted, provided to promote resident' health adding, They have diagnoses that put them at risk.

The facility' policy on pneumococcal vaccinations was requested, however, was not received.

the bug was a bed bug.

Maintenance staff would then notify the supervisor of the presence of bed

housekeeping so they could deep clean the room.

Once the deep clean was completed, housekeeping

into their room.

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Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

During interview on 8/1/24 at 8:50 a.m., family member (FM)-B explained R146 admitted to the care center about six months prior due to unsafe living conditions at the home and a series of falls. FM-B stated they visited often and R146 had been eating less lately adding aloud, The food there sucks. FM-B explained the family was worried about R146's nutritional intake and, as a result, had been trying to bring in items to bolster his intake due, in part, to the poor meals served.

During observation and interview with dietary aide (DA)-A and DA-B on 7/31/24 at 9:06 a.m. on the 7G dining room, DA-A temped R158's scrambled eggs that had immediately been set in front of him.

Temperature registered 113 degrees Fahrenheit. DA-A stated the temp was too low and R158 stated the eggs were too cold. DA-B stated, [7G residents] supposed to get their food at 8:15 a.m., to 8:30 a.m., but we are late today.

During interview with KS on 7/31/24 at 12:35 p.m., KS stated, I would say the food that was delivered today was late. If the food did not get to 2R until after 9:00 a.m., then it is 45 minutes late and the food delivered this morning to 7th floor was late also.

During observation on 7/31/24 at 1:02 p.m. on 6G, food was still being delivered to residents in the main dining room.

Posted sign on kitchenette stated cart was to arrive at 12:30 p.m

During interview with facility dietician (DC) on 7/31/24 at 1:43 p.m., DC stated, Food should not be delivered late. If it is delivered late, then I would be concerned about potential for infection.

Liquids being delivered to resident rooms must always be covered. I would be concerned about contamination and being served too warm.

Scrambled eggs and oatmeal should be at least 140 degrees when delivered to rooms and when served.

245055

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 245055 B.

Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409