Lakehouse Healthcare & Rehabilitation Center
Inspection Findings
F-Tag F0678
F 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
consistent with resident's wishes. During an interview on [DATE REDACTED] at 2:29 p.m., DON confirmed Resident R1's code status was full code, his code status had not checked when he was found unresponsive, and CPR had not been performed. During an interview on [DATE REDACTED] at 12:18 p.m., Hospice registered nurse (HRN) stated she was at the facility to see Resident R1 on [DATE REDACTED], because he was having increased pain. When she assessed Resident R1, he was a little confused however, was able to answer basic questions. HRN left the room to call the provider.
LPN-A asked HRN to go to Resident R1's room because his breathing was different. When HRN and LPN-A returned to Resident R1's room, he was not responding and was not breathing. HRN checked for a pulse while LPN-A checked for breathing. Finding no pulse and no breaths, time of death was called. HRN did not check the resident's code status, and LPN-A did not leave the room until after time of death was called. HRN confirmed CPR had not been initiated on Resident R1. During an interview on [DATE REDACTED] at 1:49 p.m., registered nurse (RN)-A stated a nurse STAT page alerted all nurses to respond to a specific location for an emergency.
Each nurse would bring equipment based on the location they were working on. Equipment included a crash cart (included supplies needed to perform CPR), vital signs machine, and automated external defibrillator (AED). If a resident was found unresponsive and not breathing, a nurse should check the POLST of the resident and if the resident was full code, CPR should be started immediately. RN-A stated there was no reason CPR would not be started on a resident who elected full code status. During a follow-up interview on [DATE REDACTED] 2:16 p.m., the DON stated if a resident was found not responding and not breathing, a nurse should check the resident's code status on the POLST. If the resident was full code, the nurse would do chest compressions, give respirations, and use the AED. 911 would also be called. If a resident's code status was DNR, CPR would not be started. DON stated there were reasons CPR would not be started listed in the CPR policy however, those signs take 4-6 hours to develop, and staff would be checking on residents before the signs had time to develop. 3 attempts were made to contact LPN-A with no return phone call. Review of the facility's CPR policy dated [DATE REDACTED], instructed staff when a resident experienced a cardiac arrest, to provide basic left support, including CPR in accordance with the resident's advance directives. And if the resident did not show obvious signs of clinical death (e.g. rigor mortis [body limb stiffening], dependent lividity [purplish red discoloration to the skin], decapitation, transection, or decomposition). The facility implemented the following actions prior to the survey which were verified through interview and document review and therefore the IJ was issued at past non-compliance:-LPN-A was immediately suspended and communication with hospice company occurred.-House-wide nurse education started including the importance of checking a resident's code status when they were found unresponsive and not breathing, including residents who had elected hospice care. Education completed [DATE REDACTED].-Nurse STAT (Code Blue) drills started [DATE REDACTED]. Drills included residents who were full code, DNR, and hospice residents.
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LAKEHOUSE HEALTHCARE & REHABILITATION CENTER in MINNEAPOLIS, MN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MINNEAPOLIS, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LAKEHOUSE HEALTHCARE & REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.