Lakehouse Healthcare & Rehabilitation Center
LAKEHOUSE HEALTHCARE & REHABILITATION CENTER in MINNEAPOLIS, MN — inspection on September 3, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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
During an interview on [DATE] 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] 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], 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].-Nurse STAT (Code Blue) drills started [DATE].
Drills included residents who were full code, DNR, and hospice residents.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.