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
During an interview on [DATE] at 2:29 p.m., DON confirmed 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] at 12:18 p.m., Hospice registered nurse (HRN) stated she was at the facility to see R1 on [DATE], because he was having increased pain.
When she assessed 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 R1's room because his breathing was different.
When HRN and LPN-A returned to 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 R1.
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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