Lakehouse Healthcare & Rehabilitation Center
Inspection Findings
F-Tag F0686
F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
impaired decision-making needing cues and supervision from staff. Resident R2 had history of moisture associated skin damage (MASD) under both breast and to buttocks. The care plan was revised on 7/28/25 to include
the intervention that directed staff to turn and reposition Resident R2 every 2-3 hours and as neededR2's progress noted dated 10/1/25 at 1:24 p.m., Resident R2's coccyx wound was upgraded to a stage 3. In review of Resident R2's record there was no indication of a comprehensive assessment that addressed Resident R2's turning and reposition program and not evident the care plan was revised after the ulcer deteriorated to a stage 3. During an
Interview on 11/14/25 at 12:20 p.m., registered nurse (RN)-A indicated that the turning and repositioning schedules were individualized, as with Resident R2, is up for meals and then laid back down in bed and then turned every 2-3 hours. RN-A was not able to articulate how every 2-3 hours for repositioning was determined to be appropriate and/or effective. During an Interview on 11/18/25 at 11:40 a.m. nursing assistant (NA)-Q stated the staff were informed of the turning and repositioning schedules on their daily report sheets, NA-Q stated up for meals otherwise in bed and turned every 2-3 hours. During an interview and observation on 11/18/25 at 1:22 p.m., RN-C described the wound during a dressing change as a stage 3, with moderate serosanguinous drainage. RN-C did not know how the turning and repositioning schedule was determined but the NA taking care of her should know. During an interview on 11/19/25 at 8:30 a.m., director of nursing (DON) indicated Resident R2 was on an alternating air mattress due to her stage 3 ulcer. This device was to assist staff with offloading to the resident. The IDT team meets daily, and they discuss the wounds quickly and then meet once a week at wound rounds and discuss how the wounds are progressing. DON could not articulate how every 2-3 hour turning and repositioning schedule was established or how they were evaluating the effectiveness of the interventions they had in place to relieve the pressure from the pressure ulcer area. During an Interview on 11/19/25 at 10:15 a.m., regional nurse consultant (RNC)-A, stated that
the facility did not use a tissue tolerance specific assessment as that had gone by the wayside years ago and indicated there was no formalized process and/or tool to determine a resident's repositioning schedule, and it was more based on the clinical picture however, the determination of which factors were used to determine the schedule were not documented. During an interview on 11/19/25 at 1035 a.m., wound nurse practitioner (NP)-A, stated first made aware of wound for Resident R2 on 7/30/25, when she evaluated the wound and took initial pictures. NP-A described the wound as superficial at that time, and Resident R2 had another area nearby that looked like MASD. Resident R2 had history of MASD in the coccyx area in late June 2025. NP-A put in orders for daily treatments, air mattress and dietary consult for protein supplement. Resident R2's wound was evaluated every week and was improving until 10/1/25, when NP debrided the area and restaged it to a stage 3 out of 4. NP-A put in different dressing orders. They showed improvement and was stable during
the evaluations on 10/8/25 and 10/10/25. The wound then deteriorated for the next 5 visits in 3 weeks (10/15/25 through 11/5/25). NP-A kept the same dressing change and encouraged staff to limit Resident R2's time up in wheelchair (up for meals only) on the visits for 10/15/25 and 10/17/25. NP-A further stated the causal factor of the pressure ulcer was pressure from lying on her back and being in the wheelchair prior to the development of the pressure ulcer on 7/25/25.Review of facility policies entitled Pressure Ulcer Monitoring and Interventions did not address turning and repositioning programs based on comprehensive assessments to prevent and/or reduce the risk of pressure ulcers.
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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.