Lakehouse Healthcare & Rehabilitation Center
LAKEHOUSE HEALTHCARE & REHABILITATION CENTER in MINNEAPOLIS, MN — inspection on November 19, 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 11/14/25 at 12:20 p.m., registered nurse (RN)-A indicated that the turning and repositioning schedules were individualized, as with 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 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 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 R2 had another area nearby that looked like MASD. 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. 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 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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