Walker Methodist Health Center

F-F807]. Resident R39 stated it was an ongoing issues and he had complained about it prior but staff told him, You keep complaining and you'll be gone [discharged ]. Resident R39 reiterated he wanted hot, Residents Affected - Some palatable meals served but the service was poor adding, It's still happening.

Resident R146

Resident R146's significant change MDS, dated [DATE REDACTED], identified Resident R146 had intact cognition and demonstrated no delusional thinking during the review period.

On 7/29/24 at 1:03 p.m., Resident R146 was observed laying in bed while in his room. Resident R146 had a bedside table pulled close to the bed which had a meal tray sitting on top with a domed lid covering. Resident R146 was asked about the care center food and responded by shaking his head in a 'no' motion (side to side) and saying aloud, like this, while his hand making a side to side motion (i.e., 'so-so'). Resident R39 stated he typically ate meals in his room and voiced the food was often bland tasting and not warm when it was finally served adding, It [food] just isn't presented well.

During interview on 8/1/24 at 8:50 a.m., family member (FM)-B explained Resident R146 admitted to the care center about six months prior due to unsafe living conditions at the home and a series of falls. FM-B stated they visited often and Resident R146 had been eating less lately adding aloud, The food there sucks. FM-B explained the family was worried about Resident R146's nutritional intake and, as a result, had been trying to bring in items to bolster his intake due, in part, to the poor meals served.

During observation and interview with dietary aide (DA)-A and DA-B on 7/31/24 at 9:06 a.m. on the 7G dining room, DA-A temped Resident R158's scrambled eggs that had immediately been set in front of him. Temperature registered 113 degrees Fahrenheit. DA-A stated the temp was too low and Resident R158 stated the eggs were too cold. DA-B stated, [7G residents] supposed to get their food at 8:15 a.m., to 8:30 a.m., but we are late today.

During interview with KS on 7/31/24 at 12:35 p.m., KS stated, I would say the food that was delivered today was late. If the food did not get to 2R until after 9:00 a.m., then it is 45 minutes late and the food delivered

this morning to 7th floor was late also.

During observation on 7/31/24 at 1:02 p.m. on 6G, food was still being delivered to residents in the main dining room. Posted sign on kitchenette stated cart was to arrive at 12:30 p.m

During interview with facility dietician (DC) on 7/31/24 at 1:43 p.m., DC stated, Food should not be delivered late. If it is delivered late, then I would be concerned about potential for infection. Liquids being delivered to resident rooms must always be covered. I would be concerned about contamination and being served too warm. Scrambled eggs and oatmeal should be at least 140 degrees when delivered to rooms and when served.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During interview with the regional director of dietary services (RD) on 7/31/24 at 2:21 p.m., RD stated the facility started a new food service company on May 1, 2024. RD stated, forty-five minutes is too long to wait Level of Harm - Minimal harm or for the carts to be delivered to the units. Those carts are not insulated, and staff should not be giving trays to potential for actual harm the residents 45 minutes to an hour after the food arrives on the floor.

Residents Affected - Some During interview with Resident R158 on 8/1/24 at 11:15 a.m., Resident R158 stated the scrambled eggs that were temped by DA-A on 7/31/24 for breakfast was, not warm enough for me.

During observation and interview with RD on 8/1/24 at 12:39 p.m., on the 7G unit, RD was asked to temp a lunch tray that was delivered to a resident room. The brat was temped at 124.2 degrees Fahrenheit. RD stated, this is not where we need it [food temps] to be and declined to offer surveyor a test tray. RD stated, I noticed the staff pulled the meal trays out of the meals carts and put them on top of the counter and let them wait. The meal trays would at least be warmer when served directly from the meal cart and not allowed to be sitting on the counter getting cold.

Resident council meeting minutes for February 16, 2024, identified, food is being brought to the floor in a timely manner however the aides on the floor aren't serving it right when it comes.

Resident Council Action form dated 6/13/24 provided to the DON identified, Residents expressed food isn't passed out right when the carts come up. There was no implementation date or staff signature on the form.

Facility policy on food temperatures and timing of serving food was requested but not received.

33925

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0807 Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33925

Residents Affected - Few Based on observation, interview and document review, the facility failed to ensure drinks of preference were offered or served to promote adequate fluid intake and improve meal satisfaction for 1 of 2 residents (Resident R39) reviewed who expressed their preferences of meal items were not honored.

Findings include:

Resident R39's significant change Minimum Data Set (MDS), dated [DATE REDACTED], identified Resident R39 had moderate cognitive impairment but demonstrated no delusional thinking during the review period.

On 7/29/24 at 1:42 p.m., Resident R39 was observed in his electric wheelchair while in his room. Resident R39 had a meal tray present on his bedside dresser which had a coffee cup filled with coffee and a white Styrofoam cup filled with

a dark-red colored juice. Resident R39 expressed multiple complaints about the care center meal service and food quality, and stated he wished they'd serve him milk with meals instead of that red crap as he pointed to the cup on his meal tray. Resident R39 stated he had repeatedly asked for milk with meals but added, I ask them for milk but don't get it. Resident R39 reiterated his displeasure multiple times with this and stated when he complains about it,

it would get better for a day to two then go back to various juices instead of milk.

Resident R39's nutritional care plan, dated 7/25/24, identified Resident R39 had a low body mass index (BMI) and consumed a regular diet with thin liquids. The care plan listed multiple interventions for Resident R39's nutrition including, Food/beverage preferences: like: strawberry, however, lacked any recorded beverage preferences or dislikes.

On 7/31/24 at 8:24 a.m., the morning meal service on Resident R39's unit was observed. A gray-colored mobile cart was pushed onto the unit which had numerous meal trays present inside. The trays contained plated, covered food along with white-colored menu slips on each which contained the respective resident' name, diet information and spacing to record likes, dislikes, and beverage preferences. At 8:27 a.m., nursing assistant (NA)-H helped remove various trays from the mobile cart and placed them on another metallic rack while NA-G pushed a cart around the dining room which had multiple juices, water and milk on it with residents seated at the tables being asked for their drink preferences. NA-H stated the trays being placed on

the metallic racks were room trays. At 8:33 a.m., registered nurse manager (RN)-E removed Resident R39's meal tray from the mobile cart and placed it on the metallic rack. Resident R39's white-colored menu slip was on the tray which listed his name along with a listing of various food or drinks along the bottom which included, * Apple ., and, * Milk, Low . However, a majority of the menu slip was covered with a napkin and not immediately visible.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0807 Resident R39's meal tray then remained on the metallic rack until 8:43 a.m., (nearly 20 minutes after it arrived to the unit) when NA-H returned to the rack and pushed it over the the mobile juice cart. NA-H then started to pour Level of Harm - Minimal harm or and place various juices on the respective trays, including Resident R39's, which remained on the metallic rack. When potential for actual harm asked how they know which beverages or drinks to put on the room trays, NA-H stated they knew they knew their preferences adding aloud, I'm used to them, so I know exactly. NA-H then looked at Resident R39's meal tray, Residents Affected - Few however, did not move the napkin to read the entire menu slip. NA-H removed a Styrofoam cup from a sleeve and filled it with ice and water, then poured another cup full of milk. NA-H placed the milk on the nurses' station ledge and then removed another cup and poured it full of a dark red-colored drink. NA-H placed the ice water and red-colored drink on Resident R39's meal tray and started to push the metallic rack towards

the rooms. The surveyor asked NA-H about the poured milk which remained on the nurses' station ledge and NA-H stated, I skip it. NA-H left the milk on the ledge and then pushed the metallic rack to the resident' rooms which included Resident R39's room.

At 8:56 a.m., NA-H placed Resident R39's tray in his room on the bedside dresser. Resident R39 was not present in the room and NA-H stated, I just drop it here. NA-H was asked about the white-colored menu slip, dated 7/31/24, on

the tray which had three items, including milk, listed on it with a star (i.e., *) next to them. NA-H reviewed the menu slip and verified the section labeled, Beverage Pref:, was left blank but expressed the starred items were the major things that they like. NA-H verified they didn't serve Resident R39 any milk, despite it being starred on

the slip, and expressed they served him the cranberry juice instead as, He [Resident R39] doesn't like milk. NA-H reiterated, I'm used to them [residents] so I know. NA-H verified they had not asked or questioned Resident R39 on what drinks he wanted with the breakfast meal that day. NA-H stated Resident R39 would once in awhile complain about the drinks on his meal tray but they (NA-H) attributed such to just him changing his mind at times. Further, NA-H stated the kitchen staff made and sent-up the white-colored menu slips for each meal.

When interviewed on 7/31/24 at 1:06 p.m., RN-E stated they believed the starred items on the menu slips were what they prefer but added, I could be wrong though. RN-E stated the staff were told to review the menu slips and ensure the diet served matches the diet listed but also staff were told to get to know your residents and what they like and don't like. RN-E stated the kitchen or dietary department had never, to their recall, explained to inform the staff what the starred items actually meant.

On 7/31/24 at 1:27 p.m., the kitchen supervisor (KS) was interviewed. KS explained the white-colored menu slips were made in the kitchen for each meal and sent up with the trays to the units adding the starred drink items were a preference, a beverage preference. KS stated the kitchen sends up the drinks and beverages to the units and the CNAs take it from there to pass them out. KS stated the starred items didn't necessarily mean they should be passed at each meal but verified the NA should be asking the resident which drinks or beverages they wanted for each meal. KS stated this was important to do for customer service and to ensure

the resident is getting what they're wanting.

A facility policy on resident drink preferences with meals was requested, however, none was received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 49034

Residents Affected - Some Based on observation and interview the facility failed to ensure all food items were properly covered when served to residents to reduce and/or prevent the risk of food borne illness. This practice had the potential to affect all residents who received their meals from the kitchen.

Findings include:

During observation and interview on 7/29/24 at 6:00 p.m., nursing assistant (NA)-N poured beverages into cups and mugs and placed on multiple meal trays which were on an uncovered cart. Uncovered cheesecake desserts were also on the individual meal trays. NA-N wheeled the uncovered cart from the dining room down the hall and passed the meal trays to at least six individuals in their rooms pushing the cart further down the hall between rooms. NA-N stated the beverages came up to the sixth floor in covered pitchers and could be poured into cups in the dining room and taken uncovered to residents' rooms.

During observation and interview on 7/31/24 at 9:12 a.m., NA-P wheeled an uncovered cart passing meal trays on the sixth floor which had uncovered bowels of cereal, brown sugar, milk, and other beverages. NA-P stated they did not have lids on the sixth floor to cover the brown sugar and other items.

During observation and interview with dietary aide, (DA)-A on 7/31/24 at 9:12 a.m. on 6G, DA-A temped a room tray that was being delivered. Four room trays were present on the meal tower cart and all the trays with uncovered orange juice, coffee, apple juice, and hot chocolate. DA-A stated she was unaware of whether liquids needed to be covered when delivered to resident rooms.

During interview with director of nursing (DON) on 7/31/24 at 10:04 a.m., DON stated, liquid drinks should be covered when bringing them to resident rooms.

During interview with kitchen supervisor (KS) on 7/31/24 at 12:35 p.m., KS stated, Food is [to be] covered when traveling a distance like down a hallway, to a different unit or floor, based upon standards of practice for infection control and food safety. KS stated, My understanding is that the food that is transported must have covers on them.

During interview with NA-C on 7/31/24 at 1:05 p.m., NA-C stated, it is not good to leave the drinks uncovered when delivering meal trays to residents in their rooms. We are supposed to cover them any time we deliver them to the resident rooms.

During interview with facility dietician (DC) on 7/31/24 at 1:43 p.m., DC stated, Liquids being delivered to resident rooms must always be covered. I would be concerned about contamination and being served too warm.

During interview with regional director of dietary services (RD) on 7/31/24 at 2:21 p.m., RD stated, Fluids must be covered [sic] concern for cross contamination and infection control if they are not covered when delivered to resident rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During observation and interview on 8/1/24 at 12:39 p.m. in the 7G unit dining room, RD stopped NA-F as he was pushing the meal cart tower down the hall to resident rooms. There were 3 resident room meal trays on Level of Harm - Minimal harm or the cart. The carrot cake rolls and liquids were uncovered. RD instructed NA-F that the carrot cake roll potential for actual harm desserts needed to be covered along with all liquids before transporting. RD verified carrot cakes and liquids were not covered. Residents Affected - Some

During interview with NA-F on 8/1/24 at 1:13 p.m., NA-F stated, we should be making sure the food is covered when transporting it including the milk and juice. I did not know or maybe I forgot the carrot cake needs to be covered also, which [it] wasn't when I was delivering those three trays.

Facility policy on covering food during transport and delivery was requested but not received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33925 potential for actual harm Based on observation, interview and document review, the facility failed to ensure laundered linens were Residents Affected - Many handled and sorted in a clean, sanitary environment to reduce the risk of contamination for 1 of 1 main washrooms reviewed; failed to ensure staff consistently implemented transmission-based (TBP) and enhanced barrier precautions (EBP) to reduce the risk of infectious spread for 4 of 4 residents (Resident R134, Resident R83, Resident R54 and Resident R2); and failed to ensure general COVID-19 mitigation methods (i.e., masking) were correctly and consistently implemented on units with active infection. These findings have potential for a cumulative effect and, as a result, have potential to affect all 228 residents, staff and visitors within the care center.

Findings include:

Laundry Room:

On 7/30/24 at 8:21 a.m., a tour of the campus main washroom was completed with laundry aide (LA)-A present. The washroom consisted of a large single space with commercial washing machines on one side, and three [NAME] commercial dryers on the opposite. In the center of the room, positioned outside the dryers (direction they open to), were a series of tables pushed together with multiple, white-colored linens stacked on them to form a large pile. The wall surrounding the table had various mobile racks with various clothing items placed on them. However, attached to the wall were multiple AirKing bladed fans and the grates covering the blades of the fans had significant, copious gray and black-colored dust build-up present and were facing the cleaned linen stacked on the tables. In addition, a large [NAME] Mobile Air Conditioner was on the floor and also facing the tables of stack linen. The machine was activated and moving air towards

the clean linen, however, the grate covering the blades of the unit also had significant, dark gray-colored dust and debris build-up present.

LA-A verified the condition of the grates and stated maintenance was supposed to be cleaning them to their knowledge, however, it had been several weeks since they were last done to their recall. LA-A stated staff could, if needed, make a maintenance slip out to have them cleaned but they had not done so themselves as

they weren't exactly sure how to do it. At this time, the housekeeping supervisor (HS) entered the interview and expressed they had recently started working at the campus and were going to find out how the conditioner and fans were being cleaned. HS verified the devices were pointed at clean linen and soiled adding, They need to be cleaned. HS stated the fans and conditioner should be kept clean to reduce possible contamination of the clean linens. The district manager of environmental services (DMES) entered

the interview and also verified the fan and conditioner grate' condition adding, We should take care of them. LA-A verified the fans were not on a routine cleaning schedule to their knowledge. DMES stated the maintenance personnel may be cleaning them or have more information.

On 7/30/24 at 3:47 p.m., the director of engineering (DOE) was interviewed. DOE verified they oversaw the maintenance department and expressed cleaning of the soiled devices observed in the washroom really would fall under my department. DOE stated the fan and conditioner grates were cleaned on a upon request basis but they were going to likely implement a monthly schedule moving forward. DOE verified nobody had asked or presented the soiled grates to their department prior to survey and stated they should be cleaned adding them having built-up dust and debris posed a fire safety hazard.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During the recertification survey, from 7/29/24 to 8/1/24, no flowsheet(s) or documented tracking was provided to demonstrate the fans and air conditioner unit were on a cleaning schedule prior to the survey. Level of Harm - Minimal harm or potential for actual harm On 8/1/24 at 1:03 p.m., the assistant director of nursing (ADON) and regional nurse consultant (RNC) were interviewed. ADON explained themselves, along with RNC, were helping to manage and oversee the facility' Residents Affected - Many infection control program. ADON and RNC expressed the washroom was audited from an environmental standpoint at times, however, were unsure if it had been audited as part of the infection control program. ADON verified staff are educated on clean linen handling and RNC expressed the fans and conditioner grate was going to be added to a schedule for routine cleaning moving-forward adding, I think definitely the practice needs to change. ADON stated soiled grates blowing onto clean linen was a cross-contamination risk, and they verified the linens were used house-wide.

A facility' policy on clean linen handling was requested, however, none was received.

44656

Resident R134

Resident R134's quarterly Minimum Data Set, dated dated dated , 7/20/24 indicated Resident R134 with severe impairment of cognitive skills, physical and verbal symptoms directed towards others and had an indwelling catheter. In addition, Resident R134 with diagnoses of Alzheimer's disease, dementia, seizures, depression, anemia, renal insufficiency (form of kidney failure), neurogenic bladder(bladder control problem due to a brain, spinal cord, or nerve issue), obstructive uropathy (disorder of the urinary tract due to obstructed urine flow), and received antipsychotics, antidepressants. Also, Resident R134 required extensive assistance of one staff member with bed mobility, eating, toilet use.

Resident R134's physician orders dated 7/29/24 direct staff for, Isolation: Resident is on Enhanced respiratory precaution due to tested positive for COVID on 7/23/24 and is in a contagious stage. Resident will be on isolation for 10 days in a private room.

Resident R134's nursing progress note dated 7/23/24 stated, Note Text: Resident test positive for covid 19 @ this time, Resident appeared to be lethragic [sic] today with poor appetite, T. 98.2, in bed @ this time and will encourage isolation.

During observation on 7/29/24 at 3:50 p.m., an Airborne Infection Isolation room sign was posted on outside of resident door. Sign stated, wear gown, N95, eye protection (Goggles or face shield), One pair of gloves. PPE cart was placed outside the door with N95 masks, gowns, gloves and hand sanitizer in the unit. PPE unit did not contain face shields or goggles.

During continuous observation on 7/29/24 at 5:44 p.m. to 5:52 p.m., nursing assistant (NA)-A exited Resident R134's room wearing PPE gown, N95 mask, and gloves. NA-A was wearing prescription eyeglasses and opened the PPE cart and then walked back into Resident R134's room without eye protection. At 5:57 p.m., NA-A exited Resident R134's room with a meal tray.

During interview with NA-A on 7/29/24 at 5:58 p.m., NA-A verified Resident R134 with Covid-19. NA-A verified he did not wear a face shield or goggles when assisting Resident R134 with eating. NA-A stated, I was told it was ok to just wear my eyeglasses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During interview with nursing manager and licensed practical nurse (LPN)-A on 7/29/24 at 6:03 p.m., LPN-A verified Resident R134 was on respiratory precautions due to Covid. LPN-A stated, [facility] they allow us to use our Level of Harm - Minimal harm or [eye]glasses as eye protection and did not need to wear a face shield or goggles when working directly with potential for actual harm Resident R134.

Residents Affected - Many During observation on the second floor (with Covid outbreak) on 7/29/24 at 4:40 p.m., an unidentified staff member was wearing surgical mask below their nose while pushing a resident in a Broda chair to the dining room.

During interview with RN-B on 7/30/24 at 9:00 a.m., RN-B stated the expectation of all staff was to wear required PPE gown, gloves, N95's and face shields or goggles when providing any kind of care to a Covid positive resident. Any time a staff enters a Covid room they are to don the PPE and remove it when they leave. Staff should not exit room with the PPE on to check the cart. [sic] important for staff to don and doff

the PPE to prevent infection and to protect everyone including other staff, families and residents from infection.

During interview with the DON on 7/31/24 at 10:04 a.m., DON stated Covid precautions include, gown, gloves, face shield and N95 mask. And staff should always wear all the required PPE including the face shield every time they enter the Covid positive room. Also, surgical masks worn above nose and mouth should be worn by all staff during outbreaks especially on the Covid units.

Uncovered Soiled Linen/Garbage Carts in hallways.

During observation on 8/1/24 at 7:51 a.m., on the fifth floor, a three-bin unit with each bin having a large plastic bag inside a mesh bag was observed in the hallway outside of a fifth floor resident room. One of the bins had a white plastic cover while the other two had no covers at all. The uncovered middle bin had a visible mound of laundry with a soiled red plaid shirt. that had a Resident R30's name on a label inside the neck of the shirt. The uncovered right bin had soiled incontinence briefs and other trash in it.

During observation and interview with nursing assistant (NA)-D on 8/1/24 at 7:53 a.m., NA-D exited room [ROOM NUMBER] with a small garbage bag and an arm full of soiled facility linen. NA-D placed the soiled facility linen including towels and bedsheet on top of the uncovered middle bin that had Resident R30's personal shirt

in it. NA-D then placed the small garbage bag into the uncovered soiled garbage bin. NA-D stated, [the two uncovered bins] are supposed to be covered but this one doesn't have covers. [laundry] is supposed to be covered for infection control.

During observation and interview on 8/1/24 at 7:58 a.m., on the third floor a three-bin unit with each having a large plastic bag inside a mesh bag was in the hallway outside of room [ROOM NUMBER]. The middle bin was uncovered and had soiled Hoyer slings in it which were visible. Nursing manager and registered nurse (RN)-B grabbed the unit and wheeled it down the hall. RN-B stated, soiled linen and garbage should not be visible from the hall. RN-B stated, this is a concern for infection control. Each of these units [resident floors] have these 3 bin units for aides to put the trash and linen in them after providing care. One bin is for trash, one for personal laundry, and one for facility laundry. They should be covered when out in the hall.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During interview with the director of nursing (DON) on 8/1/24 at 9:12 a.m., DON stated uncovered soiled linen and garbage, should not be left visible in the hallway. DON stated rationale for covering soiled linen and Level of Harm - Minimal harm or garbage was, infection control thing. potential for actual harm 48299 Residents Affected - Many Enhanced Barrier Precautions:

Resident R83's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], identified intact cognition and diagnoses of neurogenic bladder (when a person lacks bladder control due to brain, spincal cord or nerve problems), kidney disease, epilepsy, and diabetes mellitus. Resident R83 required substantial and/or maximal assistance for transfers and rolling left and right and partial and/or moderate assistance for toileting hygiene. Resident R83's MDS identified Resident R83 had an indwelling catheter and was frequently incontinent of bowel.

Resident R83's activities of daily living care plan revised 6/30/24, indicated Resident R83 required a mechanical lift with two staff assistance for transfers. Resident R83's care plan also indicated Resident R83 had an indwelling catheter related to neurogenic bladder.

During observation on 7/29/24 at 5:29 p.m., Resident R83's door had a sign which read Enhanced Barrier Precautions and instructed staff to wear gloves and a gown for high-contact resident care activities which included transferring. A cart of personal protective equipment (PPE) was next to Resident R83's door. NA-N and NA-O wore gloves, mask, and no gown to assist Resident R83. NA-N and NA-O hooked the sling underneath Resident R83 to the mechanical lift machine, placed the urinary catheter, which was within its privacy bag, on Resident R83's lap, and transferred Resident R83 from the bed to wheelchair. NA-N removed gloves and performed hand hygiene prior to leaving the room. NA-O still had gloves on and no gown and placed urinary catheter bag under Resident R83's wheelchair and made Resident R83's bed. NA-O removed gloves, wheeled Resident R83 out to the dining room, and washed hands at the nurses' station.

During interview on 7/29/24 at 5:45 p.m., NA-O stated they looked at the sign on residents' doors to know what kind of PPE to wear. NA-O verified Resident R83 had a urinary catheter and stated staff needed gown and gloves when completing care such as emptying the urinary catheter but wore gloves when transferring.

During interview on 7/29/24 at 6:12 p.m., NA-N stated residents who had a urinary catheter were on enhanced barrier precautions and needed gown and gloves when providing cares related to urinary catheters. NA-N verified Resident R83 was on enhanced barrier precautions and stated staff needed gloves to transfer Resident R83.

During interview on 8/1/24 at 9:17 a.m., LPN-H stated residents with urinary catheters were placed on enhanced barrier precautions and confirmed Resident R83 had a urinary catheter and was on enhanced barrier precautions. LPN-H stated gown and gloves were required to transfer Resident R83 and was important to follow proper PPE procedures for safety reasons, such as not spreading MRSA (methicillin-resistant Staphylococcus aureus; bacteria which is resistant to many antibiotics).

During interview on 8/1/24 at 9:40 a.m., LPN-G verified Resident R83 had a urinary catheter and was on enhanced barrier precautions which required gown and gloves for transfers. LPN-G stated it was important to wear gown and gloves when transferring residents with urinary catheters to prevent the spread of infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During interview on 8/1/24 at 1:03 p.m., the assistant director of nursing (ADON) stated residents with urinary catheters required enhanced barrier precautions, and staff were expected to wear gown and gloves when Level of Harm - Minimal harm or providing hands on cares which included transfers. potential for actual harm

During interview on 8/1/24 at 1:36 p.m., the director of nursing (DON) expected staff to follow the precaution Residents Affected - Many signs on residents' doors, and precautions were important to follow to prevent the spread of infection.

Facility policy Enhanced Barrier Precautions dated 3/24, defined EBP as the use of gown and gloves during high-contact resident care activities for residents known to be colonized or infected with a MDRO (multidrug-resistant organism) as well as those at increased risk for MDRO acquisition, such as residents with urinary catheters. The policy indicated high-contact resident care activities included transferring.

PPE:

Resident R54 quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R54 was cognitively intact. Resident R54 was independent with oral and toileting hygiene, putting on and off footwear and mobility, required set-up and/or clean-up assistance with eating, showering, upper body dressing, and personal hygiene, and supervision and/or touching assistance with lower body dressing. Resident R54's MDS identified diagnoses of schizophrenia (mental health condition which affects how people think, feel and behave), malnutrition, hypertension (high blood pressure; pressure in blood vessels is too high), peripheral vascular disease (narrowed blood vessels reduce blood flow to legs or arms), coronary artery disease (narrowing or blockage of heart's arteries).

Resident R54's care plan undated, identified enhanced respiratory isolation due to COVID-19.

Resident R54's physician's order dated 7/29/24, identified enhanced respiratory precautions due to positive COVID test on 7/24/24.

During observation on 7/29/24 at 6:09 p.m., Resident R54's door had a sign which read Enhanced Respiratory Precautions and instructed staff to wear gown, N95 respirator, eye protection, and gloves to enter room. NA-N removed their surgical mask, performed hand hygiene, and donned N95, gown, gloves, and no eye protection and entered Resident R54's room with a meal tray. At 6:10 p.m., NA-N exited Resident R54's room and doffed gown, N95, gloves, performed hand hygiene, and placed on clean surgical mask.

During interview on 7/29/24 at 6:12 p.m., NA-N verified Resident R54 was on precautions for COVID-19 and required gown, gloves, and N95 to enter room. NA-N did not think there was eye protection in the PPE cart located next to Resident R54's door. One face shield was observed in PPE cart.

During interview on 7/31/24 at 1:47 p.m., NA-P verified Resident R54 was on precautions for COVID-19 and required eye protection, gown, gloves, and N95 mask to enter room. NA-P stated Resident R54 was independent to eat and had an occasional cough which made the eye protection important to wear.

During interview on 8/1/24 at 9:40 a.m., LPN-G verified Resident R54 was on precautions for COVID-19, and gown, gloves, N95 mask and eye protection were required to enter room. LPN-G stated it was important to follow PPE procedures, even to give Resident R54 a room tray, to prevent transmission of COVID-19.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During interview on 8/1/24 at 1:36 p.m., the director of nursing (DON) expected staff to follow the precaution signs on residents' doors, and precautions were important to follow to prevent the spread of infection. Level of Harm - Minimal harm or potential for actual harm The facility policy Personal Protective Equipment dated 1/24, indicated the need for transmission-based precautions was a factor which determined the appropriate selection of PPE for a particular task. The policy Residents Affected - Many identified personal glasses were not a substitute for goggles. The policy directed the charge nurse to check isolation supply carts twice per shift.

49339

Resident R2's significant change MDS assessment, dated 6/26/24, indicated Resident R2 had intact cognition. Resident R2 was maximum to dependent on staff assistance for all activities of daily living (ADLs) except eating which she needed set up assistance. Resident R2's diagnoses included: dementia (memory loss that disrupts daily life), hemiplegia (paralysis/inability to move of one side of the body), epilepsy (disorder in which nerve cell activity

in the brain is disrupted causing seizures) and pain.

During observation on 7/31/24 at 11:55 a.m., Resident R2 was observed to have a single page document in a plastic page protector hung on the door that indicated: Respiratory Precaution Room. The sign had a person on it with PPE (proper protective equipment), it also included a stop sign on the sign with a picture of a hand along with the words: gown, N95, eye protection, one pair of gloves. At the bottom of the page, it indicated airborne infection isolation room: keep door closed if possible. To the left of the door was a three-drawer plastic bin to the left of the door which contained disposable gowns, N95 masks and face shields. On top of

the plastic bin was hand sanitizer, disposable gloves, and disposable masks.

During observation on 7/31/24 at 11:55 a.m., housekeeper (HSK)-D was observed with a surgical mask on pushing their cleaning cart to the entrance of Resident R2's. HSK-D was observed using hand sanitizer, grabbing a disposable gown from the bin, putting the gown on followed by a pair of disposable gloves. HSK-K then entered Resident R2's room. Upon exit of the room, HSK-D was observed to take off the gown and gloves and use hand-sanitizer but did not remove the surgical mask. During continual observation, HSK-D was observed to move their cart down the hallway to an adjacent room with a sign on the door, Enhanced Barrier Precautions.

During the same continual observation, HSK-D was observed to use hand sanitizer, put on gloves and then a gown to enter the room, while continuing to wear the same surgical mask worn in Resident R2's room.

During interview at 7/31/24 at 12:09 p.m., HSK-D verified that they just completed cleaning Resident R2's room. HSK-D verified they did not wear a N95 or a face shield. HSK-D stated, I can't breathe with those masks on. HSK-D stated, I changed my blue mask though, I carry them in my pocket. HSK-D verified PPE is to be worn to stop the spread of diseases. HSK-D verified that Resident R2 was on precautions for COVID.

During interview on 8/01/24 at 11:05 a.m., registered nurse (RN)-F verified Resident R2 had COVID. RN-F stated that any staff needs to have full attire on when they enter COVID rooms, or any rooms PPE is needed in. RN-F verified that all staff get training on proper PPE use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 33925 potential for actual harm Based on interview and document review, the facility failed to ensure recommended pneumococcal Residents Affected - Few immunizations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 2 of 5 residents (Resident R158, Resident R17) reviewed for immunizations.

Findings include:

A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2023, identified several tables with corresponding recommendations when to receive various versions (i.e., PPSV23, PCV13, PCV20) of the pneumococcal vaccine. The graph labeled, Adults 19-[AGE] years old with chronic health conditions ., identified persons who received only a PPSV23 had an option to either get a PCV15 or PCV20 a year after

the last PPSV23 dose. The conditions listed including alcoholism and cigarette smoking. Further, The graph labeled, Adults [at or older than] [AGE] years old, outlined persons with a complete series of pneumococcal vaccination (i.e., PCV13 at any age, PPSV23 at or above [AGE] years old) should have shared clinical decision-making between the resident and healthcare provider to determine if PCV20 was appropriate.

Resident R158's significant change Minimum Data Set (MDS), dated [DATE REDACTED], identified Resident R158 had intact cognition, demonstrated no delusional thinking, and had several medical conditions including chronic lung disease (i.e., asthma, COPD).

Resident R158's PointClickCare electronic medical record (EMR) immunization listing, printed 8/1/24, identified Resident R158 was [AGE] years old along with his respective immunization history. This identified Resident R158 received two doses of the PPSV23, with the last one being in 2010. The record lacked any other pneumococcal vaccinations being offered or received.

On 7/30/24 at 9:54 a.m., Resident R158 was interviewed and verified he was a current smoker. Resident R158 stated he admitted to the care center back in early 2024, and had not been asked about getting any of the other recommended pneumococcal vaccinations since he admitted adding, They never talked to me about it. Resident R158 stated he was open to more information on the vaccinations adding, I don't want to spread it to others.

Resident R158's medical record, including physician notes, was reviewed and lacked evidence any of the subsequent recommended pneumococcal vaccinations (i.e., PCV13 or PCV15/20) were discussed, offered or refused despite Resident R158 admitting to the care center months prior.

Resident R17's quarterly MDS, dated [DATE REDACTED], identified Resident R17 had intact cognition, demonstrated no delusional thinking, and had several medical conditions including heart failure and respiratory failure.

Resident R17's PointClickCare EMR immunization listing, printed 8/1/24, identified Resident R17 was [AGE] years old along with her respective immunization history. This identified Resident R17 had received both the PPSV23 and PCV13, with the last administration being recorded as 3/2019 (over five years prior). The record lacked any other pneumococcal vaccinations being offered or received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 On 7/31/24 at 1:45 p.m., Resident R17 was interviewed and recalled getting some immunizations years prior for pneumonia. Resident R17 stated they had not been asked about getting the newer, recommended PCV15/20 Level of Harm - Minimal harm or vaccination though adding, I have not. Resident R17 stated had it been offered, they would have accepted it due to potential for actual harm having poor breathing adding, I would take it yesterday.

Residents Affected - Few Resident R17's medical record, including physician notes, was reviewed and lacked evidence any of the subsequent recommended pneumococcal vaccinations (i.e., PCV15/20) were discussed, offered or refused despite Resident R17 having known cardiac and respiratory impairment.

On 8/1/24 at 1:03 p.m., the assistant director of nursing (ADON) and regional nurse consultant (RNC) were interviewed. ADON explained themselves, along with RNC, were helping to manage and oversee the facility' infection control program since the previous infection preventionist (IP) had abruptly resigned a few months prior. ADON verified they had reviewed Resident R158 and Resident R17's respective medical records, and explained the PointClickCare information was the most current, including with data pulled from the MIIC (Minnesota Immunization Information Connection). ADON verified neither Resident R158 or Resident R17 had their respective, eligible doses offered or provided prior to the survey to their knowledge and expressed they had been, so far, unable to locate any documentation to demonstrate otherwise but would provide it, if located. ADON explained the previous IP apparently had been offering the vaccinations but not giving them. RNC stated, in hindsight, a quality assurance (QA) project should have likely been started for immunizations but had not been. RNC and ADON both verified they were going to review a 'whole house' audit now and get the immunizations offered, as needed, moving forward adding, It's in the process. ADON stated it was important to ensure vaccinations were offered and, if accepted, provided to promote resident' health adding, They have diagnoses that put them at risk.

The facility' policy on pneumococcal vaccinations was requested, however, was not received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49034 potential for actual harm Based on observation, interview, and document review, the facility failed to implement an effective pest Residents Affected - Some control program to eliminate bed bugs from the building for 1 of 1 resident (Resident R9) with the potential to affect all 11 residents residing on the odd side of the seventh floor.

Findings include:

Resident R9's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R9 had no cognitive deficits and required moderate assistance with transferring, bathing, and toileting hygiene.

The pest control company report dated 7/31/24 at 2:15 p.m., indicated Resident R9's original room had been assessed by the pest control company, and a dead bed bug was noted.

During an interview on 7/29/24 at 2:09 p.m., Resident R9 stated she was moved from her original room to her current room last week because of a bed bug infestation. Resident R9 stated she was supposed to move back to her old room soon but was scared as she didn't believe that the bed bugs were gone.

During an interview and observation on 7/30/24 at 2:55 p.m., Resident R9 was found still residing in the new room she had been given the previous week. Resident R9 stated that the staff had moved her back to her old room yesterday. Resident R9 stated staff had assisted her to bed, given her one of her bags, and then left the room. Resident R9 stated she soon noticed these blackish-brown bugs everywhere on her bed and when she would touch them, blood would go everywhere. Resident R9 stated the bed bugs kept climbing onto her body, leaving her covered in blood. Resident R9 stated she was screaming for help and had her call light on, but she could not get out of bed by herself.

During an interview on 7/30/24 at 3:02 p.m., registered nurse (RN)-K, the nurse manager for the unit, stated that Resident R9's room had been found to have bed bugs last week after Resident R9 had visitors. RN-K stated she was unsure how the bed bugs were managed as this was completed by the director of engineering (DOE). RN-K stated that Resident R9 was moved out of the bed bug-infected room to a new one on 7/23/24 and moved back on 7/29/24. RN-K stated she was unsure who assessed the room before bringing Resident R9 back.

During an interview and observation on 7/30/24 at 3:33 p.m., Resident R9's original room was observed with a bed on

the left-hand side of the room pressed up against the wall. The bed sheets were observed with sporadic red/rust-colored stains and a small black-brown bug crawling across the bottom sheet. The bed frame was observed with a black/red grime-looking substance. The room was observed to have multiple open boxes with items overflowing and multiple personal bags on the floor of the room. The blinds were observed covered by a fabric topper. Clothing was observed overflowing out of the dresser. A multicolored personal blanket was observed on the floor. RN-K confirmed that the bug crawling on the bottom sheet was a bed bug.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 During an interview on 7/31/24 at 9:09 a.m., the DOE stated Resident R9 had a repeat issue of bed bugs that had been treated last week with a heating system by MS-A. The DOE stated Resident R9 had a lot of items in her room Level of Harm - Minimal harm or that were making it hard to get rid of all the bed bugs, but they had so far not done anything to address this potential for actual harm issue. The DOE was asked to provide documentation showing any audits of other resident rooms on the unit and any documentation of treatment used to treat the bed bug infestation in Resident R9's original room. Residents Affected - Some

During an interview on 7/31/24 at 1:03 p.m., maintenance staff (MS)-A stated he had dealt with the bed bug infestation in Resident R9's room. MS-A stated he had used an electric heating device that was manufactured to kill bed bugs and reached 130 degrees for three days. MS-A stated the facility does not normally call a pest control service until after the heat treatment has not worked. MS-A stated it was up to housekeeping to deep clean Resident R9's room, launder any loose linens, and check to ensure there were no more bed bugs before allowing the resident to re-enter the room. MS-A stated he had noticed a lot of stuff in Resident R9's room and the room looked like it needed to be cleaned to make the bed bug treatment more effective. MS-A stated he had noted the bags and boxes in Resident R9's room but did not think anyone had dealt with these items. MS-A stated he had checked one additional room for the spread of bed bugs, but this room did not share a wall and was separated by a hallway, a sitting area, and an elevator from Resident R9's original room. MS-A was asked to confirm that he had not inspected the room that shared a wall with Resident R9's room and he stated yes, he had only inspected the room that did not share a wall and was separated by a hallway, sitting area, and an elevator from Resident R9's original room.

During an interview on 7/31/24 at 1:34 p.m., the district manager for environmental services (DMES) stated

he would have expected edge to edge cleaning, including the bed frame, all linens, all personal laundry, and curtains. The DMES agreed if grime and build-up were found on the bed frame he questioned if edge-to-edge had taken place. The DMES stated he did not expect housekeeping staff to bag up or clean personal items such as bags or boxes that were left in the resident's room. The DMES stated his staff was not responsible for assessing if bed bugs were still present before Resident R9 moved back to her room.

During an interview on 7/31/24 at 1:29 p.m., the associate administrator (AA) stated he began assisting with Resident R9's bed bug issues this week but did not have knowledge of how it was handled the previous week. The AA stated he had been involved in moving Resident R9 back to her original room on 7/29/24. The AA stated it should have been maintenance who assessed for bed bugs before Resident R9 moved back to her room. The AA stated he had identified bed bugs on her bed after she had called facility staff into her room on 7/29/24. The AA stated that RN-K and he had decided Resident R9 needed to be again removed from that room and they now had a pest control company on their way to assess the room before Resident R9 returned.

During an interview on 7/31/24 at 1:40 p.m., the DOE stated they had not previously had a pest control company out to inspect and give recommendations for the current bed bug infestation but one was here now.

The DOE stated he had started three months ago, and MS-A was helping to train him. The DOE stated that MS-A was the one who would know about how the bed bug infestation was managed. The DOE stated he did not have documentation showing any audits of other resident rooms on the unit or any documentation of

the treatment used to manage the bed bug infestation in Resident R9's original room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 70 245055 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245055 B. Wing 08/01/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lakehouse Healthcare & Rehabilitation Center 3737 Bryant Avenue South Minneapolis, MN 55409

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 During an interview and observation on 7/31/24 at 1:44 p.m. in Resident R9's original room, the outside pest control agent (PC)-A stated he had employee training on bed bug management that might be useful for the Level of Harm - Minimal harm or employees at the facility. PC-A stated it was important that all items that they could be, be placed in sealed potential for actual harm bags and motioned at the bags and boxes on the floor. PC-A then stated it was important loose linens were also laundered and not left in the infested room and motioned to the loose linens on the floor and piling out of Residents Affected - Some the resident closet. PC-A stated it was also important that the facility inspected the rooms near Resident R9's room such as the room sharing a wall and the room below Resident R9's room to ensure the bed bugs had not spread.

The facility Bed Bug Protocol dated 3/14/24, indicated after staff were made aware of potential bed bugs, staff would attempt to capture the bug with scotch tape and then call maintenance to confirm the bug was a bed bug. Maintenance staff would then notify the supervisor of the presence of bed bugs. Staff would then bathe the resident and move them to a different room leaving all personal belongings behind. Maintenance staff would complete the heat treatment and then notify housekeeping so they could deep clean the room. Once the deep clean was completed, housekeeping would notify the administrator and the director of nursing that it was safe to move the resident back into their room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 70 245055