Lakehouse Healthcare & Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure services were provided in accordance with professional standards of nursing practice for 1 of 1 residents (R1) when staff inserted a Foley catheter into a gastrostomy stoma without validated competency for the procedure, without completing appropriate clinical assessment to determine safety prior to insertion, and using improper technique, including inflation of the catheter balloon within the stoma. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ordered hydration interventions were implemented for 1 of 3 residents (R1) reviewed for enteral tubes.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBPs) were followed for 1 of 1 resident (R1) when medication was administered via enteral tube. In addition, the facility failed to ensure proper infection control practices related to syringes and containers used for flushing enteral tubes for 2 of 3 residents (R1, R4) reviewed for enteral tubes.

Inspectors wroteBased on interviews and document review, the facility failed to reassess a resident after a change in condition for 1 of 4 residents (R1) reviewed for quality of care. R1 was assessed after a change in condition about 12:00 a.m., slept through the night, and was not reassessed until a visiting family member requested R1 transfer to the hospital.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure individualized turning and repositioning programs were based on a completed comprehensive assessment in order to prevent or mitigate the risk of pressure ulcer development and/or deterioration for 1 of 3 resident (R2) reviewed for pressure ulcers.

Inspectors wroteBased on interview and document review, the facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST) to provide cardiopulmonary resuscitation (CPR) for 1 of 3 residents (R1), who wished to have CPR in the event of cardiopulmonary arrest (absence of pulse and respirations). This deficient practice resulted in an immediate jeopardy (IJ) when R1 was found absent of pulse and respirations, no CPR was initiated, and R1 passed away. The facility implemented corrective action prior to survey; therefore, the deficient practice was issued at past non-compliance. The IJ began on [DATE], when R1 was found unresponsive with an absence of pulse and respirations, CPR was not initiated, and R1 passed away. The facility administrator and director of nursing (DON) were notified of the IJ on [DATE] at 2:50 p.m. which was identified at the scope and severity of and isolated IJ. [...]

Inspectors wroteDuring observation, interview and record review the facility failed to ensure facility was kept sanitary and maintained in good repair on all six resident units which had the potential to affect all 225 residents, staff, and visitors of the facility.

Inspectors wroteDuring observation, interview and record review, the facility failed to ensure an effective pest control program was in place to eliminate fruit flies and black flies for 5 residents (R6, R69, R76, R88, and R223) who verbalized concern about flies. This had the potential to affect all 225 residents of the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure all staff knocked on individual resident bedroom doors, introduced themselves, and waited for permission to enter room prior to entry for 9 of 9 residents (R69, R77, R106, R119, R146, R167, R178, R196, R252) reviewed for dignity.

Inspectors wroteDuring observation and interview, the facility failed to implement interventions to ensure residents' personal care information was kept secured and out of public view when stored on 3 of 7 facility units with mobile medication/treatment carts. This had the potential to affect 9 residents on the 2nd floor, 8 residents on the 5th floor, and 11 residents on the 7th floor whose personal information was listed on unattended care sheets.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded with the potential for inaccurate federal reimbursement and resident care planning for 1 of 5 residents (R218) reviewed for MDS accuracy.

Inspectors wroteBased on interview and document review, the facility failed to ensure a level I Pre-admission Screening (PAS) and, if needed, a Level II Pre-admission Screening and Resident Review (PASARR) was completed to screen for mental health needs for 3 of 4 residents (R40, R9, R6) reviewed for PAS.

Inspectors wroteBased on observation, interview, and document review, the facility failed to develop a comprehensive care plan to ensure correct application of a lower extremity brace for 1 of 3 residents (R178) reviewed for the use of a lower extremity brace.

Inspectors wroteBased on observation, interview and record review, the facility failed to update the plan of care 1 of 1 resident (R154) observed for position and mobility. In addition, the facility failed to revise and update a comprehensive care plan for 1 of 1 resident (R222) who had a history of resident-to-resident incidents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., nail care) was completed and provided to reduce the risk of complication (i.e., infection, skin scratches) for 1 of 1 residents (R87) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a therapeutic recreation assessment was addressed in the electronic medical record (EMR) and care planned to ensure a resident was offered appropriate activities for engagement while at the care facility for 1 of 2 residents (R76) reviewed for activities.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement interventions to ensure hearing aids were routinely applied or offered daily for 1 of 1 resident (R20) reviewed who had severe hearing loss.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents had received ordered meals to increase calorie intake and weight per provider orders for 1 of 5 resident (R214) reviewed for nutrition and weight loss.

Inspectors wroteBased on observation, interview and document review the facility failed to follow care planned interventions to prevent re-traumatization for 1 of 1 resident (R6) reviewed for trauma informed care who was diagnosed with post-traumatic stress disorder and had identified triggers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure medication errors were prevented for 2 of 2 residents (R138, R30) observed during medication administration. This resulted in a medication error rate of 7.14% (percent) with two errors out of 28 opportunities.

Inspectors wroteBased on interview and document review, the facility failed to ensure identified dental concerns (i.e., need for dentures) were acted upon and, if needed, referred to the appropriate resource in a timely manner for 1 of 2 residents (R87) reviewed who voiced dental concerns. R87's annual Minimum Data Set (MDS) assessment, dated 6/14/25, identified R87 had moderately impaired cognition. Further, the MDS identified a section labeled, L0200, along with spaces to record no natural teeth or tooth fragments(s) (edentulous). This was answered, None of the above were present. Further, R87's Clinical Census report, printed 8/14/25, identified R87's current payor source listed as, Medicaid MN.During an interview on 8/11/25 at 1:52 p.m., R87 stated, I don't have any dentures, and I want to wear dentures. [...]

Inspectors wroteBased on interview, and document review the facility failed to ensure 2 of 2 resident (R9, R105) received ordered therapeutic diet to maintain or improve their nutritional status.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure personal protective equipment (PPE) was used for 2 of 7 residents (R3, R12) when providing care for residents in enhanced barrier precautions (EBP).

Inspectors wroteBased on interview and document review, the facility failed to ensure the physician was notified of a rapid weight gain for resident with diagnosis of Congestive Heart Failure (CHF)(one warning sign of CHF is rapid weight gain which could indicate fluid buildup in the body) and failed to contact physician to receive clarification on orders for 1 of 3 resident (R1) who was admitted to the facility without weight and notification parameters related to CHF diagnosis. Findings Include:R1's admission Minimum Data Set (MDS) assessment dated [DATE] identified an admission of 6/27/25, intact cognition and a medical diagnosis of CHF.R1's physician order dated 6/27/25 identified R1's indicated to weigh R1 for 1 day, then weekly for 4 weeks then monthly. R1's hospital discharge weight was 188 pounds (lbs.) on 6/27/25. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan which provided effective and person-centered care direction to meet professional standards of care for 1 of 3 residents (R1) who admitted to the facility with a diagnosis of congested heart failure (CHF). Additionally, the facility failed to implement a baseline care plan within 48 hours of admission for 1 of 3 (R1) reviewed.

Inspectors wroteBased on interview and document review the facility failed to provide comprehensive nursing care to meet acceptable standards of clinical practice for 1 of 3 resident (R1) who was admitted to the facility with a diagnosis of congestive heart failure (CHF) and no clarification for daily weight and notification parameters were requested to ensure adequate medical care. This resulted in a 13-pound (lbs.) weight gain in ten days.

Inspectors wroteBased on interview and document review, the facility failed to timely change end of life wishes in the medical record to ensure the advanced directive (a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was followed for 1 of 3 resident's (R1) reviewed for advanced directives.

Inspectors wroteBased on interview and document review the facility failed to accurately document new or changed medication orders for 2 out of 3 residents (R1, R2) reviewed for medical records. R1's seizure medication was changed from tablet form to oral solution, but the tablet form was not discontinued, which resulted in R1 being administered two doses. In addition, R2 did not receive three medications when he returned from a hospitalization resulting in missed doses of medication required for his liver disease and diabetes.

Inspectors wroteBased on interview and record review the facility failed to provide ensure that 1 of 3 residents (R1) received treatment in accordance with professional standards of practice. R1 was discharged from the hospital with identified sores on his lower legs and the facility did not provide any cares for three days to his legs.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure an assessment for self-administration of medications (SAM) was completed for 1 of 3 (R2) residents reviewed for self-administration of medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure laundered linens were 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 (R134, R83, R54 and 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.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide a dignified dining experience for 6 of 6 residents (R18, R15, R53, R142, R208, R386 ) who were seated at the dining room table with other residents who were served meals without being served meals themselves resulting in them waiting for their meals while tablemates dined and for 1 of 1 resident (R386) who was brought to the dining room ungroomed in a hospital gown. In addition, the facility failed to ensure dignity was maintained for 1 of 1 (R164) observed for lack of clothing in bed.

Inspectors wroteBased on observation and interview the facility failed to ensure vinyl floors were clean and in good condition for 2 of 5 resident dining rooms (2nd floor memory care unit and 3rd floor) and 1 of 1 (R134) resident rooms reviewed for environment.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal care and hygiene (i.e., bathing, nail care, hair combing) was offered and/or completed for 5 of 6 residents (R39, R184, R134, R179, R383) reviewed for activities of daily living (ADLs) and who required staff assistance to complete such care.

Inspectors wroteBased on observation and interview, the facility failed to ensure mediations were kept locked or under direct observation of authorized staff in areas where residents, staff and guests could access medications on 3 of 5 resident floors.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food was delivered and served in a timely manner to preserve desired temperatures of food for 3 of 3 residents (R158, R39 and R146) reviewed for dining. This had the potential to affect all residents of facility that received meal trays.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement an effective pest control program to eliminate bed bugs from the building for 1 of 1 resident (R9) with the potential to affect all 11 residents residing on the odd side of the seventh floor.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment was completed to allow a resident to safely self-administer medications for 1 of 1 (R184) residents reviewed for self-administration of medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure a written notice of transfer was sent to the office of the Ombudsman for long term care for 2 of 4 residents (R60, R27) reviewed for hospitalization.

Inspectors wroteBased on interview and document review, the facility failed to ensure a level I Pre-admission Screening and Resident Review (PASARR) was completed prior to admission for 1 of 1 residents (R63).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure timeliness of person-centered care conferences for 3 of 5 residents (R9, R103, R134) reviewed for care conferences. R9 R9's quarterly Minimum Data Set (MDS) dated [DATE], indicated R9 was admitted on [DATE], and had no cognitive deficits. A review of R9's medical record indicated R9's last care conference was on 2/1/24 and did not demonstrate that a care conference occurred after 2/1/24 or a reason this would not have been practicable for R9. During an interview on 7/29/24 at 2:21 p.m., R9 stated she didn't remember having a care conference with facility staff since the beginning of the year and wished she had been more updated and involved in her care. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to develop proactive interventions to promote appropriate bowel function and decrease the risk for discomfort or further complications for 1 of 1 resident (R9) reviewed for bowel management. In addition, the facility failed to transcribe prescription orders for 1 of 1 (R78) reviewed for non-pressure related skin breakdown.

Inspectors wroteBased on interview and document review, the facility failed to ensure orders for an audiology referral were acted upon in a timely manner to promote better hearing and quality of life for 1 of 2 residents (R39) reviewed who expressed difficulty with hearing.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1 of 1 residents (R195) with repeated falls had implemented interventions to promote safety and reduce the risk of falls.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively reassess to determine what, if any, additional interventions with pain management were needed for 1 of 3 residents (R39); and failed to assessed and develop non-pharmacological interventions to promote comfort for 2 of 3 residents (R69, R131) reviewed for pain management.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure direct-care nursing staff were appropriately trained and competent in the use of a external ventilator machine used for 1 of 1 resident (R17) who used the machine on overnight hours and had significant respiratory disease/impairment.

Inspectors wroteBased on interview and document review, the facility failed to ensure consulting pharmacist recommendations were fully addressed or acted upon for 1 of 5 residents (R164) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review the facility failed to have an indication for use and resident specific target behaviors while taking antipsychotic medications for 1 of 5 residents (R383) reviewed for unnecessary medications. In addition, the facility failed to ensure as-needed antipsychotic medications were limited to 14 days of use or given a specific duration of therapy to ensure necessity and reduce the risk of complication for 1 of 5 residents (R164) reviewed for unnecessary medication use. In addition, the facility failed to ensure an appropriate indication was given for continued antipsychotic medication for 1 of 5 residents (R164) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a medication administration error rate of less than 5 percent (%). Twenty medication administration errors occurred out of 31 opportunities resulting in a 64.52% medication error rate for 2 of 4 residents (R184 and R376).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure routine dental services were provided or offered to promote oral hygiene and reduce the risk of complication (i.e., chewing issues, cavities) for 4 of 4 residents (R39, R50, R134, R179) reviewed for dental services.

Inspectors wroteBased 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 (R39) reviewed who expressed their preferences of meal items were not honored.

Inspectors wroteBased on interview and document review, the facility failed to ensure recommended pneumococcal 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 (R158, R17) reviewed for immunizations.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide interpretive services for 1 of 3 residents (R1) to ensure the resident was fully informed in his primary language the risks and benefits, treatment plan and alternative options to treat diabetes when he ate snacks and refused insulin therapy.

Inspectors wroteBased on observations interviews and record review the facility failed to use an interpreter during the admission process when the resident's bill of rights was presented for 1 of 3 residents (R1). Staff identified a resident's code status was a factor to let a resident exercise their right to refuse care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to develop a comprehensive care plan to understand cultural practice, medical history, and diabetic goals for 1-3 residents (R1) when he refused to follow a diabetic diet and develop strategies to encourage him to take insulin for elevated blood sugar levels.

Inspectors wroteBased on interview and document review, the facility failed to notify the family of one of six residents (R4) reviewed when R4 had an unwitnessed fall, an unrelated injury, and a change in cognition requiring hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's right to reasonable needs and preferences for 1 of 3 (R1) residents reviewed. R1's remote control for her bed was taken away leaving her dependent on staff for bed mobility. This practice limited R1 in achieving independent functioning and impaired her dignity. R1 was her own decision maker.

Inspectors wroteBased on observation, interview, and document review, the facility failed to document in the resident record the reinserting of an indwelling catheter for 1 of 3 residents (R3) reviewed for urinary incontinence. R3's admission Minimum Data Set (MDS) dated [DATE] indicated R3 had mildly impaired cognition, and an indwelling urinary catheter (a tube inserted into the bladder to drain urine). R3's Diagnoses List indicated diagnoses included left hip fracture, diabetes mellitus type 2, chronic obstructive pulmonary disease (COPD), anemia (low iron), and dysphagia (trouble swallowing). [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to transfer 1 of 3 residents (R1) safely when staff were observed using a two person transfer with gait belt and the resident was assessed and care planned for the use of a mechanical lift transfer.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure therapeutic diet per physicians orders were followed for 1 of 3 residents (R1) reviewed for therapeutic diets.

Inspectors wroteBased on observation, interview, document review, and review of facility policy, the facility failed to have an effective system in place to prevent the spread of infection. The facility failed to have a complete water management program that was consistent with the current ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Guideline, which specifically called for documentation of design and maintenance procedures to protect from the potential exposure of Legionnaire's disease (a serious pneumonia infection) within a healthcare facility. This failure created a potential for 193 of 206 facility residents, who were over the age of 65, to be infected by Legionella. In addition, the facility failed to ensure 2 nursing assistants (NA) appropriately sanitized their hands by using soap during hand washing, prior to serving drinks to residents. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents were free from potential hazards to ensure their safety for 1 of 1 resident (R11) who was found by facility staff to have a smoking and a sparking electrical power strip in her room. The power strip was not removed after the incident and was still in use at the time of the survey and discovered to have black soot marks on 1 outlet on that power strip. 2 other power strips were observed in the boiler room and fitness room by the Fire Marshall and has the potential to affect all other residents in R11's wing, those residents and staff located near the boiler room, and who used the fitness room. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to serve food that was palatable and at appropriate temperatures to four of 38 residents residing on the 6th and 7th floors (R18, R103, R121, and R123). Foods that were to be served hot were not served at temperatures that met residents' tastes preferences.

Inspectors wroteBased on observation, interview, document review, and review of the Food and Drug Administration (FDA) Code, the facility failed to assure food was stored, prepared, and served in a sanitary manner. Foods were not dated and /or labeled, covered, and disposed of after expiration. Equipment/surfaces were not clean or were not in good repair. These failures had the potential to increase the risk of food borne illnesses and affect 199 of 206 residents living at the facility who received food from dietary services.

Inspectors wroteBased on interview, document review, and review of Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to revise their pneumococcal vaccine policy to reflect current pneumococcal vaccination guidelines. This failure increased the risk for residents to not be vaccinated per current guidelines and contract pneumonia.

Inspectors wroteBased on interview and document review, the facility failed to honor a resident choice for a private room despite evidence that a private room would promote mental wellbeing for 1 of 1 resident (R191) reviewed for choices.

Inspectors wroteBased on interview, record review, and document review, the facility failed to notify the medical provider of a significant change in condition for one resident (R-190) of five residents who were reviewed for unnecessary medications. Specifically, the facility failed to notify the medical provider when the resident had an increase in abnormal involuntary movements (AIMS) while taking two antipsychotic medications.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure there were physician orders upon admission for all necessary care for one resident (R-565) of 35 sampled residents. The facility failed to ensure that there were PICC (Peripherally inserted central catheter) line dressing orders prior to changing R565's PICC line dressing.

Inspectors wroteBased on interview, observation and document review, the facility failed to provide routine baths and incontinence care to 1 of 1 resident (R92) reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide weekly baths to 1 of 1 resident (R11) reviewed for activities of daily living (ADL).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure individualized activities were provided for 3 of 3 residents (R10, R59 and R 135) reviewed for activities.

Inspectors wroteBased on observation, interview and document review, the facility failed to timely turn and reposition, and adjust wound treatment and follow physicians orders for a wound consult for 1 of 1 resident (R92) who had a facility acquired Stage II pressure injury (opening in skin caused by pressure that is not in the tissues). R92's significant change Minimum Data Set (MDS), dated [DATE], indicted R92 was cognitively intact and required extensive assistance with transfers, bed mobility, dressing, toileting, and personal hygiene. The MDS further indicated R92 was at risk for pressure injuries. R92's Medical Diagnosis list indicated R92 had a primary medical diagnosis of metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). R92'S care plan, dated 4/25/23, indicated R92 previously had a Stage II pressure injury to her right buttocks. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a resident with a limited range of motion with a care planned nursing restorative program and splints for 2 of 2 resident (R49 and R141) reviewed for range of motion.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a feeding tube and feeding tube supplies were labeled according to professional standards to avoid the possibility of feeding tube complications and or related infections for 3 of 3 residents (R10, R59 and R135).

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement immediate interventions for 1 of 1 resident with repeated suicidal ideation and depression, provide 1:1 supervision until it was determined she was no longer a threat to herself, and perform an immediate safety check of the resident and her surroundings to ensure her safety and mental well-being.

Inspectors wroteBased on interview, document review and review of the Food and Drug Administration (FDA) warnings (www.fda.gov), the facility failed to ensure one resident (R-190) of five residents reviewed for unnecessary medications had adequate indications for the continued use of two different antipsychotic (Seroquel and Zyprexa) medications. In addition, the facility failed to ensure action was taken in response to possible adverse drug reactions when the resident had an increase in symptoms of abnormal involuntary movements (AIMS) related to taking antipsychotics.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure that food preferences were honored for one resident (R-21) of 35 sampled residents. The resident's request and physician orders for a vegetarian diet were not honored.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure 2 of 2 resident (R52, R143) received ordered, therapeutic diets to maintain or improve their nutritional status.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a sanitary and homelike environment for 3 of 3 residents (R10, R59, R135) whose tube feeding poles and equipment had dried tube feeding residue on them.