Lakehouse Healthcare & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lakehouse Healthcare & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Sep 3, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF880Sep 30, 2021

  Based on observation, interview, and record review, the facility failed to place a newly admitted resident who was not vaccinated for COVID-19 into quarantine and failed to ensure personal protective equipment (PPE) was used when direct care was provided for 1 of 4 residents (R263) who required transmission based precautions (TBP). This deficient practice resulted in an immediate jeopardy (IJ) when R236 was to be on TBP and staff did not follow the practice. In addition to the resident in immediate jeopardy, the facility failed to ensure staff consistently wore face masks covering the nose and mouth and eye protection to aide in preventing the spread of COVID-19 for 4 of 22 staff (NA-K, NA-J, NA-E and RN-L) observed for source control measures. […]

• Immediate jeopardy, isolatedF760Mar 26, 2021

  Based on interview and document review, the facility failed to ensure medications were administered per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure resulted in an immediate jeopardy (IJ) for R3 when she received another resident's (R4's) medications and had developed [CONDITION(S)] (low blood pressure) and [CONDITION(S)] (slow heart rate), and required treatment in the ambulance, emergency department and hospital to stabilize. The facility had implemented immediate corrective action, therefore the deficient practice is being issued at past noncompliance. The immediate jeopardy began on 3/19/21, when R3 received her medications along with R4's medications, required emergency medications and hospitalization , and was identified on 3/25/21. […]

• Actual harm, isolatedF699Nov 10, 2022

  Based on interview and document review, the facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for 1 of 1 resident (R1) reviewed who had post-traumatic stress disorder ([CONDITION(S)]). R1 suffered harm when R1 expressed they were fearful after being cared for by nursing assistant (NA)-A and NA-A was allowed to provide care again creating re-traumatization for R1 resulting in fear of not being able to get help, fear of being targeted by NA-A, increased panic, and crying. […]

• No harm, potential for more than minimal, widespreadF921Aug 15, 2025

  During 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.Findings include: Walls:During observation on 8/12/25 at 8:56 a.m., on the sixth floor, wall outside R184's room had gouges and underlying wallboard exposed. Partial repair was done but not painted to match the wall. The wall across from aviary was tan in color with nine sections or areas of wall covering four feet by two feet with repairs but no matching paint.During observation on 8/12/25 at 9:26 a.m., in second floor dining room, two residents were seated at a dining room table. […]