Lakehouse Healthcare & Rehabilitation Center
3737 Bryant Avenue South, Minneapolis, MN 55409
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Follow this homeLakehouse Healthcare & Rehabilitation Center is a nursing home in Minneapolis, Minnesota. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating1 of 5
- Last standard health inspectionAugust 15, 2025 (1 year ago)
- Health citations since June 29, 202380 (Minnesota average 23)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Health inspection on April 30, 2026
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on June 2, 2026.
CMS has cited this home for F0658 2 times since 2025.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS lists it as corrected on June 2, 2026.
CMS has cited this home for F0693 2 times since 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 2, 2026.
CMS has cited this home for F0880 4 times since 2023.
Health inspection on March 10, 2026
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 15, 2026.
CMS has cited this home for F0684 4 times since 2024.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Health inspection on November 19, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on January 6, 2026.
CMS has cited this home for F0686 2 times since 2023.
Health inspection on September 3, 2025
1 citationCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
74 of 337 Minnesota homes (22%) got a citation at the immediate jeopardy level in 2025.
Show the 1 citation
Citation F0678. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
CMS lists it as corrected on August 29, 2025.
Health inspection on August 15, 2025
17 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 17 citations
Citation F0921. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for F0921 2 times since 2023.
Citation F0925. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for F0925 2 times since 2024.
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for F0550 2 times since 2024.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on October 2, 2025.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on October 2, 2025.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for F0645 2 times since 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for F0656 2 times since 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for F0657 2 times since 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for F0677 3 times since 2023.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for F0679 2 times since 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on October 2, 2025.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on October 2, 2025.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on October 2, 2025.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for F0759 2 times since 2024.
Citation F0791. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain dental services for each resident.
CMS lists it as corrected on October 2, 2025.
Citation F0808. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for F0808 3 times since 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 2, 2025.
Fire safety inspection on August 15, 2025
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for K0353 3 times since 2023.
Citation K0362. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on October 2, 2025.
Citation K0363. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for K0363 2 times since 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for K0712 2 times since 2024.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for K0920 3 times since 2023.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for K0923 2 times since 2024.
Citation K0930. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper storage of liquid oxygen.
CMS lists it as corrected on October 2, 2025.
CMS has cited this home for K0930 2 times since 2024.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Health inspection on July 18, 2025
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on September 3, 2025.
CMS has cited this home for F0580 3 times since 2023.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on September 3, 2025.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on September 3, 2025.
Health inspection on June 13, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS lists it as corrected on July 15, 2025.
CMS has cited this home for F0578 2 times since 2024.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on January 2, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on February 5, 2025.
Health inspection on December 23, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on January 14, 2025.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Health inspection on October 14, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on November 5, 2024.
CMS has cited this home for F0554 2 times since 2024.
Health inspection on August 1, 2024
23 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 23 citations
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 17, 2024.
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on September 17, 2024.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
CMS lists it as corrected on September 17, 2024.
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on September 17, 2024.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on September 17, 2024.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on September 17, 2024.
CMS has cited this home for F0804 2 times since 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 17, 2024.
CMS has cited this home for F0812 2 times since 2023.
Citation F0925. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on September 17, 2024.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on September 17, 2024.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on September 17, 2024.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on September 17, 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on September 17, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on September 17, 2024.
Citation F0685. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on September 17, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 17, 2024.
CMS has cited this home for F0689 3 times since 2023.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on September 17, 2024.
Citation F0726. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
CMS lists it as corrected on September 17, 2024.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on September 17, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS lists it as corrected on September 17, 2024.
CMS has cited this home for F0758 2 times since 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on September 17, 2024.
Citation F0790. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide routine and 24-hour emergency dental care for each resident.
CMS lists it as corrected on September 17, 2024.
Citation F0807. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
CMS lists it as corrected on September 17, 2024.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on September 17, 2024.
CMS has cited this home for F0883 2 times since 2023.
Fire safety inspection on August 1, 2024
21 citationsCMS lists this as a standard inspection.
Show the 21 citations
Citation K0355. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on September 17, 2024.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on September 17, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on September 17, 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on September 17, 2024.
CMS has cited this home for K0918 2 times since 2023.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on September 17, 2024.
Citation K0293. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on September 17, 2024.
CMS has cited this home for K0293 2 times since 2023.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on September 17, 2024.
CMS has cited this home for K0324 2 times since 2023.
Citation K0351. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install an approved automatic sprinkler system.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 17, 2024.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on September 17, 2024.
Citation K0930. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper storage of liquid oxygen.
CMS lists it as corrected on September 17, 2024.
Citation K0225. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on September 17, 2024.
CMS has cited this home for K0225 2 times since 2023.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on September 17, 2024.
Citation K0541. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on September 17, 2024.
CMS has cited this home for K0541 2 times since 2023.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on September 17, 2024.
Citation E0037. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Establish staff and initial training requirements.
CMS lists it as corrected on September 17, 2024.
Citation E0039. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on September 17, 2024.
Citation K0291. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on September 17, 2024.
CMS has cited this home for K0291 2 times since 2023.
Citation K0346. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
CMS lists it as corrected on September 17, 2024.
Citation K0354. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on September 17, 2024.
Citation K0741. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on September 17, 2024.
CMS has cited this home for K0741 2 times since 2023.
CMS update of July 31, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of June 26, 2024
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
Health inspection on June 10, 2024
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on July 16, 2024.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
CMS lists it as corrected on July 16, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 16, 2024.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Health inspection on April 24, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on May 15, 2024.
Health inspection on March 8, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on March 29, 2024.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Health inspection on January 11, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on February 9, 2024.
Health inspection on December 28, 2023
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on February 6, 2024.
Citation F0808. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
CMS lists it as corrected on February 6, 2024.
Health inspection on June 29, 2023
19 citationsCMS lists this as a standard inspection.
Show the 19 citations
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 1, 2023.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 1, 2023.
Citation F0804. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on September 1, 2023.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 1, 2023.
Citation F0883. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on September 1, 2023.
Citation F0561. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on September 1, 2023.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on September 1, 2023.
Citation F0635. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
CMS lists it as corrected on September 1, 2023.
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on September 1, 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on September 1, 2023.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on September 1, 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on September 1, 2023.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS lists it as corrected on September 1, 2023.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS lists it as corrected on September 1, 2023.
Citation F0740. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS lists it as corrected on September 1, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS lists it as corrected on September 1, 2023.
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on September 1, 2023.
Citation F0808. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
CMS lists it as corrected on September 1, 2023.
Citation F0921. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on September 1, 2023.
Fire safety inspection on June 29, 2023
19 citationsCMS lists this as a standard inspection.
Show the 19 citations
Citation E0041. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on September 1, 2023.
Citation K0225. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on September 1, 2023.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on September 1, 2023.
Citation K0901. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
CMS lists it as corrected on September 1, 2023.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on September 1, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on September 1, 2023.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on September 1, 2023.
Citation K0353. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 1, 2023.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on September 1, 2023.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on September 1, 2023.
Citation K0522. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have an externally vented heating system.
CMS lists it as corrected on September 1, 2023.
Citation K0741. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on September 1, 2023.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on September 1, 2023.
Citation K0291. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on September 1, 2023.
Citation K0293. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on September 1, 2023.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on July 12, 2023.
Citation K0541. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on June 28, 2023.
Citation E0004. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on September 1, 2023.
Citation K0345. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on September 1, 2023.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (612) 827-5931
- Last standard health inspection
- August 15, 2025 (1 year ago)
- Certified beds
- 277
- Residents per day, on average
- 235.5
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Lake Harriet Operator LLC
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
More health citations than the Minnesota average (80 vs 23).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- LAKE HARRIET OPERATOR HOLDINGS LLC5% or greater direct ownership interest · 100% · since 05/01/2023
- CCP MN HOLDINGS, LLC5% or greater indirect ownership interest · no percentage provided · since 05/01/2023
- GLEN HOLDCO LLC5% or greater indirect ownership interest · no percentage provided · since 05/01/2023
- HARMONY HOLDINGS 2005, LLC5% or greater indirect ownership interest · no percentage provided · since 05/01/2023
- HIGHVIEW HOLDCO LLC5% or greater indirect ownership interest · no percentage provided · since 05/01/2023
Show 9 more
- JK 2022 FAMILY TRUST5% or greater indirect ownership interest · no percentage provided · since 05/01/2023
- LIGHTHOUSE HOLDINGS 2016, LLC5% or greater indirect ownership interest · no percentage provided · since 05/01/2023
- MIMI HOLDCO LLC5% or greater indirect ownership interest · no percentage provided · since 05/01/2023
- MN HOLDINGS 101 LLC5% or greater indirect ownership interest · no percentage provided · since 05/01/2023
- MN V ASSOCIATES LLC5% or greater indirect ownership interest · no percentage provided · since 05/01/2023
- SSHG FAMILY GRANTOR TRUST5% or greater indirect ownership interest · no percentage provided · since 01/01/2025
- YDN FAMILY GRANTOR TRUST5% or greater indirect ownership interest · no percentage provided · since 01/01/2025
- FAIRBAIRN, SCOTTOperational/managerial control · not applicable · since 05/01/2023
- HEWITT, REIDOperational/managerial control · not applicable · since 03/14/2025
Questions
When was Lakehouse Healthcare & Rehabilitation Center last inspected?
CMS lists August 15, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Lakehouse Healthcare & Rehabilitation Center have?
CMS lists 80 health citations since June 29, 2023. CMS also calls these deficiencies.
Has Lakehouse Healthcare & Rehabilitation Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Lakehouse Healthcare & Rehabilitation Center?
Its CMS overall star rating is 1 of 5.
Is Lakehouse Healthcare & Rehabilitation Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.