Inspection Reports for Lakeland Rehab and Healthcare Center
500 N WILLIAMS ST, IN, 46703
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Inspection Report
Annual Inspection
Deficiencies: 0
Jun 23, 2025
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Mar 20, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00454716.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00454716 - No deficiencies related to the allegations are cited.
Report Facts
Census SNF/NF: 67
Total Capacity: 67
Census Payor Type Medicare: 6
Census Payor Type Medicaid: 31
Census Payor Type Other: 30
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 13, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00452871 completed on February 20, 2025.
Findings
Lakeland Rehab and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Complaint Details
Complaint IN00452871 was investigated and corrected as of February 20, 2025.
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 1
Feb 20, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451871 regarding deficiencies related to allegations of failure to report an injury of unknown origin.
Findings
The facility failed to ensure that an injury of unknown origin to Resident G was reported to the Indiana Department of Health. A large bruise was observed on the resident's inner right thigh, but the incident was not reported and no further investigation was completed. Staff interviews revealed lack of awareness about the bruise and its origin. The facility policy requires immediate reporting and investigation of such injuries.
Complaint Details
Complaint IN00451871 was substantiated with deficiencies cited at F609 related to failure to report an injury of unknown origin.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an injury of unknown origin for Resident G. | SS=D |
Report Facts
Residents reviewed: 3
Bruise size: 15
Bruise size: 4
Medicare census: 5
Medicaid census: 32
Other payor census: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding the bruise on Resident G and failure to report the incident |
| Nurse Practitioner | Nurse Practitioner | Evaluated Resident G's bruise and provided clinical assessment |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 29, 2025
Visit Reason
The visit was a paper compliance review related to the Annual Investigation of Complaint IN00450457 completed on January 6, 2025.
Findings
Lakeland Rehab and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the Investigation of Complaint IN00450457.
Complaint Details
Complaint IN00450457 was corrected as of the review date January 29, 2025.
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 1
Jan 6, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00448850 and IN00450457. Complaint IN00448850 had no deficiencies cited, while complaint IN00450457 resulted in federal/state deficiencies related to behavioral health services.
Findings
The facility failed to ensure an effective care plan was developed and implemented regarding sexual behaviors for two cognitively impaired residents (Resident N and Resident O). Both residents were assessed to have capacity to consent to sexual relations, but care plans lacked details on the nature of sexual relations, safety checks, and interventions. Multiple observations and interviews documented inappropriate sexual behaviors and agitation, with staff implementing 15-minute safety checks and redirection. The facility provided a plan of correction including updated care plans, staff in-service, and ongoing audits.
Complaint Details
Complaint IN00450457 alleged Resident N was sexually inappropriate with Resident O, both cognitively impaired. Allegations included touching, making out, and attempts at inappropriate contact without consent. The facility failed to notify Resident O's family/POA initially. The investigation confirmed deficiencies related to behavioral health services and care planning.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure an effective care plan was developed and implemented regarding sexual behaviors for 2 cognitively impaired residents. | SS=D |
Report Facts
Census: 64
Total Capacity: 64
Safety checks frequency: 15
BIMS score Resident N: 9
BIMS score Resident O: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Floyd | Laboratory Director or Provider/Supplier Representative | Signed the report |
| Licensed Practical Nurse (LPN) 5 | Reported Resident N's inappropriate behavior and initiated 15-minute safety checks | |
| Social Services Director (SSD) | Notified Resident N's POA and involved in plan of correction oversight | |
| Director of Nursing (DON) | Notified of incidents and involved in care planning and interviews | |
| Administrator | Involved in assessment and interviews regarding residents' capacity to consent | |
| Psychiatric Nurse Practitioner (NP) | Conducted psychiatric assessments and progress notes on Resident N and Resident O |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Nov 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00445593 and IN00446252, including a focused Infection Control Survey.
Findings
No deficiencies related to the allegations in Complaints IN00445593 and IN00446252 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00445593 - No deficiencies related to the allegations are cited. Complaint IN00446252 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type: 64
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 34
Census Payor Type - Other: 28
Total Census: 64
Inspection Report
Follow-Up
Census: 66
Capacity: 75
Deficiencies: 0
Oct 22, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to investigate Complaint Number IN00443208 that exited on 2024-09-24.
Findings
At this PSR, Lakeland Rehab and Healthcare Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and applicable Life Safety Code standards. The facility was fully sprinklered except for a detached shed used for facility services.
Complaint Details
Complaint Number IN00443208 was investigated and found corrected at this Post Survey Revisit.
Report Facts
Facility capacity: 75
Census: 66
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 0
Oct 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443111.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00443111 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 69
Total Capacity: 69
Medicare Census: 5
Medicaid Census: 36
Other Payor Census: 28
Inspection Report
Complaint Investigation
Census: 67
Capacity: 75
Deficiencies: 1
Sep 24, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint Number IN00443208 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Requirements for Participation in Medicare/Medicaid, specifically related to Life Safety from Fire and NFPA 101 standards. A deficiency was cited for an unprotected electrical junction box with exposed wiring in resident room 309, which could affect staff and one resident.
Complaint Details
This federal tag relates to complaint number IN00443208. The finding was reviewed with the Executive Director at the exit conference. No resident was found to be affected by the finding. Visitors, staff, and residents have the potential to be affected by the alleged deficient practice.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 1 electrical junction box in resident room 309 was protected; exposed wiring terminals were not enclosed. | SS=E |
Report Facts
Facility capacity: 75
Census: 67
Date of survey: Sep 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Floyd | Executive Director | Interviewed regarding the exposed electrical junction box in resident room 309 |
Inspection Report
Re-Inspection
Census: 66
Capacity: 75
Deficiencies: 0
Aug 19, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/08/24 was performed to verify compliance with previous deficiencies.
Findings
At this PSR, Lakeland Rehab and Healthcare Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered except for a detached shed and had appropriate smoke detection systems in resident rooms and corridors.
Report Facts
Facility capacity: 75
Census: 66
Inspection Report
Life Safety
Census: 62
Capacity: 75
Deficiencies: 14
Jul 8, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 07/08/2024.
Findings
The facility was found in compliance with Emergency Preparedness requirements but not in compliance with Life Safety Code requirements, with multiple deficiencies noted related to means of egress, illumination, hazardous area enclosures, cooking facilities, fire alarm system initiation, sprinkler system installation, fire extinguishers, corridor doors, electrical equipment, HVAC fire dampers, evacuation and relocation plans, fire drills, and gas equipment storage.
Severity Breakdown
SS=E: 12
SS=F: 3
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 10 means of egress were continuously maintained free of all obstructions or impediments. | SS=E |
| Failed to ensure continuity of egress lighting for 2 of 2 exits. | SS=E |
| Failed to maintain protection of 1 of 1 hot oil popcorn popper in the Main Dining Room and failed to ensure corridor doors to hazardous areas self-close and latch. | SS=E |
| Failed to ensure staff had access to the shutoff switch for 1 of 1 cook tops in the therapy gym. | SS=E |
| Failed to ensure 1 of 9 fire alarm manual pull stations was visible and continuously accessible. | SS=E |
| Failed to maintain ceiling construction in 3 of 3 smoke compartments; displaced escutcheons around sprinklers. | SS=E |
| Failed to ensure 2 of 23 portable fire extinguishers were kept in their designated place and were readily accessible. | SS=E |
| Failed to ensure 1 of 16 resident sleeping room corridor doors resist passage of smoke and fire for at least 20 minutes; door had a pencil size hole. | SS=E |
| Failed to provide ground fault circuit interrupter (GFCI) protection for 1 of 1 wet location receptacle; GFCI failed to function properly. | SS=E |
| Failed to ensure 20 of 20 fire dampers were inspected and maintained at least every four years. | SS=F |
| Failed to provide a written emergency fire safety plan that incorporated all required items including evacuation of smoke compartments. | SS=F |
| Failed to vary conditions at unexpected times during fire drills on second shift for 4 of 4 quarters. | SS=F |
| Failed to ensure 1 of 42 resident rooms did not use flexible cords as a substitute for fixed wiring; extension cord used to power television. | SS=E |
| Failed to ensure 3 of 3 cylinders of nonflammable gases such as oxygen were properly secured from falling. | SS=E |
Report Facts
Certified beds: 75
Census: 62
Fire dampers: 20
Portable fire extinguishers: 23
Fire alarm manual pull stations: 9
Resident rooms corridor doors: 16
Oxygen cylinders: 3
Fire drills: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lindsey Floyd | Executive Director | Named in relation to review and acknowledgement of findings during exit conference. |
| Senior Maintenance Director | Named in relation to multiple findings and observations during the survey. |
Inspection Report
Renewal
Census: 62
Capacity: 62
Deficiencies: 0
Jun 21, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the investigation of complaint IN00435041.
Findings
Lakeland Rehab and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1. No deficiencies related to the complaint were cited.
Complaint Details
Complaint IN00435041 was investigated and no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF beds: 62
Total census: 62
Medicaid census: 33
Other payor census: 29
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 0
Apr 24, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00432612.
Findings
No deficiencies related to the allegations in Complaint IN00432612 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00432612 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 7
Medicaid residents: 38
Other residents: 20
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 18, 2024
Visit Reason
Paper compliance review to the Investigation of Complaints IN00428017 and IN00429184 completed on March 5, 2024.
Findings
Lakeland Rehab and Healthcare Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigations.
Complaint Details
This visit was related to complaint investigations IN00428017 and IN00429184; the facility was found in compliance.
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 2
Mar 4, 2024
Visit Reason
The visit was conducted for the investigation of four complaints (IN00428017, IN00429161, IN00429184, and IN00429739) regarding resident care and facility practices.
Findings
The facility was found deficient related to two complaints: one involving failure to treat a resident with respect and dignity regarding wifi access (Complaint IN00429184), and another involving failure to provide adequate supervision to prevent a fall resulting in injury (Complaint IN00428017). Two complaints had no deficiencies cited.
Complaint Details
Complaint IN00428017 was substantiated with deficiencies related to fall prevention and supervision. Complaint IN00429184 was substantiated with deficiencies related to resident rights and dignity. Complaints IN00429161 and IN00429739 had no deficiencies cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 residents reviewed were treated with respect and dignity when verbally reporting a grievance about lack of wifi access. | SS=D |
| Failed to provide adequate supervision and staff assistance to prevent a fall for 1 of 3 residents reviewed, resulting in a fracture. | SS=D |
Report Facts
Census: 71
Total Capacity: 71
Medicare Census: 1
Medicaid Census: 40
Other Payor Census: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Terry | RN, Director of Nursing (DON) | Signed the report as Laboratory Director's or Provider/Supplier Representative |
| Employee 7 | Named in resident grievance regarding wifi access and disrespectful comment | |
| CNA 4 | Certified Nursing Assistant | Involved in fall incident with Resident B |
| QMA 2 | Qualified Medication Aid | Assisted CNA 4 during fall incident with Resident B |
| Regional Director of Operations | Interviewed regarding wifi outage and resolution | |
| Regional Nurse Consultant | Provided facility policies and interviewed staff |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 0
Sep 12, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00416802 and included a COVID-19 Focused Infection Control Survey.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation and the COVID-19 survey.
Complaint Details
Complaint IN00416802 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 64
Total Capacity: 64
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 41
Census Payor Type - Other: 21
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Aug 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413698.
Findings
No deficiencies related to the allegations in Complaint IN00413698 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00413698 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 37
Census Payor Type - Other: 27
Inspection Report
Re-Inspection
Census: 68
Capacity: 75
Deficiencies: 0
Jul 26, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 06/15/23 by the Indiana Department of Health.
Findings
At this PSR survey, Lakeland Rehab and Healthcare Center was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.73, and with Life Safety Code requirements including 42 CFR Subpart 483.90(a) and NFPA 101, Life Safety Code Chapter 19. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems in place.
Report Facts
Certified beds: 75
Census: 68
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 18, 2023
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey conducted on May 30, 2023.
Findings
Lakeland Rehab and Healthcare Center of Fort Wayne was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 0
Jun 16, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00410374.
Findings
No deficiencies related to the allegations of Complaint IN00410374 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00410374 found no deficiencies related to the allegations.
Report Facts
Census: 62
Census Bed Type Total: 62
Census Payor Type Total: 62
SNF/NF Census: 21
SNF Census: 5
NF Census: 36
Medicare Census: 5
Medicaid Census: 36
Other Payor Census: 21
Inspection Report
Routine
Census: 63
Capacity: 75
Deficiencies: 12
Jun 15, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted to assess compliance with federal and state regulations including emergency preparedness, fire safety, and facility maintenance.
Findings
The facility was found not in compliance with emergency preparedness testing requirements, emergency power system maintenance, fire alarm system inspections, sprinkler system maintenance, fire drills, corridor door integrity, emergency lighting testing, and electrical safety. Several deficiencies were noted including missing emergency preparedness exercises, incomplete generator load testing records, malfunctioning egress door keypad, untested battery-operated smoke alarms, missing fire alarm visual inspections, and electrical splices not enclosed in junction boxes.
Severity Breakdown
SS=F: 6
SS=E: 4
SS=C: 2
SS=B: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to conduct emergency preparedness exercises twice per year including unannounced staff drills. | SS=F |
| Failed to maintain emergency power system inspection, testing, and maintenance in accordance with NFPA 110 and Life Safety Code. | SS=C |
| Egress door keypad malfunctioned, preventing door release with code entry. | SS=B |
| Failed to test battery-powered emergency lighting monthly and annually as required. | SS=F |
| Failed to maintain preventative maintenance documentation for battery-operated smoke alarms in resident rooms. | SS=E |
| Staff lacked access to shutoff switch for cooktop in therapy gym. | SS=E |
| Failed to maintain fire alarm system visual inspections semi-annually as required. | SS=F |
| Failed to maintain sprinkler system inspection and testing records for all required months. | SS=C |
| Nursing Coordinator office corridor door had holes compromising smoke resistance. | SS=E |
| Electrical splices not enclosed in junction box in transfer switch room. | SS=E |
| Failed to conduct fire drills on each shift for 2 of 4 quarters. | SS=F |
| Failed to maintain complete written record of monthly generator load testing for 8 of last 12 months. | SS=F |
Report Facts
Certified beds: 75
Census: 63
Fire drills missing: 3
Battery-powered emergency lights: 10
Battery-operated smoke alarms: 15
Fire alarm visual inspections missing: 1
Generator load tests missing: 8
Inspection Report
Annual Inspection
Census: 66
Capacity: 66
Deficiencies: 6
May 30, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from May 23 to May 30, 2023.
Findings
The facility was found deficient in multiple areas including resident rights/privacy during personal care, activities of daily living support, wound care, trauma-informed care, and food service sanitation. Corrective actions and staff re-education plans were implemented for each deficiency.
Severity Breakdown
SS=D: 5
SS=F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide privacy during personal care for Resident 13. | SS=D |
| Failed to ensure follow up to improve communication ability for Resident 47 related to hearing aid provision. | SS=D |
| Failed to ensure wound care was provided as ordered for Resident 13; medication error with application of another resident's powder. | SS=D |
| Failed to ensure hand hygiene was maintained during wound care for Resident 58. | SS=D |
| Failed to ensure trauma-informed care with resident-specific triggers and approaches for Resident 59. | — |
| Failed to ensure cleanliness of kitchen floor, walls, surfaces, and outside dumpster area. | SS=F |
Report Facts
Census: 66
Total Capacity: 66
Medicare Census: 7
Medicaid Census: 40
Other Payor Census: 19
Survey Dates: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah M Trewett | RN, Director of Nursing | Named in relation to findings on resident privacy and wound care |
| RN 4 | Registered Nurse | Involved in wound care medication error |
| RN 7 | Registered Nurse | Involved in wound care hand hygiene deficiency |
| Director of Nursing | Director of Nursing | Interviewed regarding resident privacy and wound care |
| Social Service Director | Social Service Director | Interviewed regarding audiology follow-up and trauma-informed care |
| Food Service Director | Food Service Director | Interviewed regarding kitchen sanitation deficiencies |
| Administrator | Administrator | Interviewed regarding kitchen sanitation and dishwasher leak |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 0
Jan 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399537.
Findings
The complaint IN00399537 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00399537 was investigated and found unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 66
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 35
Census Payor Type - Other: 21
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 0
Jan 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00398326.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00398326 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 34
Census Payor Type - Other: 21
Inspection Report
Re-Inspection
Census: 62
Capacity: 62
Deficiencies: 0
Dec 15, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00393780 completed on November 4, 2022.
Findings
Lakeland Rehab and Healthcare Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00393780.
Complaint Details
Complaint IN00393780 - Corrected.
Report Facts
Census: 62
Total Capacity: 62
Medicare Census: 12
Medicaid Census: 33
Private Pay Census: 16
Other Pay Census: 1
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 0
Nov 22, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00394278 and IN00394509.
Findings
Complaint IN00394278 was unsubstantiated due to lack of evidence. Complaint IN00394509 was substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00394278 was unsubstantiated due to lack of evidence. Complaint IN00394509 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census: 60
Total Capacity: 60
Medicare Census: 9
Medicaid Census: 32
Other Payor Census: 19
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 1
Nov 4, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00393780, which was substantiated and resulted in an extended survey focused on substandard quality of care related to dementia services.
Findings
The facility failed to provide appropriate dementia care and psychosocial support for 5 of 25 residents on the secured memory care unit. Several residents were observed with inadequate activity engagement, lack of person-centered dementia care plans, and no documented physician orders supporting placement in the secured memory care unit. Family dissatisfaction and resident distress related to room transfers were noted. The facility lacked a defined dementia care program and specific dementia care interventions at the time of the survey.
Complaint Details
Complaint IN00393780 was substantiated. The complaint involved substandard quality of care related to dementia services on the secured memory care unit.
Severity Breakdown
SS=H: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate dementia care and services to support psychosocial well-being for residents on the secured memory care unit. | SS=H |
Report Facts
Census: 63
Total Capacity: 63
Residents affected: 5
Residents on memory care unit: 25
Medicare census: 8
Medicaid census: 32
Other payor census: 23
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 0
Oct 27, 2022
Visit Reason
This visit was for the investigation of Complaint IN00391205.
Findings
The complaint IN00391205 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00391205 - Unsubstantiated due to lack of evidence.
Report Facts
Census: 62
Total Capacity: 62
Medicare Census: 5
Medicaid Census: 35
Other Payor Census: 22
Inspection Report
Re-Inspection
Census: 63
Capacity: 75
Deficiencies: 0
Sep 20, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 07/28/22.
Findings
At this PSR survey, Lakeland Rehab and Healthcare Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems, except for a detached shed that was not sprinklered.
Report Facts
Certified beds: 75
Census: 63
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 0
Aug 11, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00385235.
Findings
The complaint investigation was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00385235 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Medicare census: 10
Medicaid census: 31
Other payor census: 23
Inspection Report
Life Safety
Census: 64
Capacity: 75
Deficiencies: 7
Jul 28, 2022
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness requirements and life safety codes.
Findings
The facility was found not in compliance with emergency preparedness requirements including incomplete subsistence needs policies and lack of annual emergency preparedness training. Life safety deficiencies included loaded sprinkler heads in the kitchen, unsealed smoke barrier penetrations, smoke barrier door damage, lack of annual fire door testing, and failure to test non-hospital grade electrical receptacles annually.
Severity Breakdown
SS=C: 1
SS=E: 4
SS=F: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Emergency preparedness policies lacked documentation for sewage and waste disposal and subsistence needs for staff and residents. | SS=C |
| Facility failed to conduct annual emergency preparedness training and demonstrate staff knowledge. | SS=F |
| Sprinkler heads in the kitchen were loaded with dirt and grease. | SS=E |
| Penetrations through smoke barrier walls were not sealed to maintain smoke resistance. | SS=E |
| One set of smoke barrier doors had holes in the door frame compromising smoke resistance. | SS=E |
| Rolling fire door between kitchen and dining room was not tested annually; last test was in July 2020. | SS=E |
| Non-hospital grade electrical receptacles in 43 resident sleeping rooms were not tested annually. | SS=F |
Report Facts
Certified beds: 75
Census: 64
Sprinkler heads: 10
Resident sleeping rooms: 43
Smoke barrier walls: 5
Smoke barrier doors: 5
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