Inspection Reports for Northern Lakes Nursing and Rehabilitation Center
516 N WILLIAMS ST, IN, 46703
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Inspection Report
Life Safety
Census: 90
Capacity: 99
Deficiencies: 0
Feb 17, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/09/25 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Northern Lakes Nursing and Rehabilitation 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, LSC, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is fully sprinklered with a fire alarm system and smoke detection in required areas.
Report Facts
Facility capacity: 99
Census: 90
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 9, 2025
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey, along with the Investigation of Complaint IN00447844.
Findings
Northern Lakes Nursing and Rehabilitation Center 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 of the recertification, state licensure survey, and complaint investigation.
Complaint Details
Complaint IN00447844 was investigated and corrected.
Inspection Report
Life Safety
Census: 85
Capacity: 99
Deficiencies: 3
Jan 9, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code (LSC) Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included an exit door in the therapy gym with a locked egress code not posted, hazardous areas not properly protected due to non-self-closing doors, and use of a portable space heater in a resident care area.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure the means of egress through 1 of 1 exit doors in the therapy gym were readily accessible; the exit door was magnetically locked and the access code was not posted. | SS=E |
| Failed to ensure 2 of 3 rooms on the service hall greater than 50 square feet used for storage of combustibles were protected as hazardous areas; doors were not self-closing or were propped open. | SS=E |
| Failed to ensure 1 of 1 portable space heaters were not used in resident care areas; a space heater was found in the Memory Care Hall nurses' station. | SS=E |
Report Facts
Facility capacity: 99
Census: 85
Number of exit doors with deficiency: 1
Number of hazardous rooms with deficiency: 2
Number of portable space heaters found: 1
Number of residents potentially affected by exit door deficiency: 5
Number of residents potentially affected by portable space heater deficiency: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dee Anna Smallman | Administrator | Named during exit conference and signature on report |
| Maintenance Director | Interviewed and involved in observations related to deficiencies | |
| On-duty charge nurse | Interviewed regarding use of space heater in Memory Care Hall |
Inspection Report
Annual Inspection
Census: 85
Capacity: 85
Deficiencies: 4
Dec 10, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00447844.
Findings
The facility was found deficient in multiple areas including failure to ensure privacy of protected health information, failure to prevent verbal abuse of residents, failure to ensure orders were entered and followed for use of splints, and failure to properly disinfect blood sugar meters between resident use.
Complaint Details
Complaint IN00447844 was investigated during this visit. The deficiency related to the allegation was F600, concerning verbal abuse of residents.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure privacy of protected health information for 1 of 24 residents reviewed (Resident 44). | SS=D |
| Failed to ensure residents were free from verbal abuse for 3 of 5 residents reviewed (Resident 15, Resident 18, Resident 44). | SS=D |
| Failed to ensure orders were entered and followed for 1 of 3 residents reviewed (Resident 15) regarding use of splints. | SS=D |
| Failed to ensure blood sugar meter (glucometer) was properly disinfected between each resident use for 2 of 2 residents reviewed (Resident 59 and Resident 26). | SS=D |
Report Facts
Census: 85
Total Capacity: 85
Survey Dates: 5
Residents reviewed for privacy: 24
Residents reviewed for abuse: 5
Residents reviewed for splint orders: 3
Residents reviewed for glucometer disinfection: 2
BIMS scores: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dee Anna Smallman | Administrator | Signed the report and involved in the investigation and policy provision. |
| LPN 30 | Licensed Practical Nurse | Observed leaving computer screens open with resident information visible. |
| CNA 2 | Certified Nurse Aide | Involved in verbal abuse incident with Resident 15. |
| LPN 3 | Licensed Practical Nurse | Notified of Resident 15's requested assistance during abuse incident. |
| CNA 4 | Certified Nurse Aide | Interviewed about staff behavior and yelling at residents. |
| CNA 6 | Certified Nurse Aide | Provided information about Resident 15's splint use. |
| RN 5 | Registered Nurse | Provided information about splint orders and instructions for Resident 15. |
| LPN 20 | Licensed Practical Nurse | Observed cleaning glucometer with alcohol pads and interviewed about disinfection practices. |
| QMA 10 | Qualified Medication Aide | Observed obtaining blood sugars and cleaning glucometer with alcohol pads. |
| Director of Nursing | Director of Nursing | Re-instructed staff on privacy, abuse prohibition, splint orders, and glucometer disinfection; conducted audits. |
| Staff Development Coordinator | Staff Development Coordinator | Reinstructed Nurses and QMAs on sanitizing glucometers. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Nov 13, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446082.
Findings
No deficiencies related to the allegations in Complaint IN00446082 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00446082 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 78
Total Capacity: 78
Medicare Residents: 2
Medicaid Residents: 45
Other Payor Residents: 31
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 0
Oct 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444084.
Findings
No deficiencies related to the allegations in Complaint IN00444084 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00444084; no deficiencies related to the allegations were found.
Report Facts
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 48
Census Payor Type - Other: 33
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 0
Aug 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437730.
Findings
No deficiencies related to the allegations in Complaint IN00437730 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00437730 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 83
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 44
Census Payor Type - Other: 35
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Jun 20, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00433916 and IN00435448.
Findings
No deficiencies related to the allegations in complaints IN00433916 and IN00435448 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00433916 and IN00435448 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census SNF/NF beds: 76
Census total residents: 76
Census Medicare residents: 3
Census Medicaid residents: 44
Census other payor residents: 29
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 0
Mar 7, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426991.
Findings
No deficiencies related to the allegations in Complaint IN00426991 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00426991 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 81
Total Capacity: 81
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 49
Census Payor Type - Other: 29
Inspection Report
Life Safety
Census: 74
Capacity: 99
Deficiencies: 0
Jan 26, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code (LSC) Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively on 01/26/2024.
Findings
Northern Lakes Nursing and Rehabilitation Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers. The facility is fully sprinklered in resident areas, has a fire alarm system with smoke detection, and has some non-sprinklered areas including a maintenance building and off-site storage unit.
Report Facts
Facility capacity: 99
Census: 74
Inspection Report
Annual Inspection
Deficiencies: 0
Jan 8, 2024
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure review completed on December 11, 2024.
Findings
Northern Lakes Nursing and Rehabilitation Center 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.
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 2
Dec 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the investigation of Complaints IN00422926 and IN00423526.
Findings
The facility was found deficient in ensuring non-pharmacologic interventions were implemented and documented prior to administering PRN opioid pain medication for one resident, and in updating dementia care interventions to reflect current cognitive status for another resident.
Complaint Details
Complaint IN00422926 was investigated with no findings related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure non-pharmacologic interventions were implemented and documented prior to administration of PRN opioid pain medication for Resident 228. | SS=D |
| Failed to ensure dementia care interventions were updated and accurate for Resident 4. | SS=D |
Report Facts
Census: 79
SNF beds: 3
SNF/NF beds: 76
Medicare residents: 1
Medicaid residents: 44
Other payor residents: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dee Anna Smallman | Administrator | Signed the report and involved in interviews |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 0
Dec 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00423526 and Complaint IN00422926, in conjunction with a Recertification and State Licensure Survey.
Findings
No findings related to Complaint IN00423526 were cited. Northern Lakes Nursing and Rehabilitation Center was found to be in compliance with applicable regulations regarding the complaint investigation.
Complaint Details
Complaint IN00423526 was investigated with no findings related to the allegations cited.
Report Facts
Census: 79
SNF Beds: 3
SNF/NF Beds: 76
Medicare Residents: 1
Medicaid Residents: 44
Other Payor Residents: 34
Inspection Report
Complaint Investigation
Census: 75
Capacity: 75
Deficiencies: 0
Aug 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00414740.
Findings
No deficiencies related to the allegations in Complaint IN00414740 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00414740 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 75
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 46
Census Payor Type - Other: 28
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Jun 27, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410950.
Findings
No deficiencies related to the allegations in Complaint IN00410950 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00410950 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 2
Medicaid residents: 51
Other residents: 23
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 16, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00410058 and IN00410262 completed on June 16, 2023.
Findings
Northern Lakes Nursing and Rehabilitation 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 of the complaint investigations.
Complaint Details
Investigation of Complaint IN00410058 and IN00410262 was reviewed and found to be in compliance.
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 1
Jun 15, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00410058 and IN00410262 regarding allegations of improper use of physical restraints on residents.
Findings
The facility failed to ensure that residents were free from physical restraints for 1 of 6 residents reviewed (Resident B). Resident B was restrained with a gait belt attached to a BRODA chair without a physician's order, which violated the resident's rights and facility policy.
Complaint Details
The investigation was related to Complaints IN00410058 and IN00410262. Both complaints resulted in federal/state deficiencies cited at F604 concerning improper restraint use.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents were free from physical restraint for 1 of 6 residents reviewed (Resident B) who was restrained with a gait belt without a doctor's order. | SS=D |
Report Facts
Residents reviewed: 6
Residents restrained improperly: 1
Census: 79
Total capacity: 79
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dee Anna Smallman | Administrator | Administrator who provided investigation file and participated in interviews |
| RN 3 | Registered Nurse | Restraint applied to Resident B without doctor's order |
| LPN 2 | Licensed Practical Nurse | Observed and removed restraint from Resident B and performed skin assessment |
| LPN 5 | Licensed Practical Nurse | Provided interview about restraint definition and resident care |
| CNA 4 | Certified Nurse Aide | Placed restraint on Resident B during shift |
| Director of Nursing | Director of Nursing | Reviewed restraint incident and communicated with staff |
| Assistant Director of Nursing | Assistant Director of Nursing | Reviewed other residents for restraint use |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 80
Deficiencies: 0
Apr 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00405142.
Findings
No deficiencies related to the allegations in Complaint IN00405142 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00405142 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 80
Total Capacity: 80
Census Payor Type Medicaid: 53
Census Payor Type Other: 27
Inspection Report
Re-Inspection
Census: 83
Deficiencies: 0
Mar 2, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00400155 completed on January 31, 2023.
Findings
Northern Lakes Nursing and Rehabilitation 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 IN00400155.
Complaint Details
Complaint IN00400155 - Corrected.
Report Facts
Census: 83
Medicare residents: 6
Medicaid residents: 51
Other payor residents: 26
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 2
Jan 31, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00400155, which was substantiated with federal and state deficiencies cited related to the allegations.
Findings
The facility failed to notify the physician of a resident's significant change in condition and failed to assess, monitor, and notify the physician of an acute change in condition that led to a delay in treatment and decline in condition for one resident. Documentation and communication failures were noted regarding the resident's symptoms and requests for hospital transfer.
Complaint Details
Complaint IN00400155 was substantiated. Federal/state deficiencies related to the allegations were cited at F580 and F684.
Severity Breakdown
SS=D: 1
SS=G: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to notify the physician of a resident's significant change in condition for 1 of 3 residents reviewed (Resident D). | SS=D |
| Failed to assess, monitor, and notify the physician of an acute change in condition that led to a delay in treatment and decline in condition for 1 of 3 residents reviewed (Resident D). | SS=G |
Report Facts
Census: 82
Total Capacity: 82
Medicare Census: 3
Medicaid Census: 50
Other Payor Census: 29
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dee Anna Smallman | Administrator | Signed the report and involved in facility administration |
| Nurse #4 | Involved in resident D change of condition and reinstructed on notification of physician and resident representative | |
| QMA 2 | Qualified Medication Aide | Administered Ibuprofen to Resident D and reinstructed on protocol for administration of PRN medications |
| LPN 4 | Licensed Practical Nurse | Cared for Resident D on 1/14/23 and interviewed regarding failure to notify physician |
| Director of Nursing | Provided facility policy and involved in staff reinstruction and audits | |
| MDS Coordinator | Reviewed and updated care plans for residents with diagnosis of hernia |
Inspection Report
Re-Inspection
Census: 78
Capacity: 99
Deficiencies: 0
Jan 26, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/15/22 was performed to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and applicable fire safety codes. The facility is fully sprinklered except for the maintenance building and off-site storage unit.
Inspection Report
Life Safety
Census: 85
Capacity: 99
Deficiencies: 2
Dec 15, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code (LSC) Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included the lack of a properly located and labeled remote emergency stop button for the new generator and the use of three flexible cord power strips in patient care areas that did not meet required UL ratings.
Severity Breakdown
SS=F: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure 1 of 1 emergency generators was equipped with a properly located and labeled remote manual stop station as required by NFPA 110. | SS=F |
| Facility failed to ensure 3 of 3 flexible cord power strips in patient care locations met the required UL rating of 1363A or 60601-1. | SS=E |
Report Facts
Facility capacity: 99
Census: 85
Power strips not meeting UL rating: 3
Generator inspections: 12
Generator exercise duration: 30
Generator long exercise interval: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dee Anna Smallman | Administrator | Named in relation to the exit conference and report signature |
| Dee Hinesley | Novatek Corporation representative who ordered the external emergency stop button | |
| Luke Cobb | Maintenance Consultant | Reviewed regulations for the external emergency stop button with Maintenance Director |
Inspection Report
Annual Inspection
Census: 78
Capacity: 78
Deficiencies: 4
Nov 17, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from November 13 to 17, 2022.
Findings
The facility was found deficient in multiple areas including failure to provide scheduled showers for a resident, failure to ensure medications were administered as ordered, failure to monitor medication side effects, and failure to maintain proper food temperatures during meal service.
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident received showers or bed baths as scheduled for 1 of 1 resident reviewed (Resident 26). | SS=D |
| Facility failed to ensure medications were administered as ordered by the physician for 1 of 1 resident reviewed (Resident 42). | SS=D |
| Facility failed to monitor medication side effects for 1 of 5 residents reviewed (Resident 19). | SS=D |
| Facility failed to ensure proper food temperatures were maintained at the time of meal service for 78 residents. | SS=F |
Report Facts
Census: 78
Total Capacity: 78
Number of showers/bed baths received: 7
Number of showers/bed baths scheduled: 10
Medication doses administered: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dee Anna Smallman | Administrator | Signed the report |
| Director of Nursing | Involved in findings related to shower scheduling, medication administration, and monitoring | |
| Assistant Director of Nursing | Involved in oversight of shower schedules and audits | |
| Dietary Manager | Involved in findings related to food temperature monitoring and corrective actions |
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 17, 2022
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure survey.
Findings
Northern Lakes Nursing and Rehabilitation Center 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: 86
Capacity: 86
Deficiencies: 0
Aug 11, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00386600.
Findings
The complaint IN00386600 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00386600 was investigated and determined to be unsubstantiated due to lack of evidence.
Report Facts
Census: 86
Total Capacity: 86
Medicare Census: 8
Medicaid Census: 44
Other Payor Census: 34
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