Inspection Reports for
Northern Lakes Nursing and Rehabilitation Center
516 N WILLIAMS ST, ANGOLA, IN, 46703
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Indiana average
Indiana average: 4.2 deficiencies/year
Deficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
91% occupied
Based on a February 2025 inspection.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Dec 4, 2025
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements for nursing home care, including resident rights, dialysis care, infection control, and facility safety.
Findings
The facility was found deficient in providing timely meal service ensuring resident dignity, consistent communication with the dialysis center, proper infection prevention and control practices, and maintaining a safe and homelike environment. Deficiencies involved multiple residents and staff practices, with minimal harm or potential for actual harm noted.
Deficiencies (4)
F 0550: The facility failed to ensure dignity with timely meal service for residents seated together, resulting in excessive wait times of up to 24 minutes for some residents to be served.
F 0698: The facility failed to ensure continuous and consistent communication with the dialysis center for a resident dependent on dialysis, lacking documented communication to ensure resident status was accessible.
F 0880: The facility failed to implement infection prevention and control practices, including improper handling of food, lack of hand hygiene by staff, and failure to wear gloves when handling soiled linens, affecting 7 of 24 residents reviewed.
F 0921: The facility failed to maintain a safe and homelike environment, with visible wall damage, missing flooring, peeling paint, and missing trim in multiple resident rooms, with no work orders submitted for repairs.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 7
Residents affected: 7
BIMS score: 3
BIMS score: 15
BIMS score: 14
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided interviews regarding meal service, dialysis communication, infection control, and policies |
| Registered Nurse 10 | Registered Nurse | Interviewed about dialysis pre and post assessments and documentation |
| Activity Aide 2 | Activity Aide | Observed serving meals and handling food during infection control observation |
| Certified Nurse Aide 5 | Certified Nurse Aide | Observed during infection control observation with hand hygiene failures |
| Housekeeper 6 | Housekeeper | Observed handling soiled linens without gloves during infection control observation |
| Director of Maintenance | Director of Maintenance | Interviewed about maintenance work orders and environment safety deficiencies |
| Assistant Administrator | Assistant Administrator | Provided current policy on maintenance work orders |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 17, 2025
Visit Reason
The inspection was conducted due to a complaint investigation related to the facility's failure to immediately notify the physician of a resident's significant change in physical condition, which resulted in the resident's death.
Complaint Details
The complaint investigation found that the facility failed to notify the physician immediately of Resident K's change in condition and failed to reassess and monitor the resident's pain and respiratory status after initial treatment. Immediate Jeopardy was identified and later removed after corrective actions.
Findings
The facility failed to notify the physician immediately when Resident K complained of radiating pain to his left arm, shoulder, and chest, and failed to reassess and monitor his condition after initial treatment. Resident K was found deceased the following morning. Immediate Jeopardy was identified and later removed after re-education and audits, but noncompliance remained at a lower severity level.
Deficiencies (2)
F 0580: The facility failed to immediately notify the physician of Resident K's significant change in condition, resulting in Resident K's death. Staff did not assess or monitor pain or respiratory status adequately after initial complaints and treatment.
F 0684: The facility failed to reassess and monitor Resident K's complaint of shoulder pain with radiating chest pain, increased heart rate, and shortness of breath after initial assessment and treatment. Resident K was found deceased the following morning.
Report Facts
Oxygen saturation: 92
Blood pressure: 10868
Pulse: 100
Tylenol dosage: 500
Metoprolol tartrate dosage: 12.5
Midodrine dosage: 5
Trazadone dosage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Worked on Resident K's hall and did not assess Resident K due to lack of report of pain or medication given. |
| LPN 2 | Licensed Practical Nurse | Did not indicate in report that Resident K had been given any prn medications or assessed at night. |
| CNA 4 | Certified Nurse Aide | Responded to Resident K's call light and reported pain but did not check on him after reporting to LPN 2. |
| QMA 5 | Qualified Medication Assistant | Administered no prn medications to Resident K on day shift and reported Resident K looked normal. |
| CNA 6 | Certified Nurse Aide | Noticed Resident K sitting up in bed, slumped over with gray color and cold skin. |
Inspection Report
Life Safety
Census: 90
Capacity: 99
Deficiencies: 0
Date: 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
Date: 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.
Complaint Details
Complaint IN00447844 was investigated and corrected.
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.
Inspection Report
Life Safety
Census: 85
Capacity: 99
Deficiencies: 3
Date: 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.
Deficiencies (3)
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.
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.
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.
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
Complaint Investigation
Deficiencies: 1
Date: Dec 10, 2024
Visit Reason
The inspection was conducted in response to a complaint (IN00447844) regarding verbal abuse allegations involving staff and residents at the facility.
Complaint Details
This finding is related to Complaint IN00447844. The complaint was substantiated based on interviews and record reviews confirming verbal abuse by CNA 2 towards residents.
Findings
The facility failed to ensure residents were free from verbal abuse, with documented incidents involving a Certified Nurse Aide (CNA 2) verbally abusing residents and using foul language. Multiple resident interviews and record reviews confirmed the abuse and staff failure to respond appropriately.
Deficiencies (1)
F 0600: The facility failed to protect residents from verbal abuse by staff, including use of foul language and yelling at residents. This affected 3 of 5 residents reviewed.
Report Facts
Residents affected: 3
BIMS scores: 14
BIMS scores: 15
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 10, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to privacy breaches, verbal abuse, failure to follow therapy orders, and infection control practices at Northern Lakes Nursing and Rehabilitation Center.
Complaint Details
This inspection is related to Complaint IN00447844 concerning verbal abuse and privacy breaches.
Findings
The facility failed to ensure privacy of protected health information, prevent verbal abuse of residents, follow therapy orders for splint use, and properly disinfect blood sugar meters between resident uses. Multiple residents and staff interviews, observations, and record reviews confirmed these deficiencies.
Deficiencies (4)
F 0583: The facility failed to keep residents' personal and medical records private, leaving protected health information visible on medication carts and computer screens unattended.
F 0600: The facility failed to protect residents from verbal abuse, with CNA 2 verbally abusing Resident 15 and others, confirmed by interviews and investigation.
F 0688: The facility failed to ensure orders were entered and followed for Resident 15's hand splint, with no official order despite therapy recommendations and observed non-use.
F 0880: The facility failed to properly disinfect blood sugar meters between resident uses, using alcohol pads instead of required bleach wipes, risking infection transmission.
Report Facts
Residents reviewed for privacy: 24
Residents reviewed for verbal abuse: 5
Residents reviewed for therapy orders: 3
Residents reviewed for infection control: 2
Resident 15 BIMS score: 14
Resident 18 BIMS score: 15
Resident 44 BIMS score: 15
Resident 59 BIMS score: 4
Resident 26 BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 30 | Observed leaving computer screen open with resident information visible | |
| CNA 2 | Certified Nurse Aide | Named in verbal abuse finding involving Resident 15 |
| LPN 3 | Licensed Practical Nurse | Notified of Resident 15's requested assistance during verbal abuse incident |
| CNA 4 | Certified Nurse Aide | Interviewed about staff behavior and yelling at residents |
| CNA 6 | Certified Nurse Aide | Interviewed about Resident 15's splint use |
| RN 5 | Registered Nurse | Interviewed about splint orders and instructions for Resident 15 |
| LPN 20 | Licensed Practical Nurse | Observed cleaning glucometer and interviewed about disinfection practices |
| QMA 10 | Qualified Medication Aide | Observed and interviewed regarding glucometer use and cleaning |
| Director of Nursing (DON) | Director of Nursing | Provided investigation files, interviewed about policies and infection control |
| Administrator | Facility Administrator | Interviewed regarding privacy and verbal abuse findings |
Inspection Report
Annual Inspection
Census: 85
Capacity: 85
Deficiencies: 4
Date: Dec 10, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00447844.
Complaint Details
Complaint IN00447844 was investigated during this visit. The deficiency related to the allegation was F600, concerning verbal abuse of residents.
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.
Deficiencies (4)
Failed to ensure privacy of protected health information for 1 of 24 residents reviewed (Resident 44).
Failed to ensure residents were free from verbal abuse for 3 of 5 residents reviewed (Resident 15, Resident 18, Resident 44).
Failed to ensure orders were entered and followed for 1 of 3 residents reviewed (Resident 15) regarding use of splints.
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).
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
Date: Nov 13, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00446082.
Complaint Details
Complaint IN00446082 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00446082 were cited. The facility was found to be in compliance with relevant regulations.
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
Date: Oct 4, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444084.
Complaint Details
Investigation of Complaint IN00444084; no deficiencies related to the allegations were found.
Findings
No deficiencies related to the allegations in Complaint IN00444084 were cited. The facility was found to be in compliance with applicable regulations.
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
Date: Aug 2, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437730.
Complaint Details
Complaint IN00437730 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00437730 were cited. The facility was found to be in compliance with applicable regulations.
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
Date: Jun 20, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00433916 and IN00435448.
Complaint Details
Investigation of Complaints IN00433916 and IN00435448 found no deficiencies related to the allegations; both complaints were not substantiated.
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.
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
Date: Mar 7, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426991.
Complaint Details
Complaint IN00426991 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00426991 were cited. The facility was found to be in compliance with applicable regulations.
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
Date: 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
Date: 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
Deficiencies: 2
Date: Dec 11, 2023
Visit Reason
The inspection was conducted as part of a regulatory survey to assess compliance with healthcare regulations, including pain management and dementia care interventions.
Findings
The facility failed to ensure non-pharmacologic interventions were implemented and documented prior to administering opioid pain medication for one resident. Additionally, the facility failed to update dementia care interventions to accurately reflect a resident's current cognitive status.
Deficiencies (2)
F 0697: The facility failed to implement and document non-pharmacologic interventions prior to administering opioid pain medication for Resident 228. No documentation was found in the medication administration record, nursing progress notes, or care plan regarding such interventions.
F 0744: The facility failed to update dementia care interventions to accurately reflect the current cognitive status of Resident 4. The care plan indicated intact memory, but interviews and progress notes showed cognitive decline.
Report Facts
Medication administration dates: 18
Residents reviewed: 3
Residents reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding non-pharmacologic interventions and provided current medication documentation procedure | |
| Administrator | Interviewed regarding facility policy on non-pharmacologic interventions prior to opioid administration | |
| Registered Nurse (RN) 3 | Interviewed regarding Resident 4's cognitive status and care plan accuracy | |
| MDS Coordinator and Social Services Director | Interviewed regarding updating care plans for cognitive status | |
| Nurse Practitioner 2 | Provided progress notes on Resident 4's cognitive status |
Inspection Report
Annual Inspection
Census: 79
Deficiencies: 2
Date: Dec 11, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the investigation of Complaints IN00422926 and IN00423526.
Complaint Details
Complaint IN00422926 was investigated with no findings related to the allegations.
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.
Deficiencies (2)
Failed to ensure non-pharmacologic interventions were implemented and documented prior to administration of PRN opioid pain medication for Resident 228.
Failed to ensure dementia care interventions were updated and accurate for Resident 4.
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
Date: 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.
Complaint Details
Complaint IN00423526 was investigated with no findings related to the allegations cited.
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.
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
Date: Aug 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00414740.
Complaint Details
Complaint IN00414740 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00414740 were cited. The facility was found to be in compliance with applicable regulations.
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
Date: Jun 27, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410950.
Complaint Details
Complaint IN00410950 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00410950 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 2
Medicaid residents: 51
Other residents: 23
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 16, 2023
Visit Reason
The inspection was conducted in response to complaints IN00410058 and IN00410262 regarding the use of physical restraints on residents.
Complaint Details
This Federal Finding relates to Complaint IN00410058 and IN00410262.
Findings
The facility failed to ensure residents were free from physical restraints unless medically necessary. Specifically, Resident B was restrained with a gait belt and BRODA chair without a physician's order, despite restlessness and fall prevention concerns.
Deficiencies (1)
F 0604: The facility failed to ensure residents were free from physical restraints unless needed for medical treatment. Resident B was restrained with a gait belt and BRODA chair without a doctor's order, and staff did not follow proper protocols.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Named in restraint use without physician order and related incident. |
| LPN 2 | Licensed Practical Nurse | Observed and removed restraint from Resident B and reported incident. |
| CNA 4 | Certified Nurse Aide | Placed restraint on Resident B during shift. |
| LPN 5 | Licensed Practical Nurse | Provided definition and explanation of restraint during interview. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 16, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00410058 and IN00410262 completed on June 16, 2023.
Complaint Details
Investigation of Complaint IN00410058 and IN00410262 was reviewed and found to be in compliance.
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.
Inspection Report
Complaint Investigation
Census: 79
Capacity: 79
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
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.
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
Date: Apr 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00405142.
Complaint Details
Complaint IN00405142 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00405142 were cited. The facility was found to be in compliance with applicable regulations.
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
Date: Mar 2, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00400155 completed on January 31, 2023.
Complaint Details
Complaint IN00400155 - Corrected.
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.
Report Facts
Census: 83
Medicare residents: 6
Medicaid residents: 51
Other payor residents: 26
Inspection Report
Complaint Investigation
Census: 82
Capacity: 82
Deficiencies: 2
Date: 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.
Complaint Details
Complaint IN00400155 was substantiated. Federal/state deficiencies related to the allegations were cited at F580 and F684.
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.
Deficiencies (2)
Failed to notify the physician of a resident's significant change in condition for 1 of 3 residents reviewed (Resident 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).
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
Date: 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
Date: 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.
Deficiencies (2)
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.
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.
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
Date: 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.
Deficiencies (4)
Facility failed to ensure a resident received showers or bed baths as scheduled for 1 of 1 resident reviewed (Resident 26).
Facility failed to ensure medications were administered as ordered by the physician for 1 of 1 resident reviewed (Resident 42).
Facility failed to monitor medication side effects for 1 of 5 residents reviewed (Resident 19).
Facility failed to ensure proper food temperatures were maintained at the time of meal service for 78 residents.
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
Date: 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
Date: Aug 11, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00386600.
Complaint Details
Complaint IN00386600 was investigated and determined to be unsubstantiated due to lack of evidence.
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.
Report Facts
Census: 86
Total Capacity: 86
Medicare Census: 8
Medicaid Census: 44
Other Payor Census: 34
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