Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northern Lakes Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to follow infection control practices during meal service and linen handling. During dining observations, one resident touched another resident’s dessert and another resident handled a peer’s silverware before the items were used again, while staff did not prevent the contamination. A CNA also touched multiple surfaces, her hair, and her eye while serving meals without hand hygiene, and a housekeeper handled soiled linens without gloves and held them against her body. The DON stated staff should supervise residents during meals and contaminated items should be removed and replaced.
Dignity was not maintained during meal service when two residents with severe cognitive impairment were seated next to tablemates who were served first, leaving them without food for extended periods. One resident waited 24 minutes after a tablemate was served, and another waited 13 minutes; both leaned toward or reached for the other residents' food, and staff were not immediately present during part of the incident. The DON stated the delayed service was excessive and undignified.
Inconsistent Dialysis Communication and Documentation: A resident with ESRD and DM who was dependent on dialysis had a physician order for vital signs before and after dialysis, but the facility did not maintain consistent communication with the dialysis center in a binder or nurses’ notes. The DON stated the facility did not communicate daily on dialysis days, did not use a communication binder, and only contacted the dialysis center as needed by phone; RN 10 stated pre- and post-dialysis assessments were documented in progress notes and dialysis treatment notes were scanned monthly.
Unsafe and Damaged Resident Rooms: The facility failed to maintain a safe and homelike environment in several resident rooms. Observations found peeling paint, exposed drywall, missing flooring, scuffed walls and doors, and damaged bathroom surfaces visible from the hallway. A resident said some wall damage had been caused by a former roommate using mechanical equipment, and the DON stated no work orders had been submitted for the room despite monthly room inspections being expected and staff being responsible for completing work orders.
A resident with multiple cardiac and respiratory conditions reported radiating shoulder and chest pain and difficulty breathing, but staff failed to notify the physician or conduct appropriate assessments. The nurse administered PRN medication without documenting interventions or follow-up, and the resident was later found deceased. The physician was only notified after the resident's death, in violation of facility policy.
A resident with multiple cardiac and respiratory conditions reported left shoulder pain radiating to the chest, increased heart rate, and shortness of breath. An LPN administered as-needed medication but did not document the intervention, perform a thorough assessment, or monitor the resident's condition afterward. The resident was not reassessed or checked on during the night and was found deceased the next morning. The facility's policy requiring immediate assessment and communication of changes in condition was not followed.
A facility failed to protect a resident's health information, as observed when a worksheet with resident details was left uncovered on a medication cart and a computer screen displaying resident information was left open. The resident involved had diagnoses including hip subluxation and diabetes, and was cognitively intact. The facility's policy required confidential information to be secured, but staff did not adhere to this, leaving sensitive information exposed.
A facility failed to follow orders for a splint for a resident with a stroke history affecting her left side. The resident reported that staff no longer placed the splint on her hand, and observations confirmed its absence. Staff interviews revealed inconsistencies in splint application, and there was no order for the splint in the resident's chart, despite care plan indications and facility policy requirements.
The facility failed to properly disinfect a glucometer between uses for two residents, using alcohol pads instead of bleach wipes as required by policy. An LPN and a QMA were observed using the glucometer for multiple residents without proper disinfection, contrary to CDC guidelines and facility policy. The DON confirmed that bleach wipes should be used for disinfection.
A facility failed to protect residents from verbal abuse when a CNA left a resident on the commode and used foul language upon returning, leading to a verbal altercation. The incident involved three cognitively intact residents, with one resident overhearing the exchange. The facility's abuse prohibition policy was not followed, resulting in a deficiency related to a complaint investigation.
Infection Control Failures During Meal Service and Linen Handling
Penalty
Summary
The facility failed to ensure infection control practices were observed during meal service and linen handling for multiple residents. During an observation in the dining room, an activity aide served a meal to one resident while another resident seated nearby grabbed the resident’s cobbler and held the bowl and food in her hands. The aide then removed the cobbler and handed it back to the original resident. In a separate meal observation, one resident grabbed another resident’s silverware, touching the handles and mouthpieces, and the resident then used the same silverware to eat. The activity aide stated she should not have handed the cobbler back after it had been touched by the other resident and should have obtained a new serving from the kitchen. Record review showed the residents involved had care needs related to dining supervision or assistance. One resident had Alzheimer’s disease, depression, and muscle weakness, with a BIMS score of 14 and a care plan calling for supervision while eating. Another resident had Pick’s disease and severe dementia, was dependent for eating, and had a care plan for meal assistance. A third resident had cerebral infarction and moderate dementia with agitation, a BIMS score of 3, and a care plan calling for close supervision and assistance during all meals. The DON stated staff should serve trays, sit next to residents, supervise them, and ensure they did not touch one another’s food or utensils, with contaminated items removed and replaced. The facility also failed to maintain hand hygiene and linen handling practices during direct resident care and meal service. A CNA touched multiple items, including a pillow, personal items, a cup, a resident’s meal tray, her hair, and her eye, and then served another resident’s tray and cut food without any hand hygiene during the continuous observation. The CNA stated she should have used hand sanitizer after contacting anything and washed her hands if she contacted something soiled. In another observation, a housekeeper removed dirty linens from a resident’s bed without gloves and held the linens against her body while placing them in a plastic bag. The housekeeper stated she should have worn gloves and kept contaminated linens from touching her body. Record review showed the residents involved had diagnoses including heart failure, dementia, cerebrovascular accident with hemiplegia, and chronic inflammatory demyelinating polyneuritis with acute pyelonephritis, and facility policies required hand hygiene after resident contact and gloves when handling soiled linens.
Dignity Not Maintained During Meal Service
Penalty
Summary
The facility failed to ensure dignified meal service for residents seated together in the dining room when two residents were left without food while their tablemates were served. During an observation, one resident was served a sandwich, pasta salad, yogurt, and peach cobbler while the resident seated next to her had no food or drink in front of her. The resident without food grabbed the cobbler from the tablemate, and staff removed it and returned it to the other resident. Over the next few minutes, the resident continued to lean toward and reach for the tablemate's food. The resident's lunch tray was not served until 24 minutes after the tablemate's tray was delivered. In a separate observation, one resident was served lunch while the resident seated next to him leaned toward and reached for his food before receiving a tray 13 minutes later. A few minutes after that resident was served, the first resident grabbed the second resident's silverware, and no staff were in the immediate vicinity. The records showed both residents had severe cognitive impairment with BIMS scores of 3. One resident had diagnoses of neurocognitive disorder with Lewy bodies and major depressive disorder, recurrent, and needed supervision and touching assistance with dining. The other resident had cerebral infarction and dementia, moderate with agitation, and needed partial or moderate assistance with eating tasks and close supervision and assistance during all meals. The DON stated staff should serve one table at a time so residents would not sit for long periods without food and said the 24-minute wait was excessive and undignified.
Inconsistent Dialysis Communication and Documentation
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met for one resident with end stage renal disease and diabetes who was dependent on dialysis. The resident’s physician order required vital signs to be assessed before dialysis and upon return from dialysis. The resident’s dialysis treatment notes were uploaded in separate batches over several months, including notes from 5/7/25 through 8/15/25 uploaded on 8/18/25, notes from 9/22/25 through 11/7/25 uploaded on 11/11/25, and notes from 8/18/25 through 8/29/25 uploaded on 12/4/25. The facility did not maintain consistent communication with the dialysis center in a binder or in the nurses’ notes to show that resident status was available before, during, and after dialysis. The DON stated the facility did not communicate with the dialysis center daily on dialysis days, did not use a communication binder, and communicated with the dialysis center only as needed by phone. The DON also stated they were not aware of any requirement to maintain regular ongoing communication with the dialysis center. RN 10 stated pre- and post-dialysis assessments were documented in progress notes and that dialysis center treatment notes were scanned into the medical record monthly.
Unsafe and Damaged Resident Rooms
Penalty
Summary
The facility failed to ensure a safe and homelike environment for 7 of 7 residents reviewed in rooms 17, 19, 20, and 21. During continuous observation, a large section of marked and scuffed wall in one room had peeling white substance behind the resident’s bed, and the damage was visible from the hallway. In another room, a 2 inch by 6 inch section of bathroom floor was missing. In a third room, black scuff marks covered the bathroom door, peeling paint and exposed soft drywall were found near the windowsill and room temperature control unit, and one of three wooden trim pieces was missing. In a fourth room, peeling paint was found next to the heater unit at floor trim level and flooring was missing in an area measuring approximately 1 foot by 1 foot; the wall damage in these rooms was visible from the hallway. Resident 1 stated that the wall damage in their room had occurred when a former roommate who needed mechanical assistance had hit the wall with equipment, and that the roommate had been gone from the room for 6 months. The Director of Maintenance stated that work orders included wheelchair and equipment maintenance, plumbing concerns, and lighting concerns, that any staff could submit a work order, and that no work orders had been submitted for the room. The Director of Maintenance also stated that monthly room inspections were expected and that he had forgotten residents’ verbal requests for work. A current policy reviewed in 2025 stated that work orders were required to establish priority of maintenance services, that work order forms were to be maintained at nurse’s stations, and that every employee had a responsibility to fill out work orders.
Failure to Notify Physician of Change in Condition Resulting in Resident Death
Penalty
Summary
A deficiency occurred when the facility failed to immediately notify a physician of a significant change in a resident's physical condition. The resident, who had a history of chronic obstructive pulmonary disease (COPD), mild dementia, intermittent atrial fibrillation, sick sinus syndrome, and left shoulder pain due to degenerative joint disease, complained of radiating pain to his left arm, shoulder, and chest, and reported difficulty breathing. Despite these symptoms, which were documented by staff, there was no evidence that the physician was notified of the change in condition at the time it occurred. The nurse on duty administered as-needed medication but did not document which medications were given or what interventions were attempted. There was no assessment of the resident's pain using a pain scale, nor was there documentation of respiratory or cardiac assessments. The nurse did not follow up with the resident after the initial complaint, nor did he communicate the situation to the nurse coming on shift. Other staff members, including a CNA, observed the resident in distress and reported it to the nurse, but no further action was taken to escalate the situation or notify the physician. The following morning, the resident was found unresponsive and without a pulse, and was pronounced deceased. Documentation shows that the physician was not notified of the resident's change in condition until after the resident was found deceased. The facility's policy required immediate communication of status changes to licensed personnel and prompt assessment and physician notification, but these procedures were not followed in this case.
Removal Plan
- Conduct audits of residents' condition to ensure no changes
- Re-educate nursing staff regarding assessments, documentation, and physician notification
Failure to Assess and Monitor Resident After Complaint of Radiating Pain and Shortness of Breath
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), mild dementia, intermittent atrial fibrillation, sick sinus syndrome, and left shoulder pain due to degenerative joint disease reported experiencing left shoulder pain radiating to the chest, increased heart rate, and shortness of breath. The resident's care plan included monitoring for pain and shortness of breath, with instructions to notify the physician if pain worsened or was not controlled by medication. On the evening in question, the resident complained of these symptoms, and a nurse administered as-needed medication but failed to document which medications were given, perform a thorough assessment, or monitor the effectiveness of the interventions. There was no documentation of a pain assessment, pain scale, or detailed evaluation of the resident's respiratory or cardiac status at that time. Following the initial complaint, the resident was not reassessed, and no further monitoring or documentation occurred throughout the night. The nurse did not report the incident or the administration of as-needed medication to the incoming nurse, and no additional checks were performed on the resident. The next morning, the resident was found unresponsive, with no pulse or respirations, and was pronounced deceased. Interviews with staff revealed that the nurse did not assess the resident's shoulder pain, breath sounds, or heart sounds, and did not notify the physician, as the resident had expressed a desire to wait and see if he felt better. Additionally, staff limited nighttime checks on the resident due to his preference for minimal disturbance, which contributed to the lack of follow-up. The facility's policy required immediate assessment and communication of any change in resident condition, including new or worsened pain, but this was not followed. The nurse failed to perform a comprehensive assessment or ongoing monitoring after the resident's complaint of radiating pain and shortness of breath, and there was a lack of communication between staff regarding the resident's change in condition and the interventions provided. The absence of reassessment and monitoring after the initial complaint and intervention directly contributed to the deficiency identified in the report.
Failure to Protect Resident Health Information
Penalty
Summary
The facility failed to ensure the privacy of protected health information for one resident, identified as Resident 44, during multiple observations. On one occasion, a worksheet containing resident information was left uncovered on top of a medication cart in the hallway, with no staff present, while unidentified residents were nearby. Additionally, a Licensed Practical Nurse (LPN) left a computer screen open on the medication cart, displaying resident information, and walked away. This occurred twice, once in the hallway and once at the nurses' station, with other staff members present who did not take action to conceal the information. Resident 44's medical records included diagnoses such as unspecified subluxation of the right hip, type 2 diabetes mellitus with hyperglycemia, and essential hypertension. The resident was cognitively intact, as indicated by a Basic Interview for Mental Status (BIMS) score of 15. The facility's policy, provided by the Administrator, stated that confidential information should not be left unattended on medication carts or open on computer screens. The Administrator acknowledged awareness of the issue and confirmed that staff should ensure resident information is kept confidential.
Failure to Follow Splint Orders for Resident with Stroke History
Penalty
Summary
The facility failed to ensure that orders for a splint were entered and followed for a resident who had a history of a stroke affecting her left side. The resident, who was discharged from therapy with a recommendation to use a splint for her left hand, reported that staff no longer placed the splint on her hand. Observations confirmed that the resident did not have a splint on her left hand, and the splint was found in a bag by her bed with instructions indicating it should be worn daily/nightly and removed for AM/PM care. Interviews with staff revealed inconsistencies in the application of the splint. A CNA indicated the splint was worn for only 4 hours a day, while an RN stated that the instructions were to wear it daily/nightly. The RN also noted that there was no order for the splint in the resident's chart, although staff shared the instructions in reports. The Director of Nursing confirmed the absence of a splint order in the resident's records, despite the care plan indicating the resident was at risk for further contracture and increased pain. The facility's policy required therapists to complete an order for discharge recommendations, which was not done in this case.
Improper Disinfection of Glucometer Between Resident Uses
Penalty
Summary
The facility failed to ensure proper disinfection of a blood sugar meter (glucometer) between resident uses, affecting two residents. On December 5, 2024, an LPN was observed cleaning the glucometer with an alcohol pad, which was the standard practice according to the LPN. However, the medication cart did not contain disposable bleach wipes, which are required for proper disinfection. On December 9, 2024, a QMA was observed using the same glucometer for two residents, cleaning it with an alcohol pad between uses. The QMA confirmed that all residents on the unit used the same glucometer and that they had been trained to clean it with an alcohol pad. The Director of Nursing (DON) later indicated that shared glucometers should be cleaned with an approved bleach sanitizer after each use, as alcohol pads are not recommended for this purpose according to CDC guidelines. The facility's policy, provided by the DON, also stated that glucometers should be cleaned with disposable bleach wipes and remain wet for one minute. The deficiency was identified through observations, interviews, and record reviews, highlighting a failure to adhere to the facility's infection prevention and control program.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect residents from verbal abuse, as evidenced by an incident involving a Certified Nurse Aide (CNA) and three residents. Resident 15, who was cognitively intact, was left on the commode by CNA 2, who instructed her to use the call light when finished. Despite Resident 15's verbal indication that she was done, CNA 2 left the room, leading to Resident 15's frustration. Resident 18, also cognitively intact, witnessed the situation and informed a Licensed Practical Nurse (LPN) of Resident 15's need for assistance. Upon returning, CNA 2 and Resident 15 were overheard yelling at each other, with CNA 2 using foul language, which was also heard by Resident 44. The incident was documented in a facility-reported incident (FRI) and an investigation was conducted by the Director of Nursing (DON). Interviews with the residents confirmed the verbal altercation, and CNA 2's file indicated a history of using inappropriate language. The facility's policy on abuse prohibition, which defines verbal abuse as the use of disparaging and derogatory terms, was not adhered to in this case. The deficiency was related to a complaint investigation, highlighting a failure to ensure residents were free from verbal abuse.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Angola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeland Rehab And Healthcare Center | 0 mi | ★★★★★ | 6 | 0 |
| Pines Of Dekalb | 15.5 mi | ★★★★★ | 2 | 0 |
| Betz Nursing Home | 17.6 mi | ★★★★★ | 1 | 0 |
| Lutheran Life Villages | 18 mi | ★★★★★ | 2 | 0 |
| Park View Care Center | 18.3 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.