Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 0 | 0 |
| Laurels Of Dekalb | 15.5 mi | — | 0 | 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 August 2026) and official state health department websites.