Northern Lakes Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Northern Lakes Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF580Sep 17, 2025

  Based on interview and record review, the facility failed to ensure the physician was immediately notified when 1 of 3 residents reviewed had a significant change in physical condition (Resident K). This resulted in Resident K's death. The Immediate Jeopardy began on [DATE] at 8:51 p.m. when Resident K complained of radiating pain to his left arm, shoulder, and chest. The facility failed to notify the physician of the change, and Resident K was observed to be deceased the following morning. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 12:45 PM. […]

• Immediate jeopardy, isolatedF684Sep 17, 2025

  Based on interview and record review, the facility failed to ensure a resident's complaint of shoulder with radiating chest pain, increased heart rate and shortness of breath (SOB) was re-assessed after initial assessment and treatments given were not monitored for effectiveness for 1 of 3 residents reviewed for quality of care. Resident K was found deceased the following morning. The Immediate Jeopardy began on [DATE] at 8:51 p.m. when Resident K complained of radiating pain to his left arm, shoulder, and chest. The facility failed to assess and monitor his condition, and he was observed to be deceased the following morning. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 12:45 PM. […]

• Actual harm, isolatedF684Jan 31, 2023

  Based on interview and record review, the facility 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). Findings include: On 1/31/23 at 10:29 A.M., Resident D's record was reviewed. Diagnoses included paraplegia and right sided inguinal hernia (a bulging of the contents of the abdomen through a weak area in the lower abdominal wall which most often contain fat or part of the small intestine). Physician notes indicated the resident was being monitored by a general surgeon and his primary care physician (PCP) for a right sided inguinal hernia, bothersome to the resident. […]

• No harm, potential for more than minimal, widespreadF812Nov 17, 2022

  Based on observation, interview and record review, the facility failed to ensure proper food temperatures were maintained at the time of meal service. 78 of 78 residents residing in the facility ate food prepared in the kitchen. Findings include: During an interview on 11/13/22 at 10:50 AM, Cook 2 indicated food temperatures were normally checked when food was finished cooking prior to placing on the steam table. He indicated lunch items are placed on the steam table between 10 and 11 AM. He indicated temperatures are not checked again prior to meal service. In an observation on 11/13/22 at 10:55 AM, just prior to meal service food temperatures taken included pureed chicken, 122 degrees, tomato soup 110 degrees, and hamburgers 104 degrees. […]

• No harm, potential for more than minimal, patternF880Dec 4, 2025

  Based on observation, interview, and record review the facility failed to ensure infection control practices were observed for 7 of 24 residents reviewed (Resident 61, Resident 30, Resident 9, Resident 70, Resident 40, Resident 1, and Resident 86).Findings include:1) During an observation, on 12/01/2025 11:41 AM, Activity Aide (AA)2 served a sandwich, pasta salad, yogurt and peach cobbler to Resident 61 at a table in the dining room. Resident 30 was seated next to Resident 61 and did not have any food or drinks in front of her. On 12/01/25 at 11:43 AM, Resident 30 grabbed a bowl of cobbler from Resident 61, held it in her hands touching the cobbler and the bowl. On 12/1/2025 11:44 AM, AA2 removed the cobbler from Resident 30 and handed it back to Resident 61. […]