Inspection visit
Inspection
20 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 20 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview and review of facility policy, the facility failed to have consistent documentation
of Advanced Directive status across all medical records for Resident #1 and #29) and failed to have any
documented evidence of Advanced Directive status for Resident #36. This affected three (#1, #29 and #36)
of four residents were reviewed for Advance Directives. The facility census was 36.
Findings include:
1. Medical record review for Resident #1 revealed an admission date of 01/08/19. Diagnoses included
mixed hyperlipidemia, essential hypertension, primary generalized osteoarthritis, other idiopathic scoliosis,
atrial fibrillation and cerebral palsy.
Review of the electronic medical record for Resident #1 on 04/30/19 at 9:25 A.M. reflected the profile page
to be silent to any advance directive code status. Review of the physician orders also found no advance
directive code status. Review of the hard medical record found a Do Not Resuscitate (DNR) form dated
01/08/19 that had been signed by both physician and resident and marked for Do Not Resuscitate Comfort
Care (DNRCC).
Interview with Registered Nurse (RN) #115 on 04/30/19 at 10:00 A.M. stated she would go to the electronic
resident profile page to ascertain code status if on the floor, or she could check the hard paper chart for
code status of a red paper stating DNRCC, or a green paper stating Full Code.
Interview with Licensed Practical Nurse (LPN) #103 on 04/30/19 at 3:00 P.M. stated she would look at the
electronic resident profile page and physician orders for code status, and the code status should be flagged
right inside the hard chart by a red no code or green full code paper right inside the hard chart.
Interview with Social Service Designee (SSD) #101 on 05/02/19 at 8:54 A.M. stated SSD #101 stated when
a resident was admitted , she determined the advance directive status and enters it on the care plan. She
passes along this information to nursing and they were to enter it in the electronic record and flag the hard
medical chart so they match. The DNR form was to be in the hard record and should also be in physician
orders. The SSD #101 stated she was to review the code status for every resident quarterly. It was also her
responsibility to audit medical records for accuracy of code status. She verified the electronic and hard
chart for Resident #1 did not match.
Interview on 05/02/19 at 2:30 P.M. with Regional Director of Clinical Services (RDCS) #104 verified theses
findings.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 15
Event ID:
365666
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365666
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Lake Rehabilitation Center
14442 State Route 33 West
Lakeview, OH 43331
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
2. Medical record review for Resident #29 revealed an admission date of 05/28/14. Diagnoses included
hypertension, hyperlipidemia, dementia without behavioral disturbance, acute embolism and thrombosis of
unspecified deep veins of right lower extremity, dermatitis, asthma, and osteoarthritis.
Review of the electronic profile page for Resident #29 reflected the resident was a Full Code status.
However, the hard medical record contained a DNR form, dated 10/05/18, which identified the resident as a
DNRCC-A.
Review of current physician orders for May 2019 found an entry which stated the resident was a Full Code.
Social service progress notes were silent to advance directive status.
Review of the plan of care, initiated 02/09/17 with a revision date of 03/18/19, stated the resident has
chosen a Full Code status.
Interview on 05/01/19 at 2:30 P.M. with RDCS #104 verified the code status for Resident #29 was not
consistent across all parts of the medical record.
3. Record review for Resident #36 revealed the resident was admitted to the facility on [DATE]. Diagnoses
included chronic kidney disease, chronic obstructive pulmonary disease, diabetes type II, sickle cell
anemia, hypertension, alcoholic cirrhosis of the liver, iron deficiency and anxiety disorder.
Review of a physician order, dated 03/13/19, revealed the resident's advanced directive was a full code
status.
Review of the social service progress note, dated 04/03/19, stated Resident #36's advanced directives
have been reviewed and were located on the chart. He has chosen to have a Full Code status.
Review of the plan of care, revised on 04/17/19, revealed Resident #36 has chosen a full code status for his
advance directive. The interventions included staff was to document his advance directive in the chart.
Interview on 05/01/19 at 2:30 P.M. with Licensed Practical Nurse (LPN) #119 verified there was no code
status listed on the electronic record face sheet. She stated if the resident was found unresponsive she
would check the resident's code status on the electronic record . Since there was no code status in the
electronic record, she would go to the resident's hard copy chart to check his code status. She verified
there was no code status listed under advanced directives in the hard copy chart.
Interview with Regional Director Clinical Services #104 she verified Resident #36 did not have a advance
directive in the electronic record or in the chart.
Review of an undated facility policy titled Advance Directive Policy revealed documentation, written or oral,
of informed consent to withhold or withdraw treatment must be placed in the resident's medical record
together with the attending physician's order regarding the withholding or withdrawal of treatment. The
physician's order should also be noted on the resident's plan of care and on the inside and outside of the
resident's medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365666
If continuation sheet
Page 2 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365666
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Lake Rehabilitation Center
14442 State Route 33 West
Lakeview, OH 43331
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Potential for
minimal harm
Based on personnel record review, staff interview, and facility policy review, the facility failed to ensure
reference checks were completed for new hires. This affected six of six employees reviewed for completion
of reference checks. This had the potential to affect all 36 residents.
Residents Affected - Many
Findings include:
Review of the personnel record for State Tested Nurse Aide (STNA) #108 revealed a hire date of 04/16/19.
There was no documentation of reference checks being completed.
Review of the personnel record for STNA #109 revealed a hire date of 02/01/19. There was no
documentation of reference checks being completed.
Review of the personnel record for STNA #112 revealed a hire date of 06/12/18. There was no
documentation of reference checks being completed.
Review of the personnel record for Director of Nursing (DON) #113 revealed a hire date of 04/22/19. There
was no documentation of reference checks being completed.
Review of the personnel record for Maintenance Supervisor #114 revealed a hire date of 04/10/19. There
was no documentation of reference checks being completed.
Review of the personnel record for Assistant Director of Nursing (ADON) #102 revealed a hire date of
02/11/19. There was no documentation of reference checks being completed.
Interview with Administrator on 05/02/19 at 2:50 P.M. verified there was no documentation of reference
checks being completed for STNA #108, STNA #109, STNA #112, DON #113, Maintenance Supervisor
#114, and ADON #102.
Review of the facility policy titled Ohio Resident Abuse Policy, last revised November 2016, revealed prior to
hiring a new employee, the facility will attempt to obtain references from two prior employers.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365666
If continuation sheet
Page 3 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365666
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Lake Rehabilitation Center
14442 State Route 33 West
Lakeview, OH 43331
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interview, the facility failed to provide written notification to a resident's
representative of a transfer to the hospital. This affected one (#22) of one resident reviewed for
hospitalization. The facility census was 36.
Findings include:
Record review for Resident #22 revealed the resident was admitted to the facility on [DATE]. Diagnoses
included dysphagia, chronic kidney disease, dementia without behaviors, and cognitive communication
deficit.
Review of the nursing progress notes, dated 03/16/19, revealed the resident had an unwitnessed fall in her
room sustaining a laceration to her head. She complained of severe pain in her left hip following the fall.
The resident was transferred to the hospital and admitted for surgical repair of a left hip fracture.
Review of the medical record revealed there was no evidence the resident's representative was given a
written notice for the resident's transfer to the hospital on [DATE].
Interview on 05/02/19 at 3:40 P.M. with the Regional Director of Clinical Services #104 verified there was no
written notice given to Resident #22's representative at the time of the resident's transfer to the hospital on
[DATE].
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365666
If continuation sheet
Page 4 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365666
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Lake Rehabilitation Center
14442 State Route 33 West
Lakeview, OH 43331
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review and staff interview, the facility failed to provide a bed hold notice to a resident's
representative when the resident was transferred to the hospital. This affected one (#22) of one resident
reviewed for hospitalization. The facility census was 36.
Findings include:
Record review for Resident #22 revealed the resident was admitted to the facility on [DATE]. Diagnoses
included dysphagia, chronic kidney disease, dementia without behaviors, and cognitive communication
deficit.
Review of the nursing progress notes, dated 03/16/19, revealed the resident had an unwitnessed fall in her
room sustaining a laceration to her head. She complained of severe pain in her left hip following the fall.
The resident was transferred to the hospital and admitted for surgical repair of a left hip fracture.
Review of the medical record revealed there was no evidence the resident's representative was given a bed
hold notice when the resident transferred to the hospital on [DATE].
Interview on 05/02/19 at 3:40 P.M. with the Regional Director of Clinical Services #104 verified there was no
bed hold notice given to Resident #22's representative at the time of the resident's transfer to the hospital
on [DATE].
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365666
If continuation sheet
Page 5 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365666
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Lake Rehabilitation Center
14442 State Route 33 West
Lakeview, OH 43331
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Based on record review and staff interview, the facility failed to ensure a comprehensive person centered
care plan was written for Resident #25 and the correct code status for Resident #29's care plan. This
affected two (#25 and #29) of 17 residents reviewed for care plans. The facility census was 36.
Findings include:
1. Medical record review for Resident #25 revealed an admission date of 01/05/19. Diagnoses included
anxiety disorder.
Review of the current physician orders, dated 03/05/19, revealed the resident had an order to receive an
antianxiety medication named Buspar five milligrams (mg.) twice daily.
Review of a Minimum Date Set (MDS) assessment, dated 04/09/19, revealed the resident had a diagnosis
of anxiety with the use of antianxiety medication.
Review of the comprehensive care plan, initiated 01/05/19 and revised 04/09/19, revealed it was silent to
the resident's diagnosis of anxiety disorder with no planned interventions to address this need, and did not
address the use of the psychoactive antianxiety medication.
Interview with MDS Coordinator #102 on 05/01/19 at 1:30 P.M. verified there was no care plan to address
the diagnosis of anxiety disorder and there were no planned interventions to address this need.
2. Medical record review for Resident #29 revealed an admission date of 05/28/14. Diagnoses included
dementia without behavioral disturbance, acute embolism and thrombosis of unspecified deep veins of right
lower extremity and osteoarthritis.
Review of the medical record revealed a Do Not Resuscitate (DNR) form, dated 10/05/18, which identified
the resident as a Do Not Resuscitate comfort care arrest (DNRCC-A).
Review of the comprehensive plan of care, initiated 02/09/17 with a revision date of 03/18/19, the resident
has chosen Full Code status, which was not the correct code status.
Interview on 05/01/19 at 2:30 P.M. with the Regional Director of Clinical Services (RDCS) #104 verified
Resident #29's comprehensive care plans had not been accurately developed to reflect the resident's code
status.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365666
If continuation sheet
Page 6 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365666
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Lake Rehabilitation Center
14442 State Route 33 West
Lakeview, OH 43331
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, resident and staff interview, and policy review, the facility failed to have care
conferences on a quarterly basis and invite a resident to attend a care conference. This affected one (#32)
of two residents reviewed for care conference attendance. The facility census was 36.
Findings include:
Record review for Resident #32 revealed the resident was admitted to the facility on [DATE]. Diagnoses
included hypertension, gastro-esophageal reflux disease, chronic obstructive pulmonary disease, and
dementia with behavioral disturbances.
Review of the annual comprehensive Minimum Data Set (MDS) assessment, dated 04/05/19, revealed the
resident has no cognitive impairments. He was assessed to have no delusion, hallucinations, or any
behavioral symptoms.
Review of the social service progress note, dated 01/23/19, stated Social Service Designee #101
approached the resident concerning a care conference and the resident refused stating no, he didn't want
to go. He stated to just find him a place to live and get him out of the facility.
Review of the progress notes, from 01/22/19 through the present date 04/30/19, revealed no
documentation that a care conference was held to discuss the resident's care.
During an interview with Resident #32 on 04/29/19 at 10:06 A.M., he stated he has not been invited to a
care conference to discuss his plan care.
On 04/30/19 at at 3:00 P.M., during an interview with Social Service Designee #101, she verified there was
no care conference held following the annual comprehensive assessment on 04/04/19. She verified
Resident #32 had not been invited to a care conference following the MDS assessment on 04/04/19. She
verified the interdisciplinary team did not have a care conference following the 04/04/19 MDS assessment.
Review of the facility's policy on Care Conference, dated 01/27/11, stated under the procedure, each
resident shall be invited to participate in their care conference. The policy also stated a care conference
should be held quarterly and annually.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365666
If continuation sheet
Page 7 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365666
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Lake Rehabilitation Center
14442 State Route 33 West
Lakeview, OH 43331
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, staff interview, and review of hospice contracts, the facility failed to ensure
collaboration and communication between the facility and hospice entities for two (#5 and #31) of two
residents reviewed for hospice services. The facility identified four residents currently receiving hospice
services. The facility census was 36.
Residents Affected - Few
Findings include:
1. Medical record review for Resident #31 revealed an admission date of 03/05/19. Diagnoses included
dementia with behaviors.
Review of the current physician orders for May 2019 reflected an order to admit to Hospice services for end
stage dementia. The medical record contained a Hospice contract signed by the resident's responsible
party, dated 04/12/19.
On 05/01/19 at 10:50 A.M. a Hospice nurse from Hospice Entity #105 was observed at the nurse's station
writing orders and talking with staff Registered Nurse (RN) #106. After the hospice nurse left the nurse's
station, an interview with RN #106 found that the hospice nurse speaks with facility staff during her visits,
but leaves no progress notes in the medical record regarding her observations and interactions with the
resident, or care rendered. There were also no care notes provided by hospice nurse aide assistants after
their visits twice weekly.
On 05/01/19 at 12:00 P.M., an interview with Regional Nurse #104 was conducted. She stated it was the
facility expectation that Hospice should be leave progress notes of all visits with the facility as part of the
medical record. She verified that the hospice entity had not provided their progress notes to the facility for
continuity of care.
Review of the contract titled Nursing Facility Agreement, dated 02/03/17, stated the agreement was
between Hospice Entity #105 and the nursing facility. The document, under section 4.8 Medical Chart,
reflected Facility and Hospice will prepare and maintain complete medical records for Hospice Patients
receiving Facility services in accordance with this Agreement and will include all treatments, progress
notes, authorizations, physician orders and other pertinent information. Documentation of care and services
provided by Hospice will be filed and maintained in the Facility chart.
2. Review of the medical record for Resident #5 revealed an admission date of 10/23/14 with diagnoses
including multiple sclerosis, paraplegia, developmental disorder, cerebral palsy, depression, and aphasia.
Further review of the medical record revealed Resident #5 was admitted to hospice services on 11/02/18
with Hospice Entity #120.
Review of the hospice binder revealed no documentation of services provided by Hospice Entity #120's
staff in March 2019 and April 2019.
Interview with Licensed Practical Nurse (LPN) #103 on 04/30/19 at 2:39 P.M. revealed hospice staff does
not leave progress notes detailing the care they provided prior to leaving the facility.
Interview with Registered Nurse (RN) #104 on 05/01/19 at 12:30 P.M. revealed Hospice Entity #120's staff
were supposed to leave progress notes in the hospice binder at the nurse's station. RN #104 verified the
facility did not have documentation of services provided by Hospice Entity #120's staff
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365666
If continuation sheet
Page 8 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365666
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Lake Rehabilitation Center
14442 State Route 33 West
Lakeview, OH 43331
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
in March 2019 or April 2019.
Level of Harm - Minimal harm
or potential for actual harm
Review of the facilities Hospice Agreement with Hospice Entity #120 revealed hospice shall promote open
and frequent communication with the facility and shall provide the facility with sufficient information to
ensure that the provision of services under this agreement is in accordance with the hospice plan of care,
assessments, treatment planning and care coordination. Hospice will promptly inform the facility of any
change in a hospice patient's condition which requires a modification to the hospice plan of care.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365666
If continuation sheet
Page 9 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365666
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Lake Rehabilitation Center
14442 State Route 33 West
Lakeview, OH 43331
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, observation, and staff interview, the facility failed to ensure Resident #5 received
tube feeding as ordered by the physician. This affected one (Resident #5) of one resident reviewed for tube
feeding. This facility identified one resident who received tube feeding.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #5 revealed an admission date of 10/23/14 with diagnoses
including multiple sclerosis, paraplegia, developmental disorder, aphasia, and cerebral palsy.
Review of the resident's physician orders, dated 08/28/17, revealed a diet order for nothing by mouth
(NPO). Further review of the physician orders, dated 01/15/19, revealed Fibersource, a tube feeding
formula, was to run at 65 milliliters per hour for a total of 22 hours each day and water was to run at 30
milliliters per hour while the tube feeding was running via gastrostomy tube (a tube used to provide
nutrients and fluid into the stomach).
Review of the Medication Administration Record (MAR) for Resident #5 revealed a new tube feeding bag
was to be hung at 6:00 P.M.
Observation on 04/29/19 at 10:38 A.M. revealed Resident #5's tube feeding was turned off. Observation on
04/30/19 at 11:00 A.M., 1:35 P.M., and 2:22 P.M. revealed Resident #5's tube feeding was turned off.
Interview with Licensed Practical Nurse (LPN) #103 on 04/30/19 at 2:39 P.M. revealed Resident #5's tube
feeding was to run for 22 hours each day from 6:00 P.M. to 4:00 P.M. and the tube feeding was supposed to
be turned off for two hours from 4:00 P.M. to 6:00 P.M. Interview with LPN #103 on 04/30/19 at 2:39 P.M.
verified Resident #5's tube feeding was turned off. LPN #103 was unable to provide an explanation as to
why the tube feeding was turned off.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365666
If continuation sheet
Page 10 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365666
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Lake Rehabilitation Center
14442 State Route 33 West
Lakeview, OH 43331
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
Based on record review and staff interview, the facility failed to act upon a physician's response to the
pharmacist recommendation for a resident. This affected one (#33) of five residents reviewed for
unnecessary medication. The facility census was 36.
Findings include:
Medical record review for Resident #33 revealed an admission date of 03/30/15. Diagnoses included
Alzheimer's disease, major depressive disorder, insomnia, psychosis, schizophrenia, and bipolar disorder
current episode depressed severe with psychotic features.
Review of current physician orders, dated May 2019, revealed the resident had orders for the following
psychoactive medications: antidepressants Trazadone 25 milligrams (mg.) daily, mirtazapine 15 mg. at
bedtime, and citalopram 20 mg. daily.
Review of a pharmacy medication regimen consultation report, dated 04/02/19, revealed the pharmacist
noted Resident #33 was receiving three antidepressants concomitantly, and recommended the physician to
consider discontinuing Trazodone while continuing mirtazapine at bedtime and while monitoring for
re-emergence of depression/insomnia and/or symptoms. Review of the physician's response, dated
04/09/19, revealed the physician agreed with the pharmacist recommendation with the following
modifications: Decrease mirtazapine to 7.5 mg. at bedtime and was signed and dated 04/09/19 by the
physician.
Below the physician signature and date, the previous Director of Nursing (DON) (Registered Nurse (RN)
#116) had signed and dated the form, 04/12/19, and written verbal order to leave at 15 mg. Further review
of physician orders found no physician signature to verify what the previous DON had written.
Review of the medication administration record (MAR) for April 2019 and May 2019 revealed the physician
recommendations for mirtazapine 7.5 mg. was never implemented. The resident continued to receive
mirtazapine at 15 mg. nightly, as of 05/01/19.
On 05/02/19 at 12:32 P.M., an interview with Regional Director of Clinical Services (RDCS) #104 verified
the medication dosage was never reduced as ordered, and the physician had never signed and authorized
the verbal order written by RN #116.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365666
If continuation sheet
Page 11 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365666
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Lake Rehabilitation Center
14442 State Route 33 West
Lakeview, OH 43331
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based observation, staff interview, and review of facility policy, the facility failed to ensure medications were
stored in a safe and secure manner for one (#90) resident residing in the facility. This had the potential to
affect 15 (#3, #5, #6, #9, #11, #12, #14, #17, #18, #21, #22, #24, #25, #28 and #37) cognitively impaired
mobile residents in the facility. The facility census was 36.
Finding include:
On 05/02/19 at 2:35 P.M., an open box was observed beside the telephone at the nurse's station. The box
was labeled with the name of Resident #90 and contained five individual blister dose packs of an
anticoagulant medication (Eliquis 2.5 milligrams (mg.)) and one blister pack of an antianginal medication
(Isordil 30 mg. half tablet). The nursing station had two entry points without doors or other type of barrier,
and there was no barrier to prevent residents or the public from reaching over the top of the desk. There
was no staff present at the nursing station at the time of the observation. When questioned, Registered
Nurse (RN) #102 and #106 stated Resident #90 was being discharged and needed the medications called
into the pharmacy. The box had been placed by the phone and not returned to the medication storage
room.
Observations from 04/29/19 through 05/02/19, during each day of the survey, cognitively impaired mobile
Residents #3 and #32 had been observed standing or sitting in a wheelchair respectively at the nurse's
station at various times daily.
Interview with the Director of Nursing (DON) on 05/02/19 at 2:40 P.M. verified the box with Resident #90
was left at the nurse's unsecured without any staff present. The DON verified there were 15 cognitively
impaired mobile residents (#3, #5, #6, #9, #11, #12, #14, #17, #18, #21, #22, #24, #25, #28 and #37) in the
facility.
Review of the facility policy titled Storage and Expiration, Dating of Medications, Biologicals, Syringes and
Needles, dated October 2016, revealed under the heading General Storage Procedures, the policy stated
the facility should ensure that all medications and biologicals, including treatment items, were securely
stored in a locked cabinet/cart or locked medication room that was inaccessible by residents and visitors.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365666
If continuation sheet
Page 12 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365666
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Lake Rehabilitation Center
14442 State Route 33 West
Lakeview, OH 43331
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on personnel file record review, staff interview and review of the facility's tuberculosis risk
assessment, the facility failed to complete tuberculosis (TB) skin testing or questionnaire was completed
upon hire and/or annual. This affected eight of eight employees reviewed for TB testing. This had to the
potential to affect all 36 residents residing in the facility.
Residents Affected - Many
Findings include:
Review of the personnel file for State Tested Nurse Aide (STNA) #108 revealed a hire date of 04/16/19.
There was no documentation that a tuberculosis skin test or questionnaire was completed.
Review of the personnel file for STNA #109 revealed a hire date of 02/01/19. There was no documentation
that a tuberculosis skin test or questionnaire was completed.
Review of the personnel file for STNA #110 revealed a hire date of 12/01/16. There was no documentation
that a annual tuberculosis skin test or questionnaire was completed.
Review of the personnel file for STNA #111 revealed a hire date of 12/01/16. There was no documentation
that a annual tuberculosis skin test or questionnaire was completed.
Review of the personnel file for STNA #112 revealed a hire date of 06/12/18. There was no documentation
that a tuberculosis skin test or questionnaire was completed.
Review of the personnel file for Director of Nursing (DON) #113 revealed a hire date of 04/22/19. There was
no documentation that a tuberculosis skin test or questionnaire was completed.
Review of the personnel file for Assistant Director of Nursing (ADON) #102 revealed a hire date of
02/11/19. There was no documentation that a tuberculosis skin test or questionnaire was completed.
Review of the personnel file for Maintenance Supervisor #114 revealed a hire date of 04/10/19. There was
no documentation that a tuberculosis skin test or questionnaire was completed.
Interview with the Administrator on 05/02/19 at 11:35 A.M. verified there was no documentation of
tuberculosis skin tests or questionnaires being completed for STNA #108, STNA #109, STNA #110, STNA
#111, STNA #112, DON #113, ADON #102, and Maintenance Supervisor #114.
Review of facility TB Risk Assessment Worksheet completed 04/23/19 revealed the facility was considered
to be at a low risk for tuberculosis.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365666
If continuation sheet
Page 13 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365666
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Lake Rehabilitation Center
14442 State Route 33 West
Lakeview, OH 43331
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of the facility's Antibiotic Use Tracking Sheet, staff interview and policy review, the facility
failed to ensure eight residents (#2, #4, #8, #10, #14, #20, #21 and #29) of 28 residents reviewed for
antibiotic stewardship had active signs and symptoms of infection prior to prescribing antibiotics. The facility
census was 36.
Residents Affected - Some
Findings include:
Review of the facility's January 2019 Antibiotic Use Tracking Sheet revealed Resident #29 had a dry scaly
scalp with no date of onset. The physician prescribed Bactrim DS (antibiotic ) for 14 days. Four residents
(#2, #10, #14 and #20) displayed symptoms of a cough without any other signs and symptoms. There was
no diagnostic testing completed for these four residents. Three of the residents (#2, # 10 and #20) were
placed on a Z- Pack ( Zithromycin antibiotic) for four days. Resident #14 was placed on Augmentin 875-125
milligrams (mg.) for seven days. The tracking sheet stated Resident #21 had a possible urinary tract
infection. The signs and symptoms were listed as increased urination , increased confusion, and increased
episodes of incontinence. There was no urinalysis or urine culture. The resident was placed on Rocephin
one gram (antibiotic) to be given intramuscularly (IM) for three days. The tracking sheet stated Resident #8
had a urinary tract infection. There was no signs or symptoms listed, no urinalysis, and no urine culture
completed . The resident was given Keflex 500 mg. (antibiotic) for seven days.
Review of the facility's February 2019 Antibiotic Use Tracking Sheet revealed Resident #20 had an upper
respiratory infection with signs and symptoms of a cough. There were no diagnostic test performed. The
resident received Doxycycline 100 mg. (antibiotic) for seven days. Three additional residents (#14, #4 and
#20) were listed as having urinary tract infections. The tracking sheet stated three residents (#14, #4 and
#20) had urinary tract infections with with the signs and symptoms being discolored urine and increased
confusion. There was no urinalysis or urine culture was completed on these three residents. Resident #14
and #20 were given Cipro 250 mg. (antibiotic) for seven days. Resident # 4 was given Invanz one gram
(antibiotic) for five days. Resident #3 was treated with an antibiotic Azithromycin 250 mg. for five days for
abnormal lung sound with no diagnostic tests.
Review of the facility's March 2019 Antibiotic Use Tracking Sheet revealed Resident #8 was placed on
Keflex 500 mg. (antibiotic) for 10 days. A urinalysis was completed without a culture to identify an organism.
Interview with Regional Director of Clinical Services #104 on 05/02/19 at 10:30 A.M. verified there was no
Infection Prevention Control Committee. She stated infections were discussed in a weekly meeting with the
Interdisciplinary team. She verified Resident #2, #4, #8, #10, #14, #20, #21 and #29 appeared on the
Antibiotic Use Tracking Sheet in January, February, and March of 2019 and did not have the indications
needed to prescribe antibiotics.
Review of the facility's policy on Antibiotic Stewardship Program, dated 04/16/18, revealed the Infection
Prevention and Control Committee is to meet monthly to oversee the tracking of antibiotic of prescribing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365666
If continuation sheet
Page 14 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365666
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/02/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Lake Rehabilitation Center
14442 State Route 33 West
Lakeview, OH 43331
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0908
Keep all essential equipment working safely.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, resident and staff interview, the facility failed maintain three resident's wheelchairs in
safe operating condition. This affected three (#18, #23 and #37) of 17 residents reviewed for safe operating
equipment. The facility identified 20 residents dependent on wheelchairs for locomotion. The facility census
was 36.
Residents Affected - Few
Findings include:
On 05/01/19 at 1:00 P.M., an observation of Resident #23 revealed the resident was propelling in his
wheelchair in the hallway. On the medial side of the left arm rest, the covering was torn with jagged rough
edges. The resident was wearing a short sleeve shirt. The resident stated the arm of his wheelchair was
torn and needed repair.
On 05/01/19 at 1:10 P.M., an observation of Resident #37 revealed the resident was in a wheelchair in the
dining room. The covering of the right arm of his wheelchair was torn in multiple areas causing the covering
to have rough edges.
On 05/01/19 at 1:12 P.M., an observation of Resident #18 revealed the resident was in a wheelchair in the
dining room. The covering of the left arm of his wheelchair was torn in multiple areas causing the covering
to have rough edges.
On 05/01/19 at 1:20 P.M., interview with the Regional Director of Clinical Services #104 verified the arms
on Resident #23, #37, and #18's wheelchairs were in disrepair with tears in the covering of the arms
causing rough edges, which could result in skin tears to the resident's arms.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365666
If continuation sheet
Page 15 of 15
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Back to topCitations
20 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F625 - Transfer and discharge-
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.
- 0029GeneralS&S Fpotential for harm
Develop a communication plan.
- 0161GeneralS&S Epotential for harm
Use approved construction type or materials.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F912 - Measure at least 80 square feet per resident in multiple resident
Have power receptacles that are properly grounded.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the May 2, 2019 survey of INDIAN LAKE REHABILITATION CENTER?
This was a inspection survey of INDIAN LAKE REHABILITATION CENTER on May 2, 2019. The surveyor cited 20 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at INDIAN LAKE REHABILITATION CENTER on May 2, 2019?
Yes, 20 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.