Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aperion Care Niles during CMS and state inspections, most recent first.
Expired Tuberculin Vial Left in Medication Refrigerator: Surveyors found an expired multi-dose vial of tuberculin test in the 2nd floor med refrigerator. An LPN stated expired meds should be discarded and not kept in the refrigerator, and the DON stated all expired meds should be removed and destroyed. The issue affected 44 residents on the 2nd floor.
Infection control practices were not followed during medication administration for several residents. An RN and an LPN used the same BP machine between residents without cleaning and disinfecting it, one RN did not disinfect the BP equipment per manufacturer guidance, and an RN completed a med pass without hand hygiene before and after administering medications. Staff and the DON stated BP equipment should be cleaned and disinfected between residents and hand hygiene should be performed before and after medication administration.
A resident with an indwelling urinary catheter was observed in bed with the catheter bag hanging on the side of the bed visible from the hallway, containing 400 cc of urine and no privacy cover. An LPN observed the same condition, and the DON stated catheter bags should have a privacy cover when located by the hallway door. The resident was alert and oriented times three, non-ambulatory, and had a history of falls, pressure ulcers, urinary retention, and neurogenic bladder.
A resident with an indwelling urinary catheter did not have a comprehensive care plan located for catheter care during survey review. The resident was alert and oriented x3, non-ambulatory, with a hx of falls, pressure ulcers, urinary retention, and urogenital implants, and had orders for catheter monitoring, foley care every shift, monthly tubing changes, and NS irrigation. The DON stated residents with catheters should have a comprehensive care plan, and the Restorative Director said a care plan should be in place.
A resident admitted after a CVA and fracture received PT/OT/ST, and PT later recommended restorative nursing for bed mobility and ROM after therapy ended. The rehab director did not communicate the recommendation to restorative nursing, saying she already knew the discharge plan and did not need to provide written handoff. The restorative director learned of the need only after speaking with the resident and then received the recommendation from the rehab director, while the DON said PT was supposed to endorse restorative recommendations during daily IDT meetings.
A resident with a gastrostomy tube had the syringe/piston hanging on the pole with an outdated date, and an RN confirmed the syringe had not been changed daily as expected. The DON was informed, and the facility policy states feeding tube syringes and irrigation containers are to be changed every 24 hours.
Missing refrigerator temperature logs and improper food storage were found for two residents. A CNA verified that a resident’s personal refrigerator had no recorded daily temp check and contained milk cartons with the same-day expiration date, and another resident’s refrigerator had no recorded daily temp check plus cut watermelon and ground meat that was not labeled or dated. The DON stated refrigerators should be checked daily and food stored in resident refrigerators should be labeled and dated.
The facility failed to maintain proper hot water temperatures in the Second Floor East Wing shower room, affecting 22 residents. A resident reported the water was too cold, and a CNA confirmed the issue despite previous maintenance attempts. The Maintenance Director measured the water temperature at 90-95°F, below the required 100-110°F.
The facility failed to consistently monitor and document refrigerator temperatures, properly label and store food, and remove expired items in residents' personal refrigerators. Observations revealed unlabeled and expired food items, and discrepancies in temperature logs. Staff admitted to not following procedures, leading to these deficiencies.
A facility failed to use a low air loss mattress correctly for a resident with a Stage 4 pressure ulcer, leading to discomfort and potential worsening of the condition. The resident, with multiple health issues, was on an improperly set air mattress due to inadequate training of staff responsible for its adjustment. The resident's requests for timely incontinence care were not met, and documentation inaccurately reflected resistance to care, contributing to the ulcer's progression.
A facility failed to perform a quarterly gradual dose reduction (GDR) evaluation for a resident on psychotropic medications, as required by their policy. The resident, with a history of cognitive and anxiety disorders, was receiving Trazodone and Depakote daily without a documented GDR assessment. The DON confirmed that GDRs should occur during quarterly reviews, but only one psychiatric progress note was available, lacking a GDR assessment.
A resident at high risk for falls was left unsupervised in their room, leading to a fall and subdural hematoma. The resident's care plan, which required supervision during meals, use of a walker, and appropriate footwear, was not followed. Staff interviews confirmed the lack of adherence to the care plan, contributing to the incident.
A facility failed to monitor a newly admitted, nonverbal resident at high risk for falls, resulting in the resident being found on the floor with significant head injuries. The resident was not observed as required, and the door to the room was not left open for proper supervision, contrary to facility policy.
Expired Tuberculin Vial Left in Medication Refrigerator
Penalty
Summary
The facility failed to ensure an expired multi-dose vial of tuberculin test was removed and discarded from the 2nd floor medication refrigerator. On 5/26/2026 at 6:48 AM, surveyors observed the vial in the refrigerator with an expiration date of 5/11/2026 and an opened date of 4/12/2026. At 6:51 AM, an LPN stated that expired medications should be discarded and not kept in the refrigerator. The deficiency affected 44 residents currently residing on the 2nd floor. On 5/27/2026 at 9:30 AM, the DON stated that all expired medications should be removed, discarded, and not kept in the refrigerator. The facility policy stated that expired medications are to be removed from active supply and destroyed in the facility.
Infection control failures during medication administration
Penalty
Summary
The facility failed to implement infection control practices during medication administration for 4 of 7 residents observed, including R39, R8, R77, and R72, during a total sample of 19 residents. On 5/26/2026, V6, a Registered Nurse, checked and measured blood pressure for R39 and then used the same blood pressure machine for R8 without cleaning and disinfecting it between residents. On the same date, V7, a Licensed Practical Nurse, measured blood pressure for R72 and did not clean and disinfect the blood pressure equipment after use. Also on 5/26/2026, V8, a Registered Nurse, measured blood pressure for R77, cleaned the blood pressure machine, but did not disinfect it according to the manufacturer's recommendation. During the medication pass on 5/26/2026, V6 completed medication administration for R39 and R8 without performing hand hygiene before and after medication administration. V6 stated hand hygiene should be performed before and after each medication administration. V6, V7, and V8 stated that the blood pressure machine and cuff should be cleaned and disinfected between each resident use. On 5/27/2026, the DON stated staff may use their personal blood pressure machine if it is cleaned and disinfected between each resident use, and that staff should perform hand hygiene before and after medication administration; the DON also stated the facility does not have a policy for cleaning and disinfecting medical equipment such as blood pressure equipment.
Uncovered Urinary Catheter Bag Visible From Hallway
Penalty
Summary
The facility failed to provide a dignity cover for one resident’s indwelling urinary catheter bag. On 5/26/2026 at 10:30 a.m., the surveyor observed R72 in bed with the catheter bag hanging on the side of the bed visible from the hallway, containing 400 cc of urine and with no privacy cover. At 10:40 a.m., an LPN observed the same condition with the surveyor, noting the catheter bag was on the side by the hallway door, filled with 400 cc of urine, and still uncovered. R72’s resident information sheet identified the resident as alert and oriented times three, non-ambulatory, with a history of falls and pressure ulcers, and with retention of urine and urogenital implants. The order summary dated 5/28/2026 included orders for urinary catheter output monitoring, monthly tubing changes, foley catheter care every shift, a 16 French catheter with a 30 cc balloon to gravity for neurogenic bladder, and irrigation with 100 cc of normal saline. On 5/26/2026 at 10:45 a.m., the LPN stated the urinary catheter bag should have a privacy cover if it is by the door to the hallway. On 5/27/2026 at 9:40 a.m., the DON stated all urinary catheter bags should have a privacy cover if they are on the side of the door by the hallway.
Missing Comprehensive Care Plan for Urinary Catheter Care
Penalty
Summary
The facility failed to ensure a person-centered comprehensive care plan was implemented for one resident with an indwelling urinary catheter. During observation, interview, and record review, the surveyor was unable to locate a comprehensive care plan for the resident’s catheter care. The resident information sheet identified the resident as alert and oriented times three, non-ambulatory, with a history of falls and pressure ulcers, retention of urine, and the presence of urogenital implants. The resident’s order summary dated 5/28/2026 included orders dated 10/24/2025 to monitor the urinary catheter for pressure ulcers, monitor output, change catheter tubing every month, provide foley catheter care every shift, maintain a 16 French millimeter balloon 30cc catheter to gravity for neurogenic bladder, and irrigate with 100cc of normal saline. The DON stated that all residents with catheters should have a comprehensive care plan with interventions and that staff placed a care plan in that day for urinary catheter care. The Restorative Director stated that a care plan should be in place.
Failure to Implement Restorative Program Recommendation
Penalty
Summary
The facility failed to implement the restorative program recommendation for one resident, R77, who was reviewed for restorative services. R77 was admitted on 3/2/2026 following an acute right pontine CVA with functional decline and a recent fracture, and had diagnoses including primary hypertension, type 2 diabetes, and hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. The physician admission note and therapy records showed that R77 received PT, OT, and Speech therapy from 3/3/2026 through 4/29/2026, and the PT discharge summary recommended continuation in a restorative program for bed mobility, passive ROM, and ROM. Interviews showed that the rehab director knew R77 was discharged from therapy and stated that the resident was cut off from Part A and later approved for only six PT and six OT sessions under Part B, after which no additional therapy was approved. The rehab director said the restorative recommendation was not communicated to the restorative department because she was aware of the discharge plan and believed written handoff was not necessary. The restorative director stated she learned of the recommendation only after speaking with the resident and then approached the rehab director, who handed over the recommendation on 5/21/2026, the same day R77 was discharged. The restorative director said she assessed R77 immediately and noted the resident could transfer from bed to wheelchair and from wheelchair to toilet. The DON stated that daily IDT meetings were held and that PT was supposed to endorse restorative recommendations to restorative nursing.
Gastrostomy Syringe Not Changed Daily
Penalty
Summary
Facility failed to follow its gastrostomy management care guidelines for one resident with a gastrostomy tube. On 5/26/26 at 9:35 AM, the resident’s gastrostomy syringe/piston was observed hanging on the pole with a date of 5/24/26. At 9:38 AM the same day, the RN stated that all syringes are to be changed daily by night staff and checked the syringe date, confirming it was dated 5/24/26. On 5/27/26 at 11:55 AM, the DON was informed of the findings and stated that staff are expected to change the irrigation syringe on a daily basis. The facility policy on Gastrostomy Tube-Feeding and Care states that feeding tube syringes and irrigation containers are to be changed every 24 hours.
Missing Refrigerator Temperature Logs and Improper Food Storage
Penalty
Summary
The facility failed to conduct daily refrigerator temperature checks inside residents’ rooms to ensure proper temperature and food safety. Based on observation, interview, and record review, the deficiency affected two residents, R10 and R84, in the sample of 19 reviewed for resident safe food storage. On 5/26/26 at 9:25 AM, R10’s personal refrigerator was observed with no daily temperature checks recorded for 5/26/26 and missing daily temperatures, and it contained two milk cartons with an expiration date of 5/26/26. At that time, V9, a CNA, stated that temperatures are usually checked daily and recorded, and verified that no temperature was recorded for R10’s refrigerator and that the milk carton had the expiration date of 5/26/26. On 5/26/26 at 9:30 AM, R84’s personal refrigerator was observed with no daily temperature checks recorded for 5/26/26 and missing daily temperatures. Inside were a container of cut watermelon and a food container with ground meat that was not labeled or dated. On 5/29/26 at 10:41 AM, V2, the DON, stated that refrigerators should be checked daily for temperature and recorded, all food brought in by family should be checked by nursing staff for appropriate diet, and food stored in the refrigerator should be labeled and dated. The facility policy on food items brought from outside stated that food brought in by a family member or visitor will be permitted with authorization, checked by nursing or food service, placed in a plastic container with a tight lid, and labeled with the resident’s name and date.
Failure to Maintain Proper Hot Water Temperatures in Shower Room
Penalty
Summary
The facility failed to maintain proper hot water temperatures in the shower room located on the Second Floor East Wing, potentially affecting 22 residents residing in that area. On March 2, 2025, a resident reported that the water in the shower room does not get hot enough, making them reluctant to take a shower due to the cold temperature. A Certified Nursing Assistant confirmed that the water temperature in the shower room does not get very hot, despite previous maintenance attempts to fix the issue. During an observation, the water was run for five minutes and was found to not get very warm. The Maintenance Director later checked the water temperature with a thermometer, which ranged between 90-95 degrees Fahrenheit, below the facility's policy requirement of 100-110 degrees Fahrenheit for a comfortable and safe temperature.
Deficiencies in Food Storage and Monitoring in Resident Refrigerators
Penalty
Summary
The facility failed to adhere to its policy and procedures for safe and sanitary food storage in residents' personal refrigerators. The deficiencies included inconsistent monitoring and documentation of refrigerator temperatures, improper labeling and storage of food items, and failure to remove expired food. These issues were observed in the rooms of four residents. The Director of Nursing indicated that the Assistant Director of Nursing was responsible for checking refrigerator temperatures, which were to be documented in a log. However, a Licensed Practical Nurse admitted to documenting temperatures without actually checking them. Additionally, the Dietary Manager, who was responsible for overseeing some of the refrigerators, acknowledged that checks were not consistently performed daily, and there was uncertainty about who was responsible when she was not present. Specific observations included refrigerators with temperature logs that were not updated daily, food items without labels or dates, and expired food items. For instance, one resident's refrigerator contained multiple unlabeled food containers and an orange without labeling. Another resident's refrigerator had expired milk cartons and open pudding cups with brownish fluid. These findings were confirmed by a Certified Nursing Assistant who acknowledged that staff were supposed to check and label food items. The surveyor also noted discrepancies in temperature logs, with recorded temperatures not matching actual readings.
Improper Use of Air Mattress for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with a Stage 4 pressure ulcer by not using a low air loss mattress in accordance with manufacturer guidelines. The resident, who is alert and oriented, has multiple diagnoses including chronic obstructive pulmonary disease, asthma, heart failure, and anxiety disorder. The resident was observed on an air mattress that was improperly set, leading to discomfort and potentially exacerbating the pressure ulcer. The wound nurse and maintenance director were responsible for the air mattress settings, but neither was adequately trained on how to adjust the mattress according to the resident's weight. The maintenance director admitted to setting the mattress pressure by sight and touch, without proper training or understanding of the manufacturer's guidelines. The wound nurse was unaware of the mattress pump's functioning and relied on the maintenance director for adjustments, despite being in charge of wound care. The resident expressed dissatisfaction with the care provided, stating that requests for incontinence care were not honored in a timely manner, which was inaccurately documented as resistance to care. The facility's documentation showed inconsistencies in the resident's care plan and assessments, with no evidence of resistance to care prior to the development of the pressure ulcer. The lack of proper mattress settings and timely incontinence care contributed to the worsening of the resident's pressure ulcer.
Failure to Conduct Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to adhere to its policy and procedures for psychotropic medication administration by not conducting a gradual dose reduction (GDR) evaluation quarterly for a resident receiving psychotropic medications. This deficiency was identified in the case of a male resident with a history of cognitive communication deficit, generalized anxiety disorder, insomnia, and partial paralysis due to a stroke. The resident was admitted to the facility with active physician orders for Trazodone and Depakote to manage sleep and anxiety, respectively. Despite receiving these medications daily, there was no documented assessment for a GDR from admission to the current date. The Director of Nursing acknowledged that GDRs are supposed to be performed during quarterly reviews and are either deemed not in the best interest of the resident or attempted if the resident's behavior suggests that psychotropic medications are no longer needed. However, in this case, only one psychiatric progress note was available, and it did not include a GDR assessment or determination. The facility's policy mandates that residents on psychotropic drugs should receive GDRs and behavioral interventions unless clinically contraindicated, with GDRs encouraged at least twice yearly unless previous attempts have been unsuccessful or are clinically contraindicated.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to a resident's care plan, which resulted in a fall incident. The resident, who was at high risk for falls due to multiple medical conditions including a history of falling, cognitive impairment, and difficulty walking, was left unsupervised in their room. The resident's care plan required supervision during meals, the use of a walker, and appropriate footwear, none of which were ensured at the time of the incident. On the day of the incident, the resident returned from an appointment and was served dinner in their room, contrary to their usual routine of eating in the dining room where supervision was more readily available. The resident attempted to stand up from their wheelchair without assistance, lost balance, and fell, resulting in a subdural hematoma. The walker was not within reach, and the resident was not wearing appropriate footwear, which contributed to the fall. Interviews with staff revealed that the resident was not closely monitored as required by their care plan. The staff acknowledged that the resident was high risk for falls and that the fall might have been prevented if the resident had been placed in a common area for closer supervision or if the assistive devices and proper footwear had been utilized as per the care plan.
Failure to Monitor At-Risk Resident
Penalty
Summary
The facility failed to effectively monitor a newly admitted resident and adhere to its practice of leaving doors open for residents identified to be at risk for falls. This failure resulted in the resident being found on the floor with significant injuries, including a laceration that required staples and sutures. The resident, who had diagnoses including Parkinson's, anxiety, insomnia, and cerebral infarction, was nonverbal and could not communicate what had happened. The incident was unwitnessed, and the resident was found by a CNA who had difficulty opening the door due to the resident and a floor mat blocking it. The blood observed at the scene appeared to be dry, indicating that the fall may have occurred earlier than reported by the staff. The resident was subsequently sent to the hospital for treatment of the injuries sustained during the fall. The facility's Director of Nursing confirmed that the expectation was for staff to leave doors open for closer observation of at-risk residents and to perform hourly monitoring, especially for new admissions and nonverbal residents. The facility's Fall Prevention Program policy also emphasized the importance of assessing fall risks and implementing appropriate interventions to ensure resident safety. However, these protocols were not followed in this case, leading to the resident's fall and subsequent injuries.
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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 Niles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elevate Care North Branch | 0.3 mi | ★★★★★ | 2 | 0 |
| Citadel At Saint Benedict | 0.5 mi | ★★★★★ | 0 | 0 |
| Celebrate Senior Living Niles | 0.6 mi | ★★★★★ | 0 | 0 |
| Elevate Care Regency | 1 mi | ★★★★★ | 2 | 2 |
| Norwood Crossing | 1.6 mi | ★★★★★ | 5 | 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.