Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Niles Care Center, Llc during CMS and state inspections, most recent first.
A resident with cognitive impairment, abnormal gait, and mobility limitations had a care plan requiring a two-person assist for transfers, but was transferred by a single CNA for ADL care. During the transfer, the resident’s legs gave way while turning, he slid, let go of the CNA, and fell to the floor, striking his leg and back and later reporting bruising and scratches. The CNA involved stated she had been informed the resident was a one-person extensive assist and this was her first time caring for him, while another CNA identified the resident as a two-person stand assist and the DON confirmed the resident was a two-person assist at the time of the incident.
The facility failed to maintain accurate MARs for two residents, leading to discrepancies between documented and actual medication administration. One resident with morbid obesity had an active order for weekly Wegovy injections, and the MAR showed a dose as given, but the pharmacist confirmed the drug was never supplied and the RN who charted it later stated it was likely a documentation error and did not recall administering the injection. Another resident with chronic pain had orders for scheduled and PRN Percocet; the MAR reflected five doses given on one day, while the controlled drug receipt and narcotic count supported only four tablets being dispensed. The LPN involved reported that the controlled drug record reflected what was actually administered and that the MAR entries were likely incorrect.
A cognitively intact resident reported that the food was so poor she ordered the same limited meal every night and had to buy her own preferred items, despite having discussed her preferences with the Dietary Supervisor. Two other cognitively intact residents stated that the kitchen frequently ran out of commonly used items such as brown sugar, butter, bananas, peach cups, pudding, and even hot dogs and hamburgers that were listed on the always available menu, especially from the middle to the end of the month. Dietary staff and the RD confirmed that corporate adjusted weekly food orders to stay within budget and that some items had been removed or had run out, while the NHA reported being unaware of residents’ concerns about food shortages.
A facility failed to serve the posted menu as planned and did not consistently tell residents about menu changes. Dietary staff altered onion sage chicken into a casserole because there was not enough chicken, but the menu board was not updated. Staff were also unsure what to serve for mechanical soft, NAS, and diabetic diets, and a resident reported that kitchen menu changes were sometimes communicated and sometimes not.
QAPI meetings did not consistently include the required MD and IP as mandatory attendees. Record review showed the MD missed multiple QAPI meetings, there was no meeting in two months, and the IP missed one meeting. The MD said he tried to attend monthly, and the NHA stated monthly QAPI meetings were held to ensure required attendees such as the MD and IP attended quarterly.
Staff failed to follow ordered infection control measures for residents with Foley catheter/wound care, incontinence care, MRSA contact precautions, and tube-feeding-related environmental cleanliness. Observations showed missing gowns during EBP transfers, incomplete perineal care with contaminated gloves touching clean surfaces, inconsistent PPE use and understanding for a resident on contact precautions for MRSA, and a heavily soiled room environment around a resident receiving tube feeds.
Failure to Maintain Resident Dignity During Dressing and Bedside Care: A resident with hemiplegia, major depressive disorder, and severe cognitive impairment was dependent on staff for dressing, yet was observed multiple times awake in bed wearing a hospital gown gathered under her armpits with her breast, abdomen, and incontinence brief exposed and the privacy curtain not pulled. Family stated she preferred her own clothes and valued modesty, and staff/DON confirmed the expectation for daily dressing assistance and privacy protection, but the resident was not dressed in her own clothes and no care refusal was documented.
A resident with CHF, HTN, and a subdural hemorrhage after a fall was transferred to the hospital, but the chart contained no transfer/discharge notice. The RN said he notified the guardian, but could not recall completing the notice, and an LPN said he had not been sending transfer/discharge notices with hospital transfers. The NHA and RCN stated the facility had not been sending the required notice, despite policy requiring it for the resident and/or legal representative.
A resident admitted with chronic atrial fibrillation, a cardiac pacemaker, and an indwelling Foley catheter did not have a baseline care plan that reflected the minimum needed care information. The plan failed to identify the Foley catheter or include any pacemaker-related information, and the current care plan also lacked these details. Record review showed Foley catheter orders were active, while pacemaker orders were not activated at the time, and the nursing admission assessment noted the Foley catheter but not the pacemaker.
A resident who was incontinent of bowel and bladder and needed extensive assistance was found with a saturated brief, wet clothing, and a strong urine odor after being up in a chair for hours. Staff did not thoroughly clean the genital folds or between the legs, did not apply barrier cream after incontinence care, and on one occasion did not change gloves or perform hand hygiene after contact with BM before touching clean surfaces and the resident’s belongings.
Inaccurate medication documentation in physician notes. A resident with depression, anxiety, and dementia had care plan documentation and physician notes that listed Lexapro 5 mg as a current medication, even though the order had been discontinued after a GDR. The SW, MD, MR, and DON all acknowledged the notes were not accurate, and psychiatry documentation still reflected Lexapro as continued.
A resident with severe chronic pain and osteoarthritis did not receive physician-ordered Norco for 11 days due to delays in obtaining the prescription and medication from the pharmacy. Despite staff awareness of the issue and the resident's ongoing severe pain, the medication was not administered until after intervention by the ombudsman. Documentation and staff interviews confirmed lapses in communication and medication management, resulting in unmet pain management needs.
A resident with chronic pain and osteoarthritis did not receive physician-ordered Norco for 11 days due to delays in obtaining the prescription and lack of timely follow-up by nursing staff and facility leadership. The resident experienced severe, uncontrolled pain during this period, and staff interviews revealed gaps in communication and awareness regarding the medication issue.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors who noted environmental hazards and insufficient staff monitoring.
The facility failed to adhere to food safety and sanitation standards, as observed during a survey. Cooked roast beef was improperly cooled, and various food items lacked proper date markings. Cleanliness issues were noted with kitchen equipment, and the dish machine did not reach required temperatures. A staff member was observed handling food with bare hands, violating contamination prevention guidelines.
The facility failed to implement proper infection control practices, as observed in multiple instances where staff did not adhere to PPE protocols for residents on contact precautions. The facility also lacked an ongoing infection control surveillance program, with no tracking of employee illnesses and no recent audits of hand hygiene or PPE use. Additionally, there was no active plan to manage the risk of legionella and other pathogens in the facility's water systems.
The facility failed to document and offer COVID-19 vaccination to its staff, specifically a CNA who was last vaccinated in 2021. The DON confirmed that the facility had not offered the vaccine in 2024 and had not tracked staff immunization status or provided education, increasing the risk of COVID-19 infections among residents.
The facility exhibited multiple environmental deficiencies, including structural damage, improper storage, and unsanitary conditions. Observations revealed holes in walls, moisture damage, stained and improperly stored items, non-operational equipment, and significant wear and tear in common areas. These issues increased the potential for contamination and decreased resident satisfaction.
A long-term care facility reported a 20% medication error rate involving four residents. Errors included improper injection sites, late medication administration, missed doses, and crushing of delayed-release medication. LPNs administered injections incorrectly, misunderstood timing protocols, failed to use backup medication supplies, and crushed medication against prescription instructions.
The facility's ineffective pest control program resulted in an ant infestation in resident rooms, hallways, and visitor restrooms. Despite having a monthly pest control service, the Maintenance Assistant did not treat the building for ants between visits. The Nursing Home Administrator was unaware of the issue, which persisted for several days, contributing to potential food infestation and resident discomfort.
A resident with a gastrostomy tube was not receiving the prescribed enteral feeding due to improper management by nursing staff. The feeding pump was often off during scheduled times, and the total volume of formula was not documented, leading to insufficient nutritional intake. The facility's staff failed to adhere to the prescribed feeding schedule and volume, as confirmed by the RD and DON.
Three residents in an LTC facility did not receive adequate assistance with ADLs, leading to dissatisfaction and hygiene concerns. A resident expressed dissatisfaction with the frequency of showers, while another appeared disheveled with long, dirty fingernails due to missed shower opportunities. A third resident was observed with soiled fingernails and expressed frustration over inadequate assistance with personal hygiene.
A resident with a G-tube was not administered enteral feeding as ordered, leading to potential health risks. Observations showed the feeding pump was often off, and the tubing was not connected. LPNs reported inconsistencies in feeding times, and the MAR lacked documentation of the total formula volume. The DON confirmed the resident did not receive the full prescribed amount of formula.
A facility failed to conduct gradual dose reductions (GDRs) for a resident on Duloxetine for major depressive disorder. The resident's dosage remained unchanged for over a year, and no attempts at GDR were made in 2024. The facility lacked documentation of GDR or physician rationale against it.
The facility failed to prevent scalding hazards by allowing hot water temperatures to exceed safe limits and did not consistently monitor these temperatures. Additionally, a resident at high risk for elopement exited the facility unnoticed due to unsecured and unalarmed doors, despite having a history of wandering behavior. The resident's wander guard was not properly checked or ordered after readmission, contributing to the incident.
A resident with Alzheimer's was physically abused by another resident with a history of aggressive behavior in the dining room. Despite interventions in place, the aggressive resident flipped the other resident's wheelchair, leading to threats and police involvement. The facility's abuse prevention measures were insufficient to prevent this incident.
A facility failed to report a suspected abuse incident involving a resident with schizophrenia, anxiety, depression, dementia, and aphasia to Law Enforcement. The incident, where a CNA allegedly held the resident's breast, was reported internally but not to authorities, violating the facility's policy and federal requirements.
A facility failed to address a resident's skin integrity in the baseline care plan, despite the resident's history of skin issues and a rash noted upon admission. The care plan did not include skin integrity, and this omission was confirmed by the DON. The facility's policy requires addressing such concerns within 48 hours of admission.
A resident admitted for a respite stay under Hospice care developed a yeast infection under her breast due to the facility's failure to address a pre-existing rash noted upon admission. The rash was documented but not followed up on, leading to a lapse in care continuity. Facility staff were unaware of the condition, resulting in the infection being discovered by a Hospice LPN four days later.
A resident with cognitive impairment reported being left in a soiled brief for over six hours and experiencing long wait times for assistance. The facility's investigation into the grievance was inadequate, with only verbal staff education conducted without documentation, failing to meet the grievance policy requirements.
A resident with moderate cognitive impairment alleged rough handling by a CNA and an LPN, which was not reported immediately to the NHA or law enforcement, violating facility policy. The NHA admitted to only reporting significant incidents, leading to an incomplete investigation. Additionally, a neglect concern was raised by the resident, which was not reported to the state agency, indicating systemic issues in handling such allegations.
Failure to Follow Two-Person Transfer Requirement Resulting in Fall
Penalty
Summary
The facility failed to ensure a safe transfer and adequate supervision to prevent an accident for one resident. Resident #103, a male with diagnoses including other abnormal involuntary movements, restless legs syndrome, abnormalities of gait and mobility, and limitation of activities due to disability, was moderately cognitively impaired with a BIMS score of 8/15. His baseline care plan effective 2/11/26 documented that he required support for mobility and a two or more person physical assist for transfers. On 2/26/26, an attended fall report documented that while staff were transferring the resident from bed for ADL care, the resident stated his legs were giving way and he was lowered to the floor by CNAs, then assisted to stand and transferred to his wheelchair, with ADLs completed without further incident and the resident denying pain at that time. A grievance form later submitted by Resident #103 stated that on that date he was lifted out of bed by only one person, despite being a two-person assist, and that during the lift he fell to the floor, hitting his leg and back on the bed and floor, causing severe bruising and scratches on his legs and back. In interviews, the resident reported that when the one CNA attempted to transfer him, they both started to turn, he began to slide, let go of the CNA, and hit the floor hard, resulting in two black and blue marks on his leg. Another CNA reported that the resident was a two-person stand assist. CNA X stated she had been told the resident was an extensive assist of one person for transfers and that this was her first time caring for him; she later learned he was actually an extensive assist of two and acknowledged she had essentially attempted to transfer him alone. The DON confirmed that the resident was a two-person assist for transfers on the date of the incident and that CNA X had transferred him by herself.
Inaccurate MAR Documentation for Wegovy and Percocet
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate medical records for two residents, resulting in medication administration records (MARs) that did not accurately reflect what was actually given. For one male resident with morbid obesity, an active order dated mid-October for Wegovy (semaglutide) 2.4 mg subcutaneously once weekly for obesity was present, and the October MAR showed the dose as administered by an RN on the scheduled date. However, the pharmacist reported the pharmacy had never sent Wegovy for this resident because the insurance did not cover it and confirmed the facility had never received the medication. The RN who documented the administration stated it was probably a mistaken computer click, did not recall giving the injection, and later told the resident he did not remember administering the shot and believed it was incorrect documentation. For another male resident with diagnoses including unspecified low back pain and unspecified pain, there were active orders for Percocet 7.5-325 mg: one tablet by mouth three times daily for pain, and one tablet by mouth as needed once daily for severe breakthrough pain. The March MAR showed three doses of the scheduled Percocet and two doses of the PRN Percocet documented as administered on the same day, totaling five tablets. In contrast, the controlled drug receipt for that date showed only four Percocet tablets signed out at four documented times. The LPN involved recalled giving the resident his routine Percocet and an additional PRN dose for increased pain, stated that whatever was on the controlled drug receipt reflected what was actually given, and acknowledged that the MAR must contain documentation errors since the narcotic count at shift end was correct. The DON confirmed that the MAR documentation indicating five tablets had to be an error because the narcotic count supported administration of only four tablets.
Failure to Honor Food Preferences and Maintain Adequate Food Supply
Penalty
Summary
The deficiency involves the facility’s failure to honor resident food preferences and maintain adequate food supplies as required by policy. One cognitively intact resident, Resident #37, reported that the food was so poor that she ordered the same dinner every night—two hamburger patties without a bun and dessert—and that she had to purchase her own English muffins because the kitchen would not obtain them for her. She also stated she preferred tomatoes on salads and more vegetables and had previously discussed her preferences with the Dietary Supervisor but remained dissatisfied. Review of the facility’s Food Preference Policy indicated that if a resident is unhappy with their diet, staff will create a care plan that the resident is satisfied with and that the Food Services Department will offer a variety of foods at each scheduled meal. Two other cognitively intact residents, Resident #16 and Resident #29, reported that the kitchen frequently ran out of various food items, particularly from the middle to the end of the month. Resident #16 stated the kitchen ran out of brown sugar, butter, bananas, peach cups, and that hot dogs and hamburgers—listed on the always available menu—had been unavailable for a week, and that food served was often disliked and condiments were not available. Resident #29 similarly reported that hot dogs, hamburgers, pudding, and bananas ran out often, especially mid- to late month. The Dietary Supervisor and Registered Dietitian confirmed that food orders were placed weekly, then adjusted by corporate to stay within budget, and acknowledged that brown sugar had been removed from orders and that bananas had run out in the past, though alternative fruits were available. The Nursing Home Administrator stated she was not aware that residents reported food running out mid- to late month.
Menu Changes Not Consistently Followed or Communicated
Penalty
Summary
The facility failed to ensure the published menu was served as planned and that residents were consistently informed in advance of menu changes affecting all residents receiving food from the kitchen. On 1/22/2026, the posted lunch menu in the main dining room and the week-at-a-glance menu listed onion sage chicken, au gratin potatoes, carrots, and spice cake, but the tray line meal was observed as au gratin potatoes and medallion carrots. When asked about the missing chicken, Dietary staff stated the chicken had been mixed into the potatoes to make a casserole because there was not enough chicken available, and the Dietary Supervisor stated he directed this change. He also stated he was not aware the menu board needed to be changed when the meal was altered, even though he knew he had to remember to update it when he changed menus. The report also showed that staff were not consistently following the menu spreadsheet or therapeutic diet instructions. Dietary staff were unsure what to serve for mechanical soft, NAS, and diabetic diets until the Dietary Supervisor reviewed the spreadsheet with them during lunch service. The cook stated that mechanical soft residents usually received the same vegetables as regular diets, with vegetables simply cooked longer, and that she thought serving hard carrots was acceptable until they were cooked longer. The Registered Dietitian stated that the same meal was served to all residents except for limited adjustments such as no salt packets for NAS diets and fruit cups instead of dessert for carbohydrate-controlled diets. During Resident Council, one resident stated that the kitchen changed menus quite a bit and sometimes residents were told about the changes and sometimes they were not.
QAPI Meetings Lacked Required MD and IP Attendance
Penalty
Summary
The facility failed to ensure that QAPI meetings had the Medical Director and the Infection Preventionist as mandatory attendees at least quarterly. Review of the QAPI Committee Adaptation and Attendance Record dated 1/28/2025, 4/25/2025, and 7/29/2025 showed that the Medical Director did not attend those meetings. The record also showed there was no QAPI meeting in September 2025 or November 2025, and the Infection Preventionist did not attend the meeting on 10/30/2025. During interview, the Medical Director stated that he tried to attend QAPI every month, in person or by phone, because he wanted to know what was going on in the facility in all different areas. He said he could not remember the dates he was not at QAPI and stated that if he did not sign the sheet then he did not attend. The Nursing Home Administrator stated that QAPI meetings were held monthly to ensure required attendees such as the Medical Director and Infection Preventionist attended quarterly. Review of the facility’s Quality Assessment and Assurance Program showed the required members included the Administrator, DON, Medical Director or other attending physician, at least three other staff members, and the Infection Control and Prevention Officer, and that QAPI was an ongoing process with monthly meetings and regular attendance expected.
Infection Control Failures With PPE, Incontinence Care, and Environmental Cleanliness
Penalty
Summary
The facility failed to implement infection prevention and control measures for residents who had physician-ordered precautions or conditions requiring contact precautions or Enhanced Barrier Precautions (EBP). For Resident #63, who had an indwelling Foley catheter and a wound on the right hallux, physician orders required EBP for wound and Foley catheter care. During observation, staff preparing to transfer the resident wore gloves but did not have gowns on, and gowns were not available in the room or on the door. On another observation, a COTA transferred the resident while wearing gloves but no gown, handled the gait belt and Foley catheter bag, and then discarded gloves after leaving the room. For Resident #55, who was incontinent of bowel and bladder and required extensive assistance with personal care, incontinence care was observed to be incomplete and inconsistent with infection control practices. CNA J cleaned the resident’s front groin folds and buttocks but did not clean the genital folds or between the legs after observing stool. The CNA did not change gloves or perform hand hygiene and used the same contaminated gloves to touch clean surfaces, including the nightstand drawer, bed controls, and the resident’s call light. The DON stated that incontinence care should include thorough cleaning of the female genital folds, glove changes after contact with bowel movement, and barrier cream use with every incontinence episode. For Resident #15, who had an infected knee wound with MRSA and was ordered for contact isolation, staff demonstrated inconsistent understanding and use of PPE. The room door displayed contact precaution signage requiring hand hygiene, gloves, and gown use before room entry. An LPN told the surveyor that PPE was unnecessary if someone was only going into the room to talk to the resident, and later stated the resident had an active MRSA infection and PPE was required. A dietary supervisor delivered a meal tray into the room without PPE, and other staff stated that gowns and gloves were not needed if they were only talking to the resident or passing water. The DON, LPN manager, and wound nurse each described situations in which PPE was not needed if staff were not touching the resident or were caring for the roommate. For Resident #13, who was severely cognitively impaired, NPO, and dependent on tube feeding, the room environment was observed to be heavily soiled. A large section of the wall behind the bed had dried brown liquid streaks, the resident’s linens rested against the soiled wall, and dried brown liquid was also present on the floor and feeding tube pole. On later observations, the same soiled wall and feeding tube pole remained in place while tube feeding continued.
Failure to Maintain Resident Dignity During Dressing and Bedside Care
Penalty
Summary
The facility failed to provide care and services to promote dignity for Resident #13, who had diagnoses including hemiplegia and major depressive disorder and was assessed as severely cognitively impaired with a BIMS score of 00/15. The resident was dependent on staff for dressing and had a care plan stating she was dependent on staff for all dressing, with the goal of maintaining her current level of functioning with assistance from staff. During observations, Resident #13 was found awake in bed wearing a hospital gown gathered under her armpits, exposing her left breast, abdomen, and incontinence brief, while the privacy curtain was not pulled around her bed. This occurred on multiple observations, and the resident was observed wearing the hospital gown throughout the day despite a dressing task list showing only one dressing assistance episode. Family reported the resident valued modesty and preferred to be dressed in her own clothes each day. Staff and the DON confirmed the expectation that she should be assisted with dressing in her own clothing and that privacy curtains should be used when private parts were exposed; the DON also confirmed refusals should be documented, but no rejection of care was documented in the last 14 days.
Failure to Provide Transfer/Discharge Notice
Penalty
Summary
The facility failed to provide a transfer/discharge notice for one resident who was reviewed for hospitalization. The resident was initially admitted with diagnoses including congestive heart failure, heartburn, and hypertension, and had a BIMS score of 14 out of 15, indicating cognitive intactness. The resident transferred to the hospital after a fall with subdural hemorrhage and returned to the facility two days later. Review of the chart showed no transfer/discharge notice from the hospitalization, and the resident stated he remembered being sent to the hospital but could not recall discussion of a transfer/discharge notice. During interviews, the RN stated he notified the resident’s guardian when the resident was transferred to the hospital, but he could not remember completing and sending a transfer/discharge notice to the resident or guardian. An LPN stated he sends a transfer form with medications and other information when a resident is transferred, but he had not heard of a transfer/discharge notice and had not been sending one with resident transfers. The NHA and RCN stated the facility had not been sending the transfer/discharge notice when residents went to the hospital and that they discussed implementing it. The facility policy required providing a transfer notice to the resident and/or an immediate family member or legal representative and documenting the process in a nursing progress note.
Baseline Care Plan Missing Foley Catheter and Pacemaker Information
Penalty
Summary
The facility failed to develop a baseline care plan that included the minimum healthcare information needed to properly care for Resident #63 within 48 hours of admission. The resident was admitted with diagnoses including chronic atrial fibrillation, a cardiac pacemaker, obstructive uropathy, and a urogenital implant with an indwelling Foley catheter. The baseline care plan dated 1/14/26 did not identify the indwelling catheter under bowel and bladder appliances and did not include any information related to the cardiac pacemaker. Record review showed the resident had physician orders to maintain the Foley catheter with a 16 Fr 5cc balloon every shift, and the TAR reflected that order, but there were no treatment orders related to the pacemaker. The nursing admission assessment noted chronic atrial fibrillation and an irregular heart rate, and also indicated a Foley catheter was in place, but it did not note that a pacemaker was present. The current care plan also contained no information related to either the Foley catheter or the pacemaker. In interview, the DON stated the baseline care plan was incorrectly completed, that the pacemaker orders had not been activated while waiting for the model number, and that the resident’s pacemaker information had been received but placed in a file to be scanned into the record.
Inadequate Incontinence Care and Hand Hygiene
Penalty
Summary
The facility failed to provide adequate incontinence care for a resident who was incontinent of bowel and bladder, required extensive assistance with mobility and personal care, and had care plan interventions for peri-care, skin protection, and UTI risk related to incontinence. The resident’s treatment order directed moisture barrier ointment to be applied to the peri-areas and buttocks every shift, and the record indicated staff were applying the cream three times a day. During an observation, the resident had been up in a chair for more than 6 hours, the chair was visibly wet, her pants were wet in the buttock area, and her brief was saturated with dark yellow-brown urine with a strong urine odor. Staff performed incontinence care but did not clean the genital folds or between the resident’s legs, and barrier cream was not applied afterward. A second observation showed the resident again in a saturated brief with a strong urine odor. Staff cleaned the front groin folds and buttocks, but did not clean the genital folds or between the resident’s legs, did not apply barrier cream, and did not change gloves or perform hand hygiene after contact with bowel movement. The same gloves were then used to open the resident’s nightstand drawer, operate bed controls, and hand the resident her call light. Staff interviews indicated the resident was often left up in her chair for long periods, only allowed incontinence care a couple of times a day, and needed very thorough care with thick barrier cream because she was a heavy wetter. The DON stated that incontinence care should include thorough cleaning of the female genital folds, glove changes after contact with BM, and barrier cream with every incontinence episode.
Inaccurate medication documentation in physician notes
Penalty
Summary
The facility failed to maintain accurate medical records for one resident with depression, anxiety, and dementia. The resident’s care plan identified a history of anxiety and depression, and a physician note documented current use of Lexapro 5 mg along with a plan to ensure proper administration of prescribed medication and medication reconciliation. However, the physician orders did not include Lexapro, and the discontinued orders showed Lexapro 5 mg had been stopped with an end date of 8/19/2024. During interview, the SW stated the resident was not taking any medications for depression and that Lexapro had been discontinued through GDR in August 2024. After review, the SW agreed the physician notes were not correct and did not document the Lexapro GDR, and earlier notes were found to contain the same inaccurate information. The MD stated he reviewed the active medication list during visits but was unsure why it was not accurately transcribed into the visit note, and he did not normally include GDR information because he expected behavioral health providers to document it. Psychiatry documentation from 11/4/24 still listed Lexapro 5 mg daily as continued. The MR stated she did not scan the notes into the EHR and was not responsible for their accuracy, and the DON stated the notes were uploaded by the MD and had not been reviewed for accuracy.
Failure to Provide Timely Physician-Ordered Pain Medication
Penalty
Summary
A resident with chronic pain, obesity, depression, and severe osteoarthritis of the left hip was admitted to the facility and required physician-ordered pain management, including Norco (hydrocodone-acetaminophen). Despite having clear physician orders for Norco, the resident did not receive the medication for 11 consecutive days. During this period, the resident reported severe, uncontrolled pain, rating it as 10 out of 10, and stated that alternative pain medications such as Tylenol and Ibuprofen were not effective. The resident indicated that staff were aware of the missing Norco and repeatedly informed him that the pharmacy had not shipped the medication yet. Review of the resident's medical records and medication administration records confirmed that Norco was not administered from the start date of the order through the period in question. Progress notes documented ongoing issues with obtaining the medication, including references to awaiting supply, missing scripts, and delays attributed to the Thanksgiving holiday. Staff interviews revealed that delays in receiving medications from the pharmacy were not uncommon, and several nurses believed that facility management was aware of the issue. However, both the DON and NHA stated they were not aware of the resident missing Norco until the ombudsman intervened. Further interviews with facility leadership and the prescribing physician highlighted communication breakdowns and procedural lapses. The DON reported that the pharmacy did not receive the necessary script and that there was difficulty getting the physician to provide it due to the holiday. The physician acknowledged he could have sent the script electronically but did not recall the specifics of the situation. The facility's policy required providing care and services according to established guidelines, but the resident's pain management needs were not met due to these failures in medication procurement and communication.
Failure to Provide Timely Physician-Ordered Pain Medication
Penalty
Summary
The facility failed to follow professional standards of practice by not ensuring timely follow-up on a physician-ordered pain medication for a resident with chronic pain, osteoarthritis, obesity, and depression. The resident was admitted with significant pain issues and had a physician order for Norco (hydrocodone-acetaminophen) to manage pain. Despite the order, the resident did not receive the prescribed Norco for at least 11 days, missing 11 doses, due to delays in obtaining the medication from the pharmacy and issues with obtaining the necessary prescription script. During this period, the resident reported severe, uncontrolled pain, rating it as 10 out of 10, and stated that alternative pain medications such as ibuprofen and acetaminophen were not effective. Nursing staff were aware that the Norco had not arrived and communicated this to the resident, but there was no documented escalation or effective resolution of the issue. Progress notes repeatedly indicated that the medication was "awaiting supply" or that the pharmacy had not received the script, yet there was no evidence of timely follow-up with the physician or pharmacy to resolve the delay. Interviews with nursing staff and facility leadership revealed a lack of awareness and communication regarding the ongoing medication issue. The DON and NHA were not aware of the missed doses until informed by an ombudsman. The physician and nurse practitioner involved were also not fully aware of the extent of the delay, and the physician did not review the medication administration record during a subsequent visit. Facility policy required providing care and services according to established practice guidelines, but this was not followed in ensuring the resident received the ordered pain medication.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to prepare and store food in accordance with professional standards for food service safety, as observed during a survey. In the kitchen's walk-in cooler, containers of cooked roast beef were found with condensation and moisture, and their temperatures were not adequately cooled to the required standards. The Director of Housekeeping, filling in for the Dietary Manager, was unsure about the cooling logs for these items. Additionally, various food items in the cooler and nourishment room were improperly dated or lacked date markings, violating the FDA Food Code requirements for date marking and disposition of ready-to-eat foods. The survey also revealed several cleanliness and maintenance issues in the kitchen. Mechanical scoops and the coffee spout were found with dried food debris and coffee accumulation, respectively. The microwave had crusted debris, and the ventilation filters on the cook line had excess grease accumulation. The preparation sink was not properly set up, allowing water to dispense onto the floor, and the chemical closet's setup put undue pressure on the mop sink faucet's vacuum breaker. Furthermore, the dish machine was not reaching the required temperatures for washing and rinsing, and an open gallon of soy sauce was improperly stored in the dry storage room. During meal service, a staff member was observed handling baked potatoes with bare hands, deviating from the initial use of utensils and gloves. This practice violated the FDA Food Code's guidelines for preventing contamination from hands. These deficiencies collectively indicate a failure to adhere to food safety and sanitation standards, potentially leading to foodborne illnesses among residents consuming food prepared in the facility's kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection control practices during resident care, as evidenced by multiple observations and interviews. For instance, a housekeeping aide was observed not wearing personal protective equipment (PPE) while handling trash and cleaning surfaces in a resident's room who was on contact precautions due to a methicillin-resistant Staphylococcus aureus (MRSA) infection. This aide believed that the contact precautions did not apply to housekeeping staff, a misunderstanding that was echoed by the Director of Housekeeping, despite the Director of Nursing's (DON) assertion that all staff should adhere to these precautions. Additionally, the facility did not maintain an ongoing infection control surveillance program. The Director of Nursing/Infection Preventionist (DON/IP) admitted that there was no tracking of employee illnesses, which could potentially lead to the spread of illness among residents. Furthermore, the facility had not conducted hand hygiene or PPE audits since May 2024, increasing the risk of cross-contamination between residents and staff. The facility also lacked an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). Observations revealed multiple stagnant water lines, and interviews with maintenance and housekeeping staff indicated a lack of awareness and documentation regarding a water management plan. The facility's policy on water systems and legionella risk prevention was not actively implemented, as there was no evidence of a completed risk assessment or a building-specific list of areas at risk for legionella growth.
Failure to Document and Offer COVID-19 Vaccination to Staff
Penalty
Summary
The facility failed to maintain proper documentation of COVID-19 vaccination status, education, and offering for its staff, specifically for a Certified Nursing Assistant (CNA) identified as DD. The CNA was last vaccinated on November 24, 2021, and there was no documentation of any subsequent offering or education regarding the COVID-19 vaccine. During an interview, the Director of Nursing (DON), who also serves as the Infection Preventionist, confirmed that the facility had not offered the COVID-19 vaccination to staff in 2024 and had not tracked their immunization status or provided education on the matter. This lack of documentation and action increased the risk of COVID-19 infections among residents.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by multiple observations during a survey. In the nourishment room, a large hole under the sink exposed the back wall, presenting a potential entry point for pests, along with moisture damage and a black staining-like substance. An empty resident room was found with a large brown splash stain and bubbling walls, indicating possible water damage. The 200 hall bath had towels and washcloths improperly stored, and a shower chair with dried brown stains. The 200 Hall Soiled Utility room had brown-tinted water from the faucet, a slow leak, and a musty odor from moisture-damaged cabinetry. The 300 Hall Soiled Utility room had a leaking valve, incomplete flushing of the hopper, and a non-operational sink with a disconnected wastewater line and a large hole in the cabinetry. Further deficiencies were noted in the 200 hall janitor's closet, where a chemical pre-dispense system was improperly set up, risking damage to the faucet's vacuum breaker. The boiler room had one non-operational water heater, though the maintenance staff believed they could meet hot water demand. The 500 hall bath had missing floor tiles, debris under shower beds, and an unused tub with dirt and debris. The lobby area had significant drywall damage, and the dining room had bubbled wallpaper, rusted floor vents, and built-up debris around door frames. These conditions collectively increased the potential for contamination and decreased resident satisfaction with their living environment.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a total error rate of 20% among four residents. For Resident #15, the error involved improper administration of subcutaneous injections. The LPN administered insulin aspart and Mounjaro injections into the deltoid muscle, which is not an acceptable location for subcutaneous injections according to the facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON). This error was confirmed through interviews with the LPNs and the DON, who clarified that subcutaneous injections should be given in fatty areas such as the back of the arms, abdomen, and outer thighs. Resident #25 experienced a late administration of baclofen, which was ordered to be given at 3:00 PM but was administered at 4:28 PM. The LPN believed that medications could be given within an hour before or after the scheduled time, but the DON confirmed that the administration was late. This discrepancy in understanding the timing of medication administration contributed to the error. For Resident #30, the error involved a missed dose of gabapentin due to its unavailability in the medication cart. The LPN did not retrieve the medication from the facility's backup medication box, despite its availability, citing a lack of time. Resident #43's error involved the crushing of acamprosate, a delayed-release medication, which should not be crushed as it alters absorption. The LPN crushed the medication despite the prescription label indicating 'Do Not Crush,' and this was confirmed by the pharmacist and the DON.
Ineffective Pest Control Program Leads to Ant Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live ants in various areas, including resident rooms, hallways, and visitor restrooms. Observations on multiple occasions revealed live ants on the bathroom floor of a resident's room, in the hallway outside the room, and in the visitor restroom. Open food containers with resident food were also found stored on the floor, which could contribute to the ant infestation. Interviews with housekeeping aides confirmed the presence of ants throughout the building, particularly around food crumbs in resident areas. Despite having a pest control service that visits monthly, the Maintenance Assistant admitted to not chemically treating the building for ants between visits. The Nursing Home Administrator was unaware of the ant issue in the visitor bathroom, despite staff using the facility and the problem persisting for several days. The lack of timely intervention and awareness of the pest issue by the facility's staff contributed to the ongoing presence of ants, posing a potential risk for food infestation and resident discomfort.
Failure to Maintain Professional Standards in Enteral Feeding Administration
Penalty
Summary
The facility failed to maintain professional nursing standards during the administration of enteral feeding for a resident with dysphagia and a gastrostomy tube. The resident was prescribed an NPO diet with enteral feeding of Vital 1.5 formula at 75cc/hr for 20 hours, starting at 3:00 PM and ending at 11:00 AM. However, observations revealed that the feeding pump was often powered off during the prescribed feeding times. Interviews with nursing staff indicated discrepancies in the start times of the feeding, with one LPN stating the feeding began at 6:00 PM instead of the ordered 3:00 PM. Additionally, the total volume of formula administered was not documented in the Medication Administration Record (MAR), and the resident did not receive the full prescribed amount of 1500 ml daily. The Registered Dietitian and Director of Nursing both confirmed the expectation that the feeding should start at 3:00 PM and end at 11:00 AM, with a total of 1500 ml administered. However, observations showed that the feeding pump was alarming due to an empty formula bottle and air bubbles in the tubing, indicating that the feeding was not properly managed. The LPNs involved did not hang a second bottle of formula, resulting in the resident not receiving the full nutritional intake as ordered. The MAR lacked documentation of actual start and stop times, further contributing to the deficiency in care.
Inadequate Assistance with ADLs and Hygiene Concerns
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents, leading to dissatisfaction with care and hygiene concerns. Resident #46, who was cognitively intact, expressed dissatisfaction with the frequency of showers received, stating he had only a couple of showers since admission, despite a preference for two showers a week. The facility's records confirmed that Resident #46 did not receive the scheduled showers consistently, with only three showers documented over a period of several weeks. Resident #27, who was moderately cognitively impaired, required supervision or touching assistance for bathing. Observations and family reports indicated that Resident #27 appeared disheveled with long, dirty fingernails, suggesting inadequate assistance with personal hygiene. The facility's records showed that Resident #27 was offered showers on only 16 out of 27 scheduled opportunities, indicating a failure to adhere to the shower schedule. Resident #38, who was cognitively intact but required maximal assistance for personal hygiene, was observed with soiled fingernails on multiple occasions. The resident expressed frustration and embarrassment over the dirty appearance of her nails and reported needing more assistance from staff. Family members also noted the resident's dirty fingernails during visits, highlighting a lack of adequate care in maintaining personal hygiene.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to ensure that enteral feeding was administered as ordered for a resident with a gastrostomy tube, resulting in the potential for weight loss, dehydration, and overall deterioration of wellbeing. The resident, who had a history of dysphagia following a stroke, was observed multiple times with her feeding pump powered off and the feeding tubing not connected to her G-tube, despite orders for continuous feeding from 3:00 PM to 11:00 AM at a rate of 75cc/hr. Interviews with nursing staff revealed inconsistencies in the administration of the resident's tube feeding. One LPN reported turning off the feeding an hour earlier than ordered, while another LPN admitted to starting the feeding later than the prescribed time. The Medication Administration Record lacked documentation of the total volume of formula administered, and observations confirmed that the resident did not receive the full prescribed amount of formula. The Director of Nursing confirmed that the resident should receive a total of 1500 ml of formula daily, which was not achieved due to the failure to hang a second bottle of formula. The Registered Dietitian also emphasized the importance of adhering to the feeding schedule to ensure the resident received the necessary nutrition. The lack of adherence to the prescribed feeding schedule and documentation requirements led to the deficiency identified by the surveyors.
Failure to Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDRs) for the ongoing use of psychotropic medications were completed for a resident reviewed for unnecessary medications. The resident had a diagnosis of major depressive disorder and was prescribed Duloxetine 60 mg to be administered enterally once a day. The Director of Nursing (DON) reported that the resident's dosage of Duloxetine had remained unchanged for over a year, and there had been no attempt at a gradual dose reduction during 2024. Additionally, the facility was unable to provide any documentation of a gradual dose reduction or a physician's rationale against it for the resident's Duloxetine prescription.
Failure to Prevent Scalding Hazards and Resident Elopement
Penalty
Summary
The facility failed to minimize the risk of scalding and burns by allowing hot water temperatures to exceed 120 degrees Fahrenheit in resident rooms and shower areas. During an inspection, it was observed that the water temperatures in several rooms and shower areas were above the recommended limit, with some reaching as high as 125.4 degrees Fahrenheit. The facility's maintenance director acknowledged the issue, citing difficulties in maintaining appropriate temperatures due to only one functioning boiler. Additionally, the facility's water temperature logs for August and October were missing, indicating a lack of consistent monitoring. The facility also failed to prevent an elopement incident involving a resident identified as high risk for elopement due to cognitive impairment and wandering behavior. The resident managed to exit the facility without staff knowledge and was found outside by a CNA. The therapy exit door, through which the resident exited, was not alarmed or locked at the time, allowing the resident to leave unnoticed. Interviews with staff revealed that the door was not secured after the last therapy session, and the alarm system was not functioning properly at the nurse's station. The resident involved in the elopement had a history of exit-seeking behavior and was supposed to have a wander guard in place. However, there was a lapse in ensuring the wander guard was checked and functioning, as there were no orders for its use after the resident's readmission to the facility. The facility's policies on monitoring residents at risk of elopement and ensuring door alarms were not adequately followed, contributing to the resident's ability to leave the premises undetected.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents, resulting in physical abuse. Resident #104, a male with Alzheimer's disease and cognitive deficits, was physically abused by Resident #103, who has a history of dementia, anxiety, and aggressive behavior. The incident occurred in the dining room where Resident #104 was approached by Resident #103 and flipped over in his chair, leading to threats exchanged between the two residents. Resident #103 has a documented history of maladaptive behavioral symptoms, including verbal altercations and aggressive behavior towards other residents and staff. Prior to the incident, Resident #103 had been involved in a similar altercation where he attempted to swing a walker at another resident. Despite these behaviors, the care plan for Resident #103 included interventions such as behavior management techniques and stress management, but these measures were insufficient to prevent the incident. The incident was witnessed by staff and a visitor, who reported that Resident #104 was rearranging tables when Resident #103 became agitated and flipped him over. The facility's policy on abuse prevention defines abuse as the willful infliction of injury or intimidation, which was not adequately prevented in this case. The failure to effectively manage Resident #103's behavior and protect Resident #104 from harm constitutes a deficiency in the facility's abuse prevention measures.
Failure to Report Suspected Abuse to Law Enforcement
Penalty
Summary
The facility failed to develop and implement policies and procedures for reporting a reasonable suspicion of a crime, specifically in the case of a resident with multiple diagnoses including schizophrenia, anxiety, depression, dementia, and aphasia. The incident involved a Certified Nursing Assistant (CNA) allegedly holding the resident's breast while changing the resident's brief. This incident was reported internally to the charge nurse and Nursing Home Administrator (NHA) but was not reported to Law Enforcement as required by the facility's Abuse Prevention Program Policy and Section 1150B of the Social Security Act. Interviews with the current NHA, Director of Nursing (DON), and another NHA revealed uncertainty and acknowledgment that the incident should have been reported to Law Enforcement. The facility's policy clearly states that such incidents should be reported immediately to Law Enforcement, but this procedure was not followed. The lack of reporting to Law Enforcement constitutes a deficiency in the facility's adherence to its own policies and federal requirements for reporting suspected abuse.
Failure to Address Skin Integrity in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan addressing skin integrity for a resident admitted under hospice care for a 5-day respite stay. The resident, who had a history of skin integrity issues, was noted to have a rash under her right breast upon admission. However, the Baseline Care Plan assessment did not include any information regarding her skin risk or current skin condition, as the section for skin risk was left blank. Despite the resident's known history and current skin issues, the care plan initiated the day after admission did not address skin integrity. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the baseline care plan assessment failed to address the resident's skin risk and the rash under her right breast. The facility's policy requires that the Baseline Care Plan be completed within 48 hours of admission and address areas of imminent concern, which was not adhered to in this case.
Failure to Address Skin Concern Leads to Worsening Condition
Penalty
Summary
The facility failed to conduct a thorough assessment and follow-up on a skin concern for a resident admitted under Hospice care for a 5-day respite stay. Upon admission, the resident had a rash under her right breast, which was noted in the Admission/Re-Admission Screener and the Shower Sheet. However, this condition was not addressed in the resident's progress notes, care plan, or treatment record. The Director of Nursing and the Licensed Practical Nurse involved were unaware of the rash under the breast, despite it being documented upon admission. The lack of communication and follow-up resulted in the rash worsening into a yeast infection, which was only discovered by a Hospice LPN four days later. The Hospice team was not informed of the skin issue, leading to a lapse in continuity of care. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's skin condition, despite the family member and CNA noting the issue upon admission.
Failure to Resolve Resident Grievance
Penalty
Summary
The facility failed to thoroughly investigate and resolve grievances for a resident, resulting in unresolved concerns and unmet needs. The resident, who had a moderately impaired cognitive status, reported being left in a soiled incontinence brief for over six hours without proper cleaning or changing of the bed linens. The resident also mentioned a two-hour wait time after pressing the call light. The grievance was documented by the Social Service Director on behalf of the resident, and it was assigned to the Unit Manager for resolution. The investigation into the grievance was inadequate, as the Unit Manager only conducted verbal education with staff at the nurse's station without any documentation. The Social Service Director, who had recently started, was unsure of the investigation's details and relied on the Nursing Home Administrator for assistance. The facility's grievance policy required a thorough investigation to identify the root cause and take corrective action, but this was not adequately followed, leading to the deficiency.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The report identifies a deficiency in the timely reporting of an allegation of abuse involving a resident with moderate cognitive impairment. The resident alleged that a CNA and an LPN were rough while assisting her, nearly causing her to hit her head. This incident was not reported immediately to the Nursing Home Administrator (NHA) or law enforcement, as required by the facility's policies. The LPN involved delayed reporting the incident, believing the allegation to be untrue, which contributed to the failure in timely notification. Further investigation revealed that the NHA was aware of the requirement to report such allegations immediately but admitted to only reporting significant incidents to law enforcement. This practice was contrary to the facility's abuse prevention policy, which mandates immediate reporting of any suspected abuse or neglect to the appropriate authorities. The NHA's failure to report the incident to law enforcement and the state agency resulted in an incomplete investigation and left the resident unprotected from potential abuse. Additionally, another concern was raised by the resident regarding neglect, which was documented in a grievance form. The resident reported being left in soiled conditions for an extended period without proper care. This allegation of neglect was not reported to the state agency, and there was no documented investigation or corrective action taken. The facility's policy requires immediate reporting and investigation of such concerns, but these procedures were not followed, indicating systemic issues in handling allegations of abuse and neglect.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 484 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Niles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Orchards At Niles | 1.6 mi | ★★★★★ | 20 | 0 |
| West Woods Of Niles | 4 mi | ★★★★★ | 24 | 1 |
| Healthwin Health & Rehabilitation | 6.1 mi | ★★★★★ | 34 | 0 |
| Majestic Care Of South Bend | 6.4 mi | ★★★★★ | 56 | 0 |
| Wellbrooke Of South Bend | 7.5 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.