Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 The Orchards At Niles during CMS and state inspections, most recent first.
Licensed staff did not follow professional standards or the facility’s Acute Change in Condition policy when a resident with dementia and other cognitive and physical impairments became confused and restless, was found to have an O2 saturation of 88% (improving to 93% on 2L O2), and had blood in the stool. The nurse documented the event and placed a note in the physician log but did not obtain a complete set of vitals or directly notify a provider. Review of records showed no provider follow-up for these concerns, and interviews with an LPN, the unit manager, and the DON confirmed that facility protocols required full assessment and immediate provider notification for such changes, including possible GI bleed.
Food storage and sanitation practices were deficient in the kitchen and at nurses’ station refrigerators. Multiple ready-to-eat items were found without discard dates or kept beyond manufacturer guidance, including dairy items, shakes, vegetables, pizza, soup, and sliced bologna. The sanitizer at the dish area and three-compartment sink tested below the expected level, and several pieces of equipment and utensils were observed with debris, sticky residue, or soil accumulation, including the juice dispenser, ice machine, scoop holder, clean scoops, and a saucepan stored with clean pans.
Unsafe and Unsanitary Environmental Conditions: Surveyors observed deteriorated wall surfaces and coming off vinyl coving in spa areas, soiled shower equipment, mixed storage of bleach cleaner with personal hygiene products, a shower call light that did not activate the hallway light, foul odors in the Memory Unit with nonfunctioning or ineffective exhaust ventilation, open dumpster doors, and unsecured oxygen tanks with no clear separation of full and empty cylinders. Two boxes of nutritional supplements were also stored on the floor in the central supply room.
Failure to Prevent Facility-Acquired Pressure Ulcer: A resident with fractured hip, weakness, and declining mobility became bed bound and dependent on staff for all care. Despite a Braden score indicating moderate risk and care plan items for skin integrity and use of a draw sheet, staff documented a facility-acquired stage 2 pressure wound on the right shoulder. The resident did not assist with repositioning, and staff confirmed the wound was pressure related while the care plan lacked wound-specific pressure ulcer prevention interventions.
Failure to monitor a resident's pureed diet and swallowing precautions. A resident with cerebral palsy, epilepsy, intellectual disabilities, and Rett's syndrome was ordered a pureed diet with thin liquids and total feeding assistance, but a family member was observed feeding mechanically altered pasta-like food and giving a straw drink without staff present. The guardian and staff reported the resident had swallowing difficulty, thick secretions, and coughing while eating, and the facility had not clearly communicated or documented the updated visitation arrangement.
Failure to track and offer the pneumococcal vaccine was cited after a resident with DM, dialysis, HTN, and acute respiratory failure with hypoxia had prior PCV13 and PPSV23 immunizations documented, but no refusal or declination was found in the record. The UM stated the resident should have had the pneumococcal booster or been offered it, and review of the chart and immunization binder did not locate documentation of a declination.
Two residents with severe cognitive impairments were involved in a physical altercation, which was witnessed by a staff member and internally reported to nursing and administrative staff. Although the incident was documented and discussed by the interdisciplinary team, the required report to the State Agency was not submitted, resulting in an incomplete investigation and failure to meet reporting requirements.
A resident with vascular dementia and hand stiffness was not wearing a recommended left resting hand splint, as observed multiple times. Despite therapy recommendations and staff training, there was no physician order or documentation of the resident's refusal to wear the splint. Interviews with staff revealed a lack of awareness and documentation regarding the splint's application, indicating a breakdown in communication and processes within the facility.
A resident with a history of urinary retention and recurrent UTIs was hospitalized due to a severe UTI and sepsis after the facility failed to provide adequate catheter care and monitoring. Despite signs of infection and abnormal urinalysis results, timely action was not taken. The facility lacked proper documentation and communication regarding the resident's condition and test results, leading to a delay in treatment and subsequent hospitalization.
A resident with vascular dementia and coordination issues was not provided with a divided plate as ordered by the physician, which was necessary for self-feeding. The resident was observed eating from a regular flat plate, contrary to the tray ticket instructions. The registered dietitian confirmed the importance of the divided plate for the resident's ability to eat independently.
A facility failed to maintain accurate medical records and monitor a resident's condition, leading to a lack of documentation for catheter care, test results, and vital signs related to an impending UTI. Despite symptoms like cloudy urine and decreased appetite, there were gaps in documentation and no orders for catheter care. Staff interviews revealed that abnormal urinalysis results were not promptly addressed, and CNA tasks showed no documentation of catheter care for 30 days. The resident was eventually sent to the ER.
The facility did not hold Quality Assessment and Assurance (QAA) meetings quarterly as required, and the Medical Director missed two meetings. There was a gap in meetings from January to August, with the Nursing Home Administrator meeting department heads individually instead. The QAPI policy mandates quarterly meetings with specific members, including the DON and Medical Director.
The facility failed to ensure the Infection Preventionist (IP) completed specialized training in infection prevention and control. The DON, responsible for the infection control program, did not complete the post-test of the CDC IP certification training, resulting in a lack of certification. The UM assisting in the program also lacked certification. The NHA was unaware of these deficiencies.
The facility failed to provide annual abuse prevention training for all staff, affecting 33 out of 104 employees. This deficiency was identified through interviews and record reviews, revealing that staff were often pulled to work on the floor, leaving insufficient time for training. Despite measures to track and remind staff of training requirements, the facility's records showed a significant number of staff had not completed the necessary training.
The facility failed to provide consistent, meaningful, and person-centered activities for residents in the dementia care unit. Despite having an activity calendar, scheduled activities were not conducted, leaving residents idle or asleep without engagement. Residents with specific interests, such as music, crafts, and socializing, were not observed participating in these activities. Documentation showed a lack of recorded group activities and minimal one-on-one interactions. Staffing challenges and lack of training contributed to the deficiency.
The facility failed to employ a dietary manager with appropriate training and certifications, leading to potential food service sanitation failures and foodborne illness risks. The kitchen has been without a manager for over a month, and the Registered Dietitian visits infrequently without monitoring the kitchen. The NHA is aware of the situation but is unable to provide adequate oversight due to other responsibilities.
The facility failed to properly label and date foods in the kitchen, risking foodborne illness for residents. Observations included unlabeled and undated cheese, milk, shredded pork, cranberry concentrate, bread crumbs, thickener, sugar, and bacon bits, violating the 2017 FDA Food Code.
The facility failed to provide behavioral health care training for 104 staff members, with 78 not receiving annual abuse prevention training. CNA V reported time constraints due to work duties, while Receptionist EEE tracked training completion and sent reminders. Administrator A confirmed training was completed as needed, but evidence of compliance was lacking.
A resident with osteomyelitis and end-stage renal disease requested a hospital transfer due to severe pain, but the Medical Director denied the request, citing non-emergency and transfer management concerns. The resident felt angry and frustrated, and despite the Medical Director's disapproval, the resident was eventually sent to the ER. This incident reflects a failure to uphold the resident's dignity and self-determination.
A resident with osteomyelitis and end-stage renal disease was moved to a different room without proper notification, despite initially refusing the change. The facility failed to provide written notice or documentation of the resident's agreement to the move, as required by policy. Interviews revealed inconsistencies in the facility's handling of the situation, leading to the deficiency.
The facility failed to maintain accurate advanced directive information for two residents, leading to discrepancies in their code status documentation. One resident's electronic medical record indicated a Full Code status, while a physical document showed a DNR status. Another resident's code status was updated by the guardian to allow CPR, but this change was not reflected in the medical record. Staff were unaware of these discrepancies, resulting in potential misalignment with residents' medical care preferences.
A resident with dementia and Alzheimer's was subjected to physical abuse by a CNA during a shower, where the CNA covered her mouth and sprayed water in her face to silence her. This incident, which increased the resident's agitation, was witnessed by another CNA who reported the behavior to management. The offending CNA had a history of similar actions, but these were not reported until this incident. The facility had not provided abuse-related education in recent staff training.
A resident, who was cognitively intact, reported a theft of money from their room and informed the police and facility staff. The NHA reported the incident to the State Agency but failed to submit the final investigation due to going on vacation, and no other management team member completed the submission within the required timeframe.
The facility failed to complete PASARR and OBRA Level II documentation for two residents. One resident lacked an Annual Resident Review, and the social worker was unsure of the responsible party for completion. Another resident, with dementia and borderline personality disorder, did not have a Level II assessment or exemption letter, as the original PASRR was not submitted by the referring facility.
The facility failed to provide adequate ADL care for three residents, leading to poor personal hygiene and grooming. A resident with dementia was observed with unkempt facial hair, another with Alzheimer's had long facial hairs, and a male resident with a fractured humerus was in a state of poor hygiene. Care plans requiring assistance were not followed, and staff faced challenges accessing necessary grooming supplies.
A resident at risk for pressure ulcers due to impaired mobility and a history of wounds did not receive necessary preventative care. Despite orders for a protective dressing, the resident missed multiple treatment opportunities and was left sitting for extended periods without repositioning. Staff interviews revealed a lack of awareness and adherence to treatment plans, and the resident's risk assessment was outdated.
A resident with dementia and mobility issues was transferred by a CNA without using a gait belt, contrary to the care plan requiring two-person assistance and a gait belt. The CNA, unfamiliar with the resident's needs, believed a one-person transfer was sufficient. Other staff confirmed the correct protocol, and the DON emphasized the necessity of using a gait belt for transfers.
A facility failed to develop a person-centered care plan for a resident with dementia, anxiety, and depression, focusing mainly on medication without addressing her need for meaningful activities. The resident frequently exhibited distressing behaviors, which staff struggled to manage due to inconsistent documentation and lack of training. The facility did not provide adequate dementia care training for 39 out of 104 employees, potentially compromising the resident's well-being.
The facility failed to maintain accurate medical records for three residents, leading to discrepancies in medication administration and treatment documentation. A resident received the wrong insulin without updating the physician's order, another had nebulizer treatments inaccurately documented, and a third had incomplete wound care records.
The facility failed to ensure proper use of PPE for two residents under enhanced barrier precautions due to open wounds. Staff, including CNAs and a hospice nurse, were observed not wearing gowns during high-contact care activities, despite signage indicating EBP requirements. Interviews revealed inconsistencies in understanding and implementing EBP protocols, with some staff unaware of the need for PPE or misunderstanding which residents required it.
The facility failed to offer recommended Pneumococcal vaccines to eligible residents, impacting two residents reviewed for immunizations. One resident, over 65 and admitted in early 2024, had prior vaccinations but was eligible for additional doses, with no documentation of education or consent. Another resident had a historical dose but was also eligible for further vaccination, with no record of being educated or offered the vaccine. The DON acknowledged the oversight, indicating a lack of action in ordering vaccines and documenting processes.
The facility did not maintain documentation of staff COVID-19 vaccinations. The DON stated that while the vaccine was available, there was no record of it being offered or declined by staff. The NHA was unaware of the need to document staff education, vaccine offering, or vaccination status.
The facility failed to conduct annual performance evaluations for CNAs, as revealed by personnel file reviews and staff interviews. CNAs, including one who had been employed for four years, reported not receiving evaluations. Staff interviews indicated confusion over responsibility for generating and completing evaluations, with the nursing department ultimately responsible but not fulfilling this duty.
The facility was cited for failing to maintain a clean and sanitary environment, with observations of dirt, debris, and dried liquids in resident rooms and hallways. Staff interviews revealed inconsistent cleaning practices, with mopping only half of the hallway at a time and deep cleaning conducted monthly. Cobwebs were also noted in a resident's room, indicating a lack of regular cleaning.
The facility failed to maintain safe and comfortable temperatures in resident rooms, affecting two residents. One resident's room was hot and stuffy, with no AC unit, despite a care plan indicating a need for hydration due to malnutrition. Another resident reported discomfort due to heat, as his room lacked an AC unit and fan. Temperature logs showed high temperatures, and staff were inadequately trained in temperature checks. Complaints about the heat were noted, but the facility's response was insufficient.
The facility failed to implement enhanced barrier precautions (EBP) for two residents, leading to potential infection spread. A resident with a pressure ulcer and another with a diabetic ulcer were not provided care with the required PPE, despite EBP signs. Staff interviews confirmed non-compliance with EBP protocols, resulting in a deficiency citation.
The facility failed to maintain resident dignity and timely care for two residents. One resident was found with food debris on her bed after meals, contrary to staff practices of ensuring cleanliness. Another resident reported dissatisfaction with night CNAs, who allegedly made rude comments and delayed assistance, stating they were only required to change her every two hours. Despite documented complaints, there was no indication of verbal abuse being reported to management.
A resident with cerebral palsy, epilepsy, and Rett's syndrome did not receive consistent care plan interventions, leading to inadequate protection against skin breakdown and contractures. Observations showed missing protective equipment and improper wheelchair positioning, while staff interviews revealed gaps in documentation and follow-through on care plans.
Three residents in an LTC facility were not provided with adequate personal hygiene care, resulting in unmet needs. A resident with Alzheimer's and limited mobility had plaque buildup and decaying teeth, while another with limited mobility had unbrushed teeth and disheveled hair. A third resident, dependent on staff due to multiple conditions, was observed with greasy hair and plaque buildup. Missed showers and inconsistent documentation of refusals contributed to the deficiency.
A resident with severe malnutrition and muscle wasting was not provided sufficient hydration, as her water was often left untouched and out of reach. Despite care plan interventions, her fluid intake was consistently below her needs, and staff did not adhere to the facility's hydration policy, leading to potential dehydration.
The facility failed to maintain accurate medical records for a resident, resulting in inconsistent documentation of allergies. Staff members had conflicting interpretations of hospital discharge paperwork, leading to the incorrect recording of 'no known allergies' despite the resident having documented allergies to multiple medications.
The facility failed to develop, implement, and update person-centered care plans for three residents, resulting in potential unmet care needs and risk of injury. One resident's allergies were not documented, another's care plan lacked specific information about mobility and visual impairment, and a third resident's care plan was outdated regarding transfer needs.
The facility failed to ensure safe transfers by not using gait belts during manual transfers and not having two staff members present during mechanical lift transfers. A CNA transferred a resident with Alzheimer's disease without a gait belt, and another CNA transferred a resident with cerebral infarction using a mechanical lift alone, contrary to facility policy.
The facility failed to ensure proper pre and post dialysis treatment assessment and monitoring communication between the facility and the dialysis provider for two residents, resulting in a potential disruption in the continuity of care. Both residents lacked physician orders for dialysis treatments, and staff interviews confirmed the absence of necessary communication forms.
The facility failed to provide a dignified dining experience for several residents, resulting in feelings of disappointment. Multiple residents were observed with their lunch trays but without staff assistance, leading to visible worry and disappointment. The DON acknowledged the dignity concern and the facility's policy emphasizes treating residents with respect.
The facility failed to maintain accurate medical records for a resident, resulting in missed wound dressing changes and bed baths. The resident, who was cognitively intact, reported that staff frequently missed daily wound dressing changes and bed baths. Observations and interviews confirmed discrepancies in documentation and a lack of monitoring, leading to missed treatments and care.
A resident with multiple medical conditions experienced a delayed discharge to an assisted living facility due to the LTC facility's failure to promptly send a necessary referral, resulting in additional private pay charges. The Social Work Director was on maternity leave, and the family had to contact the Ombudsman to resolve the issue.
The facility failed to accurately assess a resident with multiple diagnoses, including diabetes and a tibial fracture, upon admission. The skin assessment did not document existing blisters, redness, or a wound on the right great toe, despite these conditions being noted by the referring hospital. The DON confirmed the omissions, indicating a lapse in the assessment process.
A facility failed to establish a baseline care plan within 48 hours for a resident admitted with multiple significant diagnoses, including diabetes and a right tibia fracture. The resident's baseline care plan was not completed until several days after admission, resulting in a lack of person-centered ADL care instructions for the nursing staff.
The facility failed to implement a comprehensive care plan for a resident with multiple complex medical conditions, including cerebral palsy and Rett's syndrome. The care plan indicated the use of palm protectors, but there was no order for hand paddles for contractures. Observations and staff interviews revealed inconsistencies in care plan implementation and documentation, resulting in a lack of service for the resident's well-being.
Failure to Notify Provider and Fully Assess Resident With Acute Change in Condition
Penalty
Summary
Licensed staff failed to follow professional standards of practice and the facility’s Acute Change in Condition policy when a resident experienced an acute change in condition. The resident, a female with dementia, mild cognitive impairment, dysphagia, cognitive communication deficit, muscle weakness, lack of coordination, and need for assistance with personal care, was documented in a nurse’s note at 2:15 AM as being confused and restless, with an oxygen saturation of 88% that improved to 93% after application of 2L O2, and with blood noted in her stool. Despite these findings, there was no documentation in the medical record of a full set of vital signs (blood pressure, temperature, pulse) for that event, and the nurse only placed a note in the physician book rather than directly contacting the provider. Review of the physician binder showed an entry stating the resident was confused and had blood in her stool and “need to be checked,” but facility-provided provider notes contained no evidence that a provider ever evaluated the resident for the low oxygen saturation, confusion, and blood in the stool. Interviews with LPNs and the Unit Manager indicated that facility practice and standing orders required obtaining a full set of vitals, initiating oxygen per protocol, and directly contacting the provider for new issues or acute changes in condition such as altered mental status, low O2 saturation, and possible GI bleed. The DON confirmed that the nurse should have called the physician immediately rather than relying on the physician log, especially given the holiday week and upcoming weekend, and that the failure to call represented a deviation from the facility’s Acute Change in Condition policy, which requires urgent phone calls for significant changes such as abrupt confusion and frank blood in stool.
Food Storage, Sanitizer, and Equipment Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain food service safety practices for storage, dating, and handling of ready-to-eat foods in the kitchen and at nurses’ station refrigeration units. During observation, multiple items were found without required discard dates or with dates that exceeded manufacturer instructions, including shredded lettuce, Mighty Shakes, Magic Cups, whipped cream bags, half and half, pizza, cut vegetables, soup, and sliced bologna. The Dietary Manager stated that items in the kitchen were held for three days before being discarded, that delivered shakes were placed directly into refrigeration and dated based on delivery date, and that kitchen staff did not check resident refrigeration units at nurses’ stations. At the nurses’ station, an open container of half and half was labeled and dated 8/9/25 despite manufacturer directions stating it was only good for 7 days after opening. Other items observed there included a ziplock bag of pizza with no discard date, a ziplock bag of cut vegetables dated 8-14-25, and a cup of soup with no date to indicate discard. In the kitchen coolers, an open bag of shredded lettuce was found dated beyond its best-by date, a box of Mighty Shakes delivered on 7/31/25 had no discard date, Magic Cups had no date, and whipped cream bags delivered on 8/11/25 remained in the cooler despite labeling that they should be kept frozen and are perishable after 2 weeks under refrigeration. The report also documented sanitation and cleanliness issues in food service equipment. The sanitizer near the dish machine and the three-compartment sink was found testing between 0-50 ppm even though the Dietary Manager stated sanitizer was typically 200 ppm. Observations further found sticky debris on the juice dispenser, a white slimy layer on the ice machine, a scoop holder with debris and a dead beetle-like insect, three mechanical scoops stored with dried food debris, and a saucepan with greasy sticky residue stored with clean pans. These findings were cited against FDA Food Code requirements for sanitizer concentration and for clean food-contact surfaces, utensils, and equipment.
Unsafe and Unsanitary Environmental Conditions
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in multiple areas observed by surveyors. In the Woods Spa room, the wall surfaces behind the commode and along the wall leading to the sink were chipping and bubbling, with portions of deteriorated wall exposing drywall behind the commode and the vinyl coving coming off the wall. The Maintenance Director stated that loose debris is typically scraped away, the wall is skim coated with plaster, and repainted, but that the problem comes back over time, and she stated she would look into using a non-porous wall covering in those problem areas. Additional observations found two boxes of TwoCal nutritional supplements stored on the floor in the central supply room, contrary to the Maintenance Director’s statement that this is not where they are normally stored. In the River Spa room, vinyl coving to the left of the shower was coming off the wall with bubbling and chipping of the wall surface, and the shower equipment had a padded seat cushion with brown and orange greasy debris, a shower bed with leftover hair shavings and white crusted debris on the underside mesh, and a cabinet with Comet Bleach cleaner comingled with body wash and other personal hygiene products. The call light in the shower did not activate the hallway call light when tested. In the Memory Unit, a foul odor was noted in the hall, the exhaust vent in the soiled utility room was closed, and the shared bathroom between resident rooms had a strong odor despite appearing clean. The exhaust ventilation in that bathroom and in the bathroom of another resident room could not be heard running or shown to have suction. Outside, both trash dumpsters had back sliding doors open, and the oxygen tank storage area had no conspicuous designation between full and empty tanks, with 21 empty to near-empty oxygen tanks standing upright and unsecured.
Failure to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer for a female resident who had been admitted with diagnoses including a displaced fracture of the greater trochanter of the right femur, muscle weakness, and an unspecified fall. Her MDS showed substantial to maximal assistance was needed for mobility, including rolling in bed, and a Braden Scale score of 15 indicated moderate risk for pressure injury development. The resident later had a significant decline and was admitted to hospice services. A nursing note documented that the resident acquired an in-house stage 2 pressure wound on the right posterior shoulder, measuring 1.5 cm x 1.0 cm x 0.1 cm. A weekly wound observation later described the wound as a stage II pressure ulcer on the right shoulder with light serous drainage. During observation, staff turned and positioned the resident in bed for a dressing change, and the resident did not assist with turning or repositioning. The RN stated the resident was not able to reposition herself in bed and that the wound was pressure related. Review of the care plan showed interventions for limited mobility and potential impairment to skin integrity, including keeping skin clean and dry and using a draw sheet or lifting device to move the resident, but no care plan was noted related to the wound itself. Staff interviews indicated the resident had become bed bound, was dependent on staff for all care, and needed staff to provide repositioning in bed. The RN confirmed the resident did not have pressure ulcer prevention interventions in the care plan, and the UM stated the skin care plan needed updating.
Failure to Monitor Pureed Diet and Swallowing Precautions
Penalty
Summary
The facility failed to monitor dietary recommendations and swallowing precautions for Resident #59, who had diagnoses including spastic quadriplegic cerebral palsy, epilepsy, intellectual disabilities, and Rett's syndrome. The resident's chart showed orders for a regular diet with pureed texture, thin liquids, and fortified foods at each meal, along with care plans identifying swallowing risk and the need for pureed foods and staff feeding assistance. A nutritional assessment also indicated that a pureed diet was needed with total feeding assistance. On observation, the resident was seen being fed by a family member in the courtyard and later in the dining room without staff visible. The family member used a clear plastic spoon to feed the resident mechanically altered pieces or lumps of pasta in orange sauce and also gave the resident a straw to drink from a cup. The guardian stated the resident remained under a visitation agreement and reported that the mother was supposed to feed the resident in the dining room for staff observation, but that the mother had been feeding the resident thick pasta-like food that was not on the approved food list. The guardian also stated the resident produced thick secretions and that the food could cause choking. Interviews with the DON and Social Worker showed the facility had received a revised visitation letter in May but it was not placed in the resident's medical record at the time, and staff communication about the updated visitation arrangement was unclear. The DON stated staff should observe what the family member was feeding the resident, while the Social Worker stated staff did not watch the mother feed the resident and had not thought about inspecting food brought in. The SLP stated the resident had previously been on mechanical soft foods but was changed to pureed foods because she was not chewing well, and a progress note documented that the resident was coughing, holding food in her mouth, and having a hard time swallowing when eating.
Failure to Track and Offer Pneumococcal Vaccine
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after the facility failed to track and offer the pneumococcal vaccine for 1 of 5 residents reviewed for immunizations. Resident #4 was a male with diagnoses including diabetes, dialysis, high blood pressure, and acute respiratory failure with hypoxia. Record review showed he received PCV13 on 12/22/2015 and PPSV23 on 08/06/2014, and CDC vaccine schedule guidance noted that adults 50 years or older who previously received both PCV13 and PPSV23 but had not received PPSV23 at age 65 years or older should receive 1 dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. During interview, the Unit Manager stated there was no refusal documented in the medical record, that the resident should have had the pneumococcal booster or been offered it, and that review of the medical record and immunization binder did not locate a declination.
Failure to Report Resident-to-Resident Physical Incident to State Agency
Penalty
Summary
The facility failed to report a resident-to-resident physical incident to the State Agency as required. Two residents with significant cognitive impairments were involved: one with schizophrenia and anxiety, and another with Alzheimer's disease, depression, and dementia. The incident occurred when one resident approached another in the dining room, yelled, and struck her on the right upper arm. The event was witnessed by a Certified Occupational Therapist Assistant, who reported it to the nurse. The nurse completed an incident report and notified the Director of Nursing (DON) and Nursing Home Administrator (NHA). The interdisciplinary team discussed the incident and decided to send the resident who struck out to a psychiatric hospital. Despite internal documentation and discussion, the facility did not submit an initial report or a final investigation to the State Agency, as confirmed by a review of the Michigan Facility Reported Incident website. Interviews with staff revealed uncertainty about whether the incident was reported to the State Agency, and the facility's policy required such incidents to be reported. The lack of reporting resulted in an incomplete investigation and the potential for continued resident-to-resident incidents.
Failure to Apply Recommended Hand Splint for Resident
Penalty
Summary
The facility failed to ensure that a left resting hand splint was applied to a resident as per therapy recommendations, which could potentially lead to contracture progression, pain, and a decline in range of motion. The resident, a female with vascular dementia and stiffness of the hand, was observed multiple times without the splint, despite therapy recommendations for its use when out of bed. The care plan indicated the need for the splint, but there was no physician order for it, and staff were unaware of its current status. Interviews with staff, including a CNA, PT, LPN, and the DON, revealed a lack of awareness and documentation regarding the splint's application and the resident's refusal to wear it. The PT confirmed that the splint was recommended to manage contracture progression and pain, and training was provided to the nursing staff. However, the LPN and DON acknowledged the absence of a physician order and documentation of any refusal by the resident to wear the splint, indicating a breakdown in communication and documentation processes within the facility.
Inadequate Catheter Care Leads to Hospitalization
Penalty
Summary
The facility failed to provide adequate monitoring, assessment, and care for a resident with an indwelling catheter, leading to hospitalization due to a severe urinary tract infection (UTI) and sepsis. The resident, who had a history of urinary retention and recurrent UTIs, was admitted with a chronic indwelling Foley catheter. Despite clear signs of infection, including cloudy and bloody urine, and abnormal urinalysis results indicating a UTI, the facility did not take timely action to address the resident's condition. The resident's urology visit notes indicated the need for immediate catheter change and urine culture and sensitivity (C&S) testing, which were not performed within the recommended timeframe. There was a significant delay in obtaining and acting upon the urine test results, with no documentation of nurse's notes or physician visits for several days. The resident's vital signs were not regularly monitored, and there were no orders for catheter care or monitoring documented in the Treatment Administration Record (TAR). Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and test results. The Director of Nursing (DON) was not informed of the urologist's orders, and there was no process in place to ensure timely receipt and action on visit notes and test results. The resident's condition deteriorated, leading to hospitalization with septic shock due to a urologic infection, highlighting the facility's failure to provide appropriate care and monitoring for the resident's catheter and urinary health.
Failure to Provide Adaptive Dining Equipment as Ordered
Penalty
Summary
The facility failed to provide adaptive dining equipment as per the physician's order for a resident with vascular dementia, lack of coordination, and hand stiffness. The resident had a physician's order for a regular diet with mechanical soft texture and thin liquids consistency, requiring a divided plate for all meals. However, during an observation, the resident was served a meal on a regular flat plate instead of the specified divided dish, which was noted on the resident's tray ticket. The registered dietitian confirmed that the resident sometimes needed assistance with eating and that the divided dish was essential for the resident's self-feeding ability. The divided plate helped the resident see the food better and facilitated getting food onto utensils due to the edges in each well of the plate. The failure to provide the divided plate as ordered resulted in the potential for difficulty with self-feeding and weight loss for the resident.
Failure to Maintain Accurate Medical Records and Monitor Resident's UTI
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, resulting in a lack of documentation related to catheter care, test results, vital signs, and resident status concerning an impending urinary tract infection (UTI). The resident was admitted with a diagnosis of urinary retention and exhibited symptoms such as being pale, not eating or drinking, and having cloudy and bloody urine. Despite these symptoms, there was a significant gap in documentation, with no nurse's notes or physician visits recorded between certain dates. The urinalysis results, which indicated a serious infection, were not promptly addressed, and there were no orders for catheter care or monitoring in the resident's Treatment Administration Record. Interviews with staff revealed that the resident's abnormal urinalysis results were not acted upon in a timely manner, and there was a lack of regular monitoring for signs of a UTI. The CNA tasks showed that catheter care and output were not documented for the past 30 days. The Director of Nursing and Infection Preventionist acknowledged the absence of documentation for the resident's symptoms and the need for regular monitoring, given the resident's history of repeated UTIs. The failure to document and follow up on the resident's condition led to the resident being sent to the emergency room.
Failure to Conduct Quarterly QAA Meetings with Required Members
Penalty
Summary
The facility failed to ensure that Quality Assessment and Assurance (QAA) meetings were held at least quarterly and that the required individuals attended these meetings. The review of the Quality Assurance and Performance Improvement (QAPI) meeting sign-in sheets showed that meetings were conducted on specific dates, but the Medical Director did not attend the meetings on two occasions. Additionally, there was a significant gap between meetings, with no QAPI meetings held from January 25, 2024, to August 29, 2024. During an interview, the Nursing Home Administrator acknowledged the absence of QAPI meetings during this period, stating that she had been meeting with each department head individually instead. The facility's QAPI policy requires the QAA Committee to meet at least quarterly and include specific members, such as the Director of Nursing Services, the Medical Director, and other staff members, to coordinate and evaluate activities under the QAPI program.
Infection Preventionist Training Deficiency
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) completed specialized training in infection prevention and control. During an interview, the Director of Nursing (DON) B, who was responsible for the infection control program, admitted to completing all modules of the CDC IP certification training but did not complete the post-test, resulting in her not having an IP certificate. Additionally, the Unit Manager (UM) LL, who assisted in the infection control program, reported not having completed the IP certification training and was not a certified IP. The Nursing Home Administrator (NHA) A was unaware that DON B had not completed the IP certification training.
Failure to Provide Annual Abuse Prevention Training
Penalty
Summary
The facility failed to provide the required annual abuse prevention education for all employees, which has the potential to affect all 79 residents residing in the facility. The deficiency was identified through interviews and record reviews, revealing that 33 out of 104 staff members did not receive the necessary training prior to the survey. The training is crucial for preventing abuse, neglect, and exploitation, especially for residents with dementia or Alzheimer's disease, who are at higher risk. The lack of training was attributed to staff being pulled to work on the floor, leaving insufficient time to complete the training. Interviews with staff members, including a CNA and the receptionist, highlighted the challenges in completing the training. The CNA mentioned that they could access the training application at home and submit a slip for payment upon completion. The receptionist was responsible for tracking training completion and sending reminders to employees. Despite these measures, the facility's records showed a significant number of staff had not completed the required training, indicating a systemic issue in ensuring compliance with the training schedule.
Inadequate Resident Activities in Dementia Care Unit
Penalty
Summary
The facility failed to provide consistent, meaningful, and person-centered activities for residents in the dementia care unit, affecting four out of seven residents reviewed. The activity calendar for the unit listed various activities, but during observations, these activities were not being conducted as scheduled. Residents were observed sitting idle or sleeping in common areas without engagement in any planned activities. The lack of individualized activities was evident, as residents were not seen participating in activities that matched their interests or care plans. Resident #16, with diagnoses including dementia and anxiety, was noted to have interests in music, crafts, and socializing. However, during the survey period, she was not observed participating in any of these activities. Similarly, Resident #56, who expressed interest in reading, music, and outdoor activities, was not seen engaging in these activities. The documentation for both residents showed a lack of recorded group activities and minimal one-on-one interactions. Resident #60, who valued music and social activities, was observed mostly asleep or idle in his wheelchair, with no engagement in activities that matched his preferences. Resident #178, who had interests in computers and trains, was not provided with activities related to these interests. The facility's activity staff faced challenges, such as understaffing and lack of training, which contributed to the deficiency in providing adequate activities for the residents.
Lack of Dietary Manager in Kitchen
Penalty
Summary
The facility failed to employ a dietary manager with the necessary training and certifications to oversee the kitchen, which increased the potential for food service sanitation failures and foodborne illness for all residents consuming food from the kitchen. During an initial tour of the kitchen, it was revealed that the facility had been without a dietary manager for over a month since the previous manager left. The dietary staff member interviewed was unsure about the schedule and responsibilities of the Registered Dietitian (RD), who reportedly visits the facility for about 8 hours a month but does not monitor the kitchen during these visits. The Nursing Home Administrator (NHA) acknowledged the absence of a dietary manager and mentioned attempting to assist in the kitchen despite being occupied with her own responsibilities. This lack of oversight and management in the dietary department was identified as a deficiency by the surveyors.
Improper Food Labeling and Dating in Kitchen
Penalty
Summary
The facility failed to ensure proper labeling and dating of foods in the kitchen, which could potentially lead to the spread of foodborne illness to all residents consuming food from the kitchen. During an initial tour of the main kitchen, it was observed that the cook's reach-in refrigerator contained a bag of open cheese slices in a Ziploc bag with no label and date, and shredded pork thawing on a middle rack with ready-to-eat food below it. Additionally, the dietary aide's reach-in refrigerator had an open gallon of Vitamin D milk, an open gallon of 2% milk, and an 8-ounce milk in a cup covered with plastic wrap, all without labels or dates. On a subsequent tour, further issues were noted, including cranberry concentrate in a plastic container with a use-by date that had already passed, bread crumbs and thickener stored in large plastic containers with preparation dates but no use-by dates, and sugar stored without any label or date. The reach-in freezer also contained open bacon bits in a package with no label or date. These observations indicate a failure to comply with the 2017 FDA Food Code, which requires ready-to-eat, time/temperature control for safety food to be clearly marked with the date by which it should be consumed or discarded.
Deficiency in Behavioral Health Training Compliance
Penalty
Summary
The facility failed to ensure that 104 staff members received the necessary training for behavioral health care and services, as required by the facility assessment. This deficiency was identified through interviews and record reviews, revealing that 78 out of 104 staff members did not receive annual abuse prevention training before the survey began. Certified Nursing Assistant (CNA) V reported that the training was scheduled to be completed but faced challenges due to being pulled to work on the floor and having charting responsibilities, leaving little time for training. CNA V mentioned the option to complete training at home and submit a slip for payment. Receptionist EEE was responsible for running reports to ensure employees completed necessary classes before working on the floor. During orientation, Receptionist EEE checked that classes were completed and sent reminders to employees. The training was tracked electronically by Receptionist EEE, and reports were generated monthly by department to remind supervisors and employees. Administrator A confirmed that nursing staff would complete required training as needed, but the facility could not provide evidence of compliance for the majority of the staff.
Failure to Respect Resident's Right to Dignity and Self-Determination
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as Resident #20, who was cognitively intact and had diagnoses including osteomyelitis and end-stage renal disease requiring dialysis. The deficiency arose when the resident requested to be transferred to the hospital due to severe pain and the perception that the facility lacked adequate pain management. The Medical Director, referred to as MD WW, communicated with the resident via phone and denied the request for hospital transfer, stating it was not a life-threatening emergency and expressing concern about the number of hospital transfers. This interaction left the resident feeling angry and frustrated. The Licensed Practical Nurse (LPN) involved, identified as LPN EE, confirmed the resident's request and the subsequent conversation with MD WW, who emphasized the need to manage the number of hospital transfers. Despite MD WW's disapproval, the resident was eventually sent to the emergency room. During a follow-up interview, MD WW acknowledged the conversation and referred to the resident as a 'frequent flyer,' indicating a pattern of frequent hospital visits. This situation highlights the facility's failure to respect the resident's right to self-determination and dignified treatment, as the resident's concerns and requests were not adequately addressed.
Failure to Provide Proper Notification of Room Change
Penalty
Summary
The facility failed to provide proper notification of a room change to a resident, resulting in feelings of anger and frustration. The resident, who was cognitively intact and had diagnoses including osteomyelitis and end-stage renal disease with dialysis, reported being moved to a different room after a confrontation with a former roommate. Despite refusing the room change initially, the resident was moved without receiving any written notice or documentation of the change. The facility's policy requires written notice of room changes, including reasons for the move, but this was not adhered to in this case. Interviews with the Nursing Home Administrator and Social Services Director revealed inconsistencies in the documentation and communication regarding the room change. Both reported that the resident had refused the room change initially, but later agreed to it, although no documentation was available to support this claim. The Social Services Director was responsible for documenting and notifying residents of room changes, but failed to provide evidence of the resident's agreement or written notification of the room change. This lack of documentation and failure to follow policy led to the deficiency identified by the surveyors.
Failure to Maintain Accurate Advanced Directives
Penalty
Summary
The facility failed to maintain updated and accurate advanced directive information for two residents, leading to potential discrepancies in their medical care preferences. For Resident #12, there was a contradiction between the electronic medical record, which indicated a Full Code status, and a physical document in the code status binder that indicated a DNR (Do Not Resuscitate) status. The Director of Nursing (DON) and Unit Manager (UM) were unaware of the updated DNR directive completed in 2022, which had not been recorded in the electronic medical record. The Social Services Director (SSD) confirmed that the DNR directive was completed with the resident's POA in 2022 but was not entered into the medical record as per facility policy. For Resident #60, there was inconsistency in the resident's code status. The care plan and medical treatment decisions initially indicated a DNR status, but a subsequent update by the guardian changed the status to allow CPR. Despite this change, the family member confirmed the resident's preference for CPR in case of cardiac arrest. The Unit Manager stated that changes to the medical record should be made by the nurse who initiated the advanced directive, but this process was not followed, leading to discrepancies in the resident's code status documentation.
Resident Abuse During Shower by CNA
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by staff, specifically involving a resident with dementia and Alzheimer's disease. During a shower, a Certified Nursing Assistant (CNA) covered the resident's mouth and sprayed water in her face to prevent her from being heard yelling. This action was witnessed by another CNA who reported that the offending CNA often behaved inconsiderately and disrespectfully towards residents, causing discomfort during care. The incident led to increased agitation and mental anguish for the resident. Interviews revealed that the offending CNA had a history of similar behavior with other residents, but these concerns were not reported to management until the incident in question. Another CNA and a Licensed Practical Nurse (LPN) confirmed witnessing the abuse and reported it to the Nursing Home Administrator (NHA). The NHA acknowledged that this was the first reported concern against the offending CNA, although additional allegations surfaced post-termination. The facility had conducted a staff in-service prior to the incident, but it did not include education related to abuse.
Failure to Submit Investigation of Alleged Theft
Penalty
Summary
The facility failed to submit the investigation of an allegation of theft to the State Agency for one resident, resulting in the potential for the allegation to not be thoroughly investigated. The resident, who was cognitively intact, reported that money was stolen from their room and subsequently called the police and notified facility staff. The Nursing Home Administrator (NHA) initially reported the allegation to the State Agency on the day it was discovered. However, the NHA went on vacation the following day, and no one from the management team submitted the final investigation and report to the State Agency within the required five working days.
Failure to Complete PASARR and OBRA Level II Documentation
Penalty
Summary
The facility failed to ensure that the PASARR (Preadmission Screening/Annual Resident Review) documentation and OBRA Level II exemption criteria were completed appropriately for two residents. Resident #39, who has diagnoses including dementia, anxiety, psychotic disorder with delusions, major depressive disorder, insomnia, and traumatic brain injury, did not have an Annual Resident Review (ARR) from 2024 in his medical record. The social worker reported that her portion of the PASRR was uploaded, but she was unsure who was responsible for ensuring the provider completed their part. It was noted that it had been five months since Resident #39's PASARR should have been completed. Resident #60, with diagnoses including dementia, borderline personality disorder, anxiety, PTSD, and insomnia, did not have a letter from OBRA indicating exemption from continued Level II assessment or a completed OBRA Level II assessment. The social worker believed that due to the resident's dementia, he was exempt from a Level II OBRA assessment, despite the diagnosis of borderline personality disorder. The original PASRR completed prior to Resident #60's admission was not in the OBRA system, as the referring facility had handwritten it and never submitted it. The social worker submitted a new Level I PASRR into the OBRA system for review.
Deficiency in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) care for three residents, resulting in potential negative outcomes. Resident #16, a female with dementia and muscle weakness, was observed multiple times with unkempt facial hair, indicating a lack of personal hygiene assistance. Her care plan required limited to extensive assistance from one staff member for personal hygiene, which was not adequately provided. Resident #61, diagnosed with Alzheimer's disease and dementia, also exhibited signs of neglect in personal grooming. She was repeatedly observed with long facial hairs, despite her care plan specifying the need for grooming assistance according to her preferences. This lack of attention to her personal hygiene needs suggests a failure to adhere to her care plan. Resident #178, a male with a fractured humerus and dementia, was observed in a state of poor hygiene, wearing soiled clothing and an unshaven face. His care plan required extensive assistance from one staff member for personal hygiene, which was not met. Additionally, there was confusion regarding the necessity of his immobilizer, and staff reported difficulties in accessing razors for shaving. These observations highlight a significant lapse in providing necessary ADL care for these residents.
Failure to Prevent Pressure Ulcers in At-Risk Resident
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of pressure ulcers for Resident #54, who was at risk due to impaired physical mobility and a history of multiple pressure wounds. Despite physician orders for preventative interventions, including the application of a hydrocolloid dressing to the right hip, the resident missed 10 out of 13 treatment opportunities since the order was placed. Observations revealed that the resident was left sitting in a specialized wheelchair for extended periods without being repositioned, contrary to the care plan that required frequent repositioning to offload pressure. Interviews with facility staff, including CNAs, LPNs, and the Unit Manager, highlighted a lack of awareness and adherence to the prescribed treatment plan. The staff reported inconsistencies in the application of protective dressings and a misunderstanding of current treatment orders, with some staff unaware of the need for a protective dressing on the resident's right hip. Additionally, the resident's Braden Assessment, which should have been conducted quarterly, was last completed 11 months prior, indicating a lapse in regular risk assessment for pressure injuries.
Failure to Follow Transfer Protocols for Resident
Penalty
Summary
The facility failed to ensure that staff followed the care plan for transfer techniques for a resident, resulting in the potential for a fall or injury. The resident in question had diagnoses including dementia, abnormalities of gait and mobility, and lack of coordination, and was assessed as severely cognitively impaired. During an observation, a CNA was seen transferring the resident from the bed to a wheelchair without using a gait belt, despite having one in her possession. The CNA admitted to not using the gait belt and mentioned it was her first time caring for the resident, believing the resident required only a one-person transfer. The care plan for the resident specified that transfers required the assistance of two staff members and the use of a gait belt. Interviews with other staff members, including CNAs and nurses, confirmed that the resident was indeed a two-person transfer with a gait belt. The Director of Nursing also stated that the expectation was for a gait belt to be used for every transfer, except when using a mechanical lift. This oversight in following the care plan posed a risk of fall or injury to the resident.
Deficiency in Dementia Care and Staff Training
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident diagnosed with dementia, anxiety, and major depressive disorder. The care plan lacked comprehensive interventions to address the resident's cognitive and emotional needs, focusing primarily on medication administration and basic communication with family members. Despite the resident's expressed preferences for group activities and outdoor time, the care plan did not include specific strategies to engage the resident in meaningful activities or address her frequent tearfulness and agitation. Observations and interviews revealed that the resident frequently exhibited distressing behaviors, such as crying, delusions, and hallucinations, which were not effectively managed by the staff. The staff's attempts to redirect or console the resident were often unsuccessful, and there was a lack of consistent documentation and tracking of the resident's mood and behavior symptoms. The facility's behavior/mood symptom tracking tool was not consistently updated, and there was no evidence of a coordinated approach to managing the resident's symptoms. Additionally, the facility failed to provide adequate dementia care training for its staff, with 39 out of 104 employees lacking documented training. This lack of training likely contributed to the staff's inability to implement effective interventions for the resident's dementia-related behaviors. The facility's failure to ensure qualified staff and a comprehensive, person-centered care plan potentially compromised the resident's physical, mental, and psychosocial well-being.
Inaccurate Medical Records and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to discrepancies in medication administration and treatment documentation. For Resident #13, there was a failure to administer the correct insulin as per the physician's order. The resident was prescribed Novolog, but was instead given Humalog without updating the medical records to reflect this change. Interviews with the nursing staff and the pharmacist revealed that the pharmacy would send whichever insulin was available, and the nurses administered it without updating the physician's order in the computer system. Resident #69's medical records showed inaccuracies in the documentation of nebulizer treatments. Although the resident was scheduled to receive nebulizer treatments four times a day, observations and interviews indicated that the treatments were not consistently administered, and refusals were not properly documented. The Medication Administration Record (MAR) inaccurately reflected that treatments were given when they were not, as confirmed by the LPN who admitted to not administering the doses but still marking them as completed. For Resident #21, there was a failure to document wound care treatments accurately. The resident had a physician's order for daily wound care, but the Treatment Administration Record (TAR) showed multiple instances where the treatment was not documented as completed. Interviews with nursing staff revealed a lack of awareness regarding the missed treatments, and the DON noted that refusals should have been documented if they occurred, which was not done.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) during care for residents under enhanced barrier precautions (EBP), specifically for two residents with open wounds. For Resident #29, who was under EBP due to an open wound on the toe, multiple staff members, including CNAs and a hospice nurse, were observed not wearing gowns during high-contact care activities such as transfers and dressing assistance. Despite signage indicating EBP requirements, some staff members were unaware of the need for PPE or misunderstood which residents required it. Interviews with staff revealed inconsistencies in understanding and implementing EBP protocols, with some staff incorrectly believing that Resident #29 was not under EBP. Similarly, for Resident #41, who had an open malignant lesion on the back, staff were observed not wearing gowns during direct care activities, including incontinence care and wound dressing changes. The hospice nurse and CNA involved in Resident #41's care did not adhere to the EBP requirements, despite the presence of signage and the resident's documented need for enhanced precautions. Interviews with the Director of Nursing and other staff confirmed that the expectation was for gowns and gloves to be worn during any direct, hands-on care for residents under EBP, highlighting a failure in adherence to infection control protocols.
Failure to Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure timely offering of recommended Pneumococcal vaccines to eligible residents, specifically affecting two residents out of five reviewed for immunizations. Resident #5, who was over the age of 65 and admitted in February 2024, had historical vaccinations of Pneumococcal PPSV23 and PCV13 but was eligible for additional doses of PCV15 or PCV20. However, there was no documentation of education, consent, or declination in the resident's record. Similarly, Resident #14 had a historical dose of Pneumococcal PPSV23 but was also eligible for further vaccination. There was no record of this resident being educated, offered, or declining the vaccination. The Director of Nursing (DON) acknowledged the oversight during an interview, indicating that the facility had not ordered the necessary vaccines for these residents, nor had they documented any educational or consent processes. This lack of action resulted in the potential for developing vaccine-preventable diseases among the residents.
Failure to Document Staff COVID-19 Vaccination Status
Penalty
Summary
The facility failed to maintain proper documentation related to staff COVID-19 vaccinations. During an interview, the Director of Nursing (DON) reported that while the COVID-19 vaccine was available for staff, there was no documentation maintained regarding whether the vaccine was offered or declined by the staff. Additionally, the Nursing Home Administrator (NHA) was unaware of the requirement to keep records of staff education, vaccine offering, or tracking the vaccination status of facility staff.
Failure to Conduct Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure that annual performance evaluations for Certified Nursing Assistants (CNAs) were completed, which could potentially impact the delivery of nursing and related services. The review of employee personnel files revealed that several CNAs, including CNA V, CNA W, and CNA T, had not received their annual performance evaluations. Interviews with CNAs and other staff members confirmed that these evaluations had not been conducted. CNA V, who had been employed at the facility for four years, reported not receiving any performance evaluations during her tenure. Similarly, CNA U, who worked specific days of the week, also reported not having received an evaluation. Further interviews with facility staff, including the Receptionist EEE and the Director of Nursing (DON) B, highlighted a lack of clarity and responsibility regarding the generation and completion of these evaluations. Receptionist EEE mentioned that the evaluations were previously on paper and was unsure of their current format. DON B indicated that the evaluations were supposed to be generated by human resources for the nursing department to complete, but this process had not been followed. Administrator A confirmed that the nursing department was responsible for these evaluations, which had not been conducted, indicating a breakdown in the facility's internal processes for staff performance management.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by multiple observations of dirt, debris, and dried liquid materials in various areas. On several occasions, surveyors noted dried material on the floors of resident rooms and hallways, as well as dirt and debris scattered throughout the facility. Specific instances included dried liquid running down walls, chunks of dirt resembling dried mud, and straw paper scattered across floors. Additionally, cobwebs were observed in a resident's room, indicating a lack of regular cleaning. Interviews with staff revealed inconsistencies in cleaning practices. A housekeeper reported mopping only half of the hallway at a time due to excessively wet mops, while the Maintenance Director, who also served as the housekeeping supervisor, described a cleaning routine that involved mopping one side of the hallway and then the other. The Maintenance Director also mentioned that deep cleaning was conducted once a month, but observations during the survey indicated that regular cleaning was insufficient, as evidenced by dirt and dried liquid on walls and floors, including areas near the laundry chute.
Failure to Maintain Safe Temperature Levels in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe and comfortable temperature in resident rooms, specifically affecting two residents, Resident #111 and Resident #114. Observations revealed that Resident #111's room was located at the end of a hallway where temperatures increased, and the room was notably hot and stuffy despite fans being present. The resident's care plan indicated a risk for nutritional problems due to malnutrition and weight loss, with interventions to offer hydration regularly. However, the room temperature was recorded at 80 degrees, and no air conditioning unit was present. Interviews with the Maintenance Director and Assistant Director of Nursing highlighted issues with the facility's cooling system. The Maintenance Director noted that the air conditioning units were inadequate for cooling individual rooms, especially those at the end of hallways. The Assistant Director of Nursing reported that temperature checks were being conducted hourly, but there was a lack of direction on how to perform these checks properly. Despite the high temperatures, residents were not moved to cooler areas, and there were no additional measures like offering ice cream or popsicles to help cool them down. Resident #114 also reported discomfort due to the heat, as his room lacked an air conditioning unit and fan, despite being designated to receive one. Temperature logs showed consistently high temperatures in several rooms, with some reaching up to 88 degrees. The facility's cooling system was further strained by a frozen rooftop unit, which was working overtime. Observations indicated that staff were not properly trained in taking room temperatures, as demonstrated by a CNA incorrectly using an infrared thermometer. Complaints from residents about the heat were noted, but the facility's response was insufficient to address the issue effectively.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper infection control protocols, specifically enhanced barrier precautions (EBP), for two residents, leading to a potential increase in the spread of infection. Resident #110, a female with multiple health issues including a stage 3 pressure ulcer, was observed in situations where staff did not don the required personal protective equipment (PPE) such as gowns and gloves. During an observation, a Hospice RN and a CNA entered the resident's room and provided care without wearing the necessary PPE, despite the presence of an EBP sign outside the room. The CNA acknowledged the oversight, and the RN admitted to being unaware of the updated EBP requirements. Similarly, Resident #114, a male with a diabetic ulcer and other health conditions, was also not provided care in accordance with EBP protocols. Observations revealed that CNAs entered the resident's room and performed care activities without donning gowns and gloves, as required by the EBP sign posted outside the room. The CNAs involved were either unaware of the EBP requirements or mistakenly believed the precautions applied to the resident's roommate instead. Interviews with staff, including CNAs and the Director of Nursing, confirmed a lack of compliance with EBP protocols. The facility's policy on EBP, which mandates the use of gowns and gloves during high-contact care activities for residents with wounds or infections, was not followed. This failure to implement EBP as per the facility's policy and CDC guidelines resulted in a deficiency citation for the facility.
Failure to Maintain Resident Dignity and Timely Care
Penalty
Summary
The facility failed to maintain an environment that promoted and enhanced resident dignity for two residents. Resident #111, who had diagnoses including muscle weakness, malnutrition, and anorexia, was observed with food debris on her bed and clothing after being assisted with a meal. Staff interviews revealed that it was standard practice to ensure residents were clean and free of food debris after meals, but this was not adhered to in Resident #111's case, potentially leading to feelings of humiliation and embarrassment. Resident #101, with diagnoses including heart failure, epilepsy, and kidney disease, experienced issues with staff responsiveness and treatment. A family member reported that the resident expressed dissatisfaction with the night CNAs, who allegedly made rude comments and delayed assistance, stating they were only required to change her every two hours. Despite complaints being documented, there was no indication that verbal abuse was reported to the Unit Manager or Director of Nursing, although concerns about staff behavior were noted.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, resulting in a lack of service to maintain the resident's highest practicable physical, mental, and psychosocial well-being. The resident, a female with cerebral palsy, epilepsy, intellectual disabilities, and Rett's syndrome, had a care plan that included interventions such as wearing palm protectors and addressing skin integrity issues. However, observations revealed that these interventions were not consistently implemented. The resident was observed without necessary protective equipment, such as long fluffy socks and sheepskin braces, which were intended to prevent skin breakdown and contractures. The resident's feet were improperly positioned in the wheelchair, leading to abrasions and potential skin breakdown. Despite recommendations for a new wheelchair and adjustments to the current one, these measures were not promptly executed, leaving the resident vulnerable to further injury. Interviews with staff indicated a lack of consistent documentation and follow-through on care plan interventions. The Unit Manager and Registered Nurse acknowledged the absence of protective devices and the need for adjustments to the resident's wheelchair. The facility's failure to ensure the implementation of the care plan interventions contributed to the resident's compromised well-being.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for three residents, resulting in unmet personal hygiene needs. Resident #110, who has Alzheimer's, glaucoma, confusion, impaired balance, and limited mobility, was observed with plaque buildup and decaying teeth, indicating a lack of oral hygiene. The resident's care plan required assistance with personal hygiene, but showers were missed on several scheduled dates. Resident #111, with limited mobility, was observed with unbrushed teeth and disheveled hair, suggesting a lack of grooming. Despite the care plan indicating the need for assistance with personal hygiene, the resident's appearance showed neglect in these areas. Observations confirmed that the resident's teeth remained unbrushed and hair uncombed throughout the day. Resident #113, who is totally dependent on staff for personal hygiene due to cerebral palsy, epilepsy, intellectual disabilities, and Rett's syndrome, was observed with greasy, uncombed hair and plaque buildup on her teeth. The resident's care plan required extensive assistance with personal hygiene, but showers were missed on multiple occasions. Interviews with staff revealed inconsistencies in documenting refusals and providing necessary care, contributing to the deficiency.
Failure to Maintain Resident Hydration
Penalty
Summary
The facility failed to maintain sufficient hydration for Resident #111, a female with diagnoses including muscle weakness, muscle wasting, abnormal weight loss, and severe protein-calorie malnutrition. Her care plan, revised in December 2022, identified her as at risk for nutritional problems and included interventions such as offering hydration every shift and ensuring fluids were within reach. Despite these interventions, observations revealed that Resident #111's water was often left untouched and out of reach, indicating a lack of adherence to her care plan. Over a period of several days, documentation of Resident #111's fluid intake was inconsistent and often below her estimated needs of 1100-1400 ml per day. Observations showed that her water was frequently full and not consumed, and staff interviews indicated that she did not get out of bed and ate only 25-50% of her meals. The facility's policy required staff to offer fluids regularly, especially during hot weather, but this was not consistently done for Resident #111. Interviews with staff, including an LPN and the Director of Nursing, revealed expectations for regular rounding and offering drinks to residents, which were not met in Resident #111's case. The facility's hydration policy emphasized individualized interventions and regular monitoring, but these were not effectively implemented, leading to the potential for dehydration and unmet resident needs.
Inaccurate Documentation of Resident Allergies
Penalty
Summary
The facility failed to maintain accurate medical records for Resident #101, resulting in inaccurate documentation of allergies. Resident #101 had pertinent diagnoses including dependence on renal dialysis, muscle weakness, and urinary tract infection. The Admission Record and Care Plan for Resident #101 indicated 'No Known Allergies,' which was inconsistent with the Discharge Service Communication that listed multiple allergies, including penicillin, morphine, fluoxetine, meperidine, and tramadol. The discrepancy was noted during a review of the resident's records and interviews with staff members, who provided conflicting interpretations of the hospital discharge paperwork indicating 'allergies not on file.' Licensed Practical Nurse (LPN) S, Registered Nurse (RN) W, and Unit Manager/Licensed Practical Nurse (UM/LPN) X had differing views on how to interpret and verify allergies from hospital discharge paperwork. The President of Clinical Operations (VPoCO) stated that if no allergies were documented on the discharge papers, the expectation was to document 'no known allergies.' However, a telephone interview with RN CC from the dialysis care center revealed that Resident #101 had documented allergies to morphine, penicillin, fluoxetine, meperidine, and tramadol since 2019. This inconsistency in allergy documentation highlights a failure in the facility's process for verifying and maintaining accurate medical records for residents.
Failure to Update and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop, implement, and update person-centered care plans for three residents, resulting in potential unmet care needs and risk of injury. Resident #101 had multiple documented allergies, including anaphylaxis to penicillin, which were not included in the care plan. The Unit Manager/Licensed Practical Nurse (UM/LPN) confirmed that allergies should be verified on admission and a care plan should be created for any allergies, but this was not done for Resident #101. Resident #104 had a care plan that lacked specific information regarding his physical mobility and visual impairment. Despite being a double amputee and legally blind, the care plan did not specify the type of assistance required for ambulation or the use of assistive devices. The resident reported needing a mechanical lift for transfers and being legally blind, but these details were not reflected in the care plan. The UM/LPN acknowledged that care plans should be personalized and updated regularly, but this was not done for Resident #104. Resident #109's care plan was outdated and did not reflect his current transfer needs. The care plan indicated that the resident could transfer with two-person assistance and a gait belt, but observations and staff interviews revealed that he had been using a sit-to-stand mechanical lift for months. The Director of Therapy and other staff members confirmed the resident's current transfer status, but the care plan had not been updated to reflect this change. This discrepancy highlights a failure to keep the care plan current and accurate, potentially compromising the resident's safety and care quality.
Failure to Ensure Safe Resident Transfers
Penalty
Summary
The facility failed to ensure safe transfers of residents by not using gait belts during manual transfers and not having two staff members present during mechanical lift transfers. Specifically, a CNA transferred Resident #102 from a wheelchair to a bed without using a gait belt, despite the facility's policy requiring gait belts for all non-mechanical lift transfers. The CNA admitted to knowing the requirement but did not follow it. The resident had diagnoses including Alzheimer's disease, lack of coordination, and unsteadiness of feet, making the proper use of transfer aids crucial for safety. Additionally, Resident #109, who had diagnoses including cerebral infarction, Parkinson's disease, and seizures, was transferred by a CNA using a sit-to-stand lift without the assistance of a second staff member. The facility's policy mandates that two staff members must be present for mechanical lift transfers. The CNA confirmed that she performed the transfer alone, and the resident corroborated this account. The facility's policy and staff interviews consistently indicated that these procedures were not followed, leading to the potential for injury during transfers.
Failure to Ensure Proper Dialysis Communication and Physician Orders
Penalty
Summary
The facility failed to ensure proper pre and post dialysis treatment assessment and monitoring communication between the facility and the dialysis provider for two residents, resulting in a potential disruption in the continuity of care. Resident #101, who had diagnoses including dependence on renal dialysis, muscle weakness, and urinary tract infection, did not have a physician order for dialysis treatments. Similarly, Resident #104, diagnosed with end-stage renal disease, sepsis, and hypotension, also lacked a physician order for dialysis treatments. Interviews with staff revealed that dialysis communication sheets, which should include vital signs, medications given, and other assessment information, were not consistently sent with the residents to their dialysis appointments or returned to the facility with post-treatment information. This lack of communication and documentation was confirmed by multiple staff members, including a Unit Manager, Licensed Practical Nurses, and a Registered Nurse, who were unable to locate any dialysis communication forms for the residents in question. The deficiency was further highlighted by the fact that the dialysis center did not keep copies of the communication forms, relying entirely on the facility to maintain this critical documentation. The absence of these forms and the lack of physician orders for dialysis treatments for both residents were acknowledged by the staff during interviews. This failure in maintaining proper communication and documentation between the facility and the dialysis provider posed a risk of unrecognized adverse reactions or resident decline related to dialysis treatments, thereby disrupting the continuity of care for the affected residents.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for several residents, resulting in feelings of disappointment. During an observation, multiple residents were seen seated with their lunch trays in front of them but without staff assistance. Specifically, Resident #109 and Resident #111 were seated together with their lunch trays but no staff were present to assist them. Similarly, Resident #108 and Resident #110 were seated together, and Resident #110 received his lunch tray but was not assisted immediately. Resident #104 and Resident #112 were also observed without their lunch trays while other residents at their table had already received theirs. This delay in receiving and assisting with meals led to visible worry and disappointment among the residents, as noted by their comments and expressions. In an interview, the Director of Nursing (DON) acknowledged that it was a dignity concern for residents to have their food in front of them without assistance, as the food would get cold and it was not respectful to the residents. The facility's policy on promoting and maintaining resident dignity, which was revised recently, emphasizes the importance of treating each resident with respect and ensuring their quality of life. The observations and interviews indicate that the facility did not adhere to this policy during the dining experience of the residents involved.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records for one resident, resulting in an inaccurate reflection of the resident's medical treatments. Resident #100, who was cognitively intact with a BIMS score of 15/15, reported that the facility staff were not completing dressing changes for his pressure ulcer as ordered and were not providing bed baths as frequently as required. Observations confirmed that the resident's wound dressing was not changed daily as ordered, and there were multiple instances where bed baths were not documented or provided. The resident's appearance, with greasy hair and food crumbs in his beard, further indicated neglect in personal care. Interviews with the LPN Unit Manager revealed that the facility did not have a system in place to monitor the documentation of care and treatment, leading to missed treatments and care for Resident #100. The LPN Unit Manager could not explain the discrepancies in the documentation, such as the wound dressing being dated incorrectly and missing documentation for bed baths and wound care. The lack of proper documentation and follow-up on missed treatments contributed to the deficiency in maintaining accurate medical records for the resident.
Failure to Facilitate Resident-Initiated Discharge
Penalty
Summary
The facility failed to facilitate a resident-initiated discharge per the resident's choice, resulting in a delay in discharge and the accumulation of unnecessary service charges. Resident #102, who had multiple medical conditions including diabetes, diabetic neuropathy, a fractured right tibia, and heart disease, expressed a desire to move to an assisted living facility (ALF). Despite multiple requests from the resident and his family, the facility did not promptly send the necessary referral to the ALF, causing a significant delay in the resident's discharge process. The resident was discharged from physical therapy and was ready to transition to the ALF, but the facility's inaction postponed this move, leading to additional private pay charges for services that were no longer required. The Social Work Director (SSD) was on maternity leave during a critical period and was not aware of the resident's discharge plans. Upon her return, she completed the referral, but this was after several weeks of delay. The family member reported leaving multiple messages with the facility, including the Administrator, without receiving a response. The delay in sending the referral was only resolved after the family contacted the Ombudsman. The resident was eventually discharged to the ALF, but not before incurring additional costs due to the facility's failure to act in a timely manner.
Failure to Complete Accurate Resident Assessments
Penalty
Summary
The facility failed to complete accurate assessments for a resident, resulting in an inaccurate reflection of the resident's status. The resident, who had multiple pertinent diagnoses including diabetes, diabetic neuropathy, a fracture of the right tibia, a wound on the right great toe, and peripheral vascular disease, was admitted with specific skin conditions noted by the referring hospital. However, the facility's admission assessment did not accurately document these conditions. The skin assessment completed on 11/15/23 failed to include descriptions of blisters, redness to the shin area, or the wound on the right great toe, despite these issues being present and noted in the transfer documentation from the hospital. This omission resulted in an incomplete and inaccurate assessment of the resident's skin integrity and overall health status. The Director of Nursing (DON) confirmed that the skin assessment lacked necessary details and acknowledged that the nurses were educated on completing assessments during their initial orientation. However, the deficiencies in the assessment process were evident as the critical skin conditions were not documented properly. During an interview, the DON reviewed the skin assessment and confirmed that the blisters, redness, and the right great toe ulcer were not noted in the assessment. The DON also mentioned that new admissions and their needs were discussed during morning meetings, but the specific skin issues of this resident were not captured in the assessment. This failure to accurately document the resident's skin conditions upon admission highlights a significant lapse in the facility's assessment process, potentially leading to impaired medical and functional problems due to unidentified needs.
Failure to Establish Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to completely assess and establish a baseline care plan for a resident within 48 hours of admission. The resident, who was admitted with multiple significant diagnoses including diabetes, diabetic neuropathy, a right tibia fracture, a wound on the right great toe, heart disease, muscle weakness, urinary retention, a left leg amputation below the knee, peripheral vascular disease, and prostate cancer, did not have a baseline care plan in place to address his activities of daily living (ADL) needs. Despite being cognitively intact with a BIMS score of 15 out of 15, the resident's baseline care plan was not completed until several days after admission, resulting in a lack of person-centered, resident-specific ADL care instructions for the nursing staff. The review of the records indicated that the baseline care plan summary was completed late and lacked the resident's signature to verify that the summary was provided. The comprehensive care plan was not initiated until several days after the resident's admission. The Director of Nursing confirmed that the baseline care plan should have been completed within 48 hours of admission to ensure that nursing staff had the necessary care plan focuses and interventions to provide effective and person-centered care. The facility's policy on baseline care plans, revised in January 2024, mandates that such plans be developed within 48 hours of admission and include essential healthcare information, but this was not adhered to in this case.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with multiple complex medical conditions, including cerebral palsy, epilepsy, intellectual disabilities, and Rett's syndrome. The care plan, revised on 10/27/23, indicated the use of palm protectors at all times, but there was no order for hand paddles for contractures in the resident's upper extremities. Observations on 2/16/24 revealed that the resident had a paddle pad in her left hand but not in her right hand, which was contracted. Interviews with staff indicated that the care plan was not fully implemented, and the necessary orders were not documented in the resident's medical record. Certified Nursing Assistant (CNA) U and Licensed Practical Nurse (LPN) BB reported that they relied on paper records and assignment sheets, which were not always updated with the latest care plan changes. The Director of Nursing (DON) B confirmed that an order for the hand paddles was missing and that the resident had them upon admission from an Adult Foster Care (AFC) facility. The DON also mentioned that staff were expected to implement care plan interventions during walking rounds, but this was not consistently done, leading to a lack of service for the resident to maintain her highest practicable physical, mental, and psychosocial well-being.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 497 citations issued within 25 miles in the last 12 months — including the 6 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.
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A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Niles Care Center, Llc | 1.6 mi | ★★★★★ | 33 | 2 |
| West Woods Of Niles | 5.5 mi | ★★★★★ | 24 | 1 |
| Healthwin Health & Rehabilitation | 7.4 mi | ★★★★★ | 34 | 0 |
| Majestic Care Of South Bend | 8 mi | ★★★★★ | 56 | 0 |
| Wellbrooke Of South Bend | 8.9 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.