Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 West Woods Of Niles during CMS and state inspections, most recent first.
A resident admitted with multiple pressure ulcers, including a stage IV sacral wound managed with a wound vac and planned wound clinic follow-up, did not consistently receive ordered wound care. Facility staff reported being unable to change the wound vac dressing due to perceived lack of supplies, removed the wound vac, and initiated wet-to-dry dressings without a documented provider order, despite the NP expecting continuation of wound vac therapy. Wound assessments and TAR entries showed missing or incomplete documentation, skipped treatments, and absence of treatment orders for some wounds, while progress notes and staff interviews described necrotic tissue, exposed bone, odor, warmth, increased drainage, and a rapid decline in the resident’s condition. The resident was eventually sent to the hospital with altered mental status, where ED and consult notes documented septic shock from a necrotic sacral ulcer with osteomyelitis and additional unstageable or deep tissue injuries.
Annual CNA performance evaluations were not completed as required. Interviews and record review showed the facility used its scheduling/talent profile system and QAPI report to track evaluations, but one CNA reported no annual review for several years, another was only recently scheduled, and one employee file showed the last evaluation was completed over a year earlier. HR could not locate an evaluation for one CNA and described a process in which the DON was supposed to verify completion in the QAPI report and system.
Cold Meals and Beverages Served to Residents: Two residents reported that meals and beverages were served at unappetizing temperatures, including lukewarm or cold food and cold coffee. Surveyors observed lunch service without heated bases or heated plates, and a test tray measured well below expected hot-holding temperatures, with chicken and mashed potatoes ranging from 118F to 140F.
Food storage and sanitation deficiencies were identified in the kitchen after surveyors found improperly dated and stored ready-to-eat foods, items held beyond label instructions, and products kept without required discard dates. Surveyors also observed debris on freezer gaskets, the coffee unit, the ice scoop holder, the can opener, utensil drawers, and clean utensil containers, and the CDM stated the facility did not have chlorine test strips to verify the dish machine.
Incomplete wound and catheter care documentation was found for two residents. A resident with a stage 4 sacral pressure ulcer and multiple wound orders had several TAR entries left blank or marked only as "See progress note," and some progress notes contained no wound care details or only a period. Another resident with wound care orders and Foley cath care also had multiple missed or undocumented TAR entries. Staff confirmed the charting did not show whether ordered care was completed or missed.
Infection control practices were not maintained for residents with respiratory symptoms and confirmed COVID-19. A resident with fever, cough, congestion, and hoarseness and a roommate with nasal congestion and SOB were not promptly placed on transmission-based precautions, and staff were unsure whether testing had been completed when symptoms began. Shared lift equipment was observed heavily soiled with dust, debris, and dried material, and a resident’s tube feeding area had dried splatter on the wall, pole, floor, and bed frame, with a suction machine covered in dust and debris.
Unsafe and Unclean Resident Rooms: Surveyors found two resident rooms with poor housekeeping and maintenance issues. One resident with dementia and stroke-related impairments had a broken oscillating fan with exposed, dusty blades and a dusty pedestal fan, while another resident with dementia, COPD, and other conditions had a room with crumbs, dirt, debris, and dust on the fall mat, floor, and nightstand, and the room remained unkempt on a later check.
A resident with MS, neurogenic bladder, muscle wasting, depression, and anxiety, who required assistance with ADLs, became involved in a non-work-related relationship with an Infection Preventionist (IP). The resident reported that the IP initiated contact via social media, frequently visited his room, and later met him at a hotel during an LOA, where they engaged in sexual activity and spent the night together. He alleged missing cash and vapes after the encounter and showed staff social media messages and an image of the IP in thong underwear linked to her profile. A CNA corroborated frequent room visits by the IP and observed numerous messages on the resident’s phone, and a law enforcement officer reported that the IP admitted to a romantic relationship and sexual activity with the resident, with hotel surveillance showing them together in a manner beyond a nurse–resident relationship. These facts support a finding that the facility failed to protect the resident from sexual abuse by a staff member.
A resident with a stage 4 sacral pressure ulcer and a wound vac experienced progressive wound deterioration and functional decline that were not effectively recognized or acted upon. Nursing documentation showed repeated increases in drainage, foul odor, warmth, edema, necrotic tissue, and bone exposure, and staff and family reported that the resident became more confused, combative, and dependent for ADLs. An LPN discontinued the wound vac and changed to wet-to-dry dressings after observing a hot, necrotic wound down to bone, and left messages for the wound clinic and NP, but there were gaps in follow-up orders, delayed wound clinic referral, and uncertainty about provider notification. Multiple treatments and documentation entries were missing, and an additional leg wound was discovered without treatment orders only when the resident was being sent to the hospital. The NP, who was aware of general concerns and had ordered labs, did not see the resident again until he appeared significantly worse, at which point he was transferred to the ED and diagnosed with altered mental status and septic shock related to the sacral wound.
Failure to issue SNF-ABNs when Medicare Part A coverage ended. Three residents with diagnoses including CKD, breast cancer, and traumatic subdural hemorrhage did not receive SNF-ABN notices when their Part A stays ended and they transitioned to custodial care, hospice, or discharge. Financial staff stated the forms were not issued because of those transitions, while corporate financial staff said the residents should have received the notices when Medicare A services stopped.
Failure to report resident elopement incident: A resident who was only permitted to go outside with specific approved persons exited the building while the door alarm was sounding and was found outside smoking by herself. Staff gave conflicting accounts about who knew she was outside and when, and the incident was documented as potential neglect but was not reported to the State Agency.
A resident with acute osteomyelitis and moderate cognitive impairment was given a facility-initiated discharge notice, but the discharge was not approved because the facility never submitted the required discharge plan. Staff documented attempts to plan a safe discharge, while the resident became aggressive and said he would leave in his van. The NHA said the resident had no actual discharge location, and records showed the resident was discharged to a private home/apt. without home health services.
A resident with stroke, multiple contractures, epilepsy, tube feeding, and a persistent vegetative state had a care plan calling for a low bed in the lowest position except during direct care and comfort rounds for positioning and repositioning. However, during several observations, the resident’s bed was not in the lowest position and was at transfer height at times, including while the resident was supine with an arm contracted upward. Staff interviews confirmed the resident required positioning checks due to suctioning needs, mucus congestion, coughing, and seizures, while the CCC stated care plans were maintained by the interdisciplinary team.
A resident with cognitive impairment and exit-seeking behavior left the building unsupervised after an alarm sounded, and staff did not immediately ensure his safety or report the incident right away. In a separate event, another resident with Parkinson’s disease, dementia, and mobility limitations was observed without ordered fall precautions in place and later was found on the floor with a forehead hematoma after increased confusion overnight.
The facility failed to consistently monitor hydration, meal intake, and weight trends for residents at risk for altered nutrition and hydration. One resident with dementia, diabetes, and stroke history had lab values consistent with dehydration and was repeatedly observed with fluids untouched and meals largely uneaten, while staff reported fluid intake was not tracked consistently. Another resident with dementia had a 16-day gap in FAR documentation and a significant weight loss without a reweight, and a third resident with Parkinson’s disease and dementia had incomplete ordered weight monitoring and reported needing more feeding setup assistance and adaptive utensils.
A resident with ESRD did not have required pre-dialysis assessments documented before leaving for HD on multiple occasions. Nursing staff were responsible for checking the fistula site, obtaining weight and VS, and completing the hemodialysis communication form, but the forms were missing required documentation and also did not consistently reflect the resident’s refusals of dialysis.
Delayed physician review of pharmacy recommendations for a resident with depression, delusions, bipolar disorder, dementia, and chronic pain. The resident was receiving olanzapine and sertraline, and monthly pharmacy reviews identified concerns with both medications as well as a duplicate calcium carbonate order. The physician did not document agreement with the first two recommendations until survey exit, and the DON could not locate earlier pharmacy review records.
A resident with MS, depression, anxiety, chronic pain, and other significant conditions was prescribed Adderall without a documented ADHD diagnosis or other clear support for continued use. Records showed agitation, marijuana use, and repeated concerns from the HCP, psychiatry, and IDT that the stimulant was not appropriate, while the resident refused gradual dose reduction or discontinuation. The neurologist note reviewed did not document support for ongoing Adderall use, and the NP reported the medication appeared to contribute to irritability and behavioral outbursts.
A resident with diabetes, edema, and hypertension experienced worsening lower extremity edema and developed open areas on the legs, but staff failed to consistently assess, monitor, and document the resident's skin and wound care as required. Orders for daily weights and weekly skin assessments were not followed, and wound assessments were missing from the medical record, despite facility policy and care plan interventions.
Staff failed to follow Enhanced Barrier Precautions for two residents with wounds and indwelling devices, including not updating care plans, lacking required signage and PPE outside rooms, and not donning gowns and gloves during high-contact care activities such as transferring and dressing changes. These lapses were observed during direct care and confirmed through staff interviews and record review.
A resident with dementia, stroke-related deficits, Alzheimer’s disease, diabetes, and cognitive communication impairment was found unresponsive after receiving evening meds and was sent to the hospital. ED and hospital records showed bradycardia, decreased respirations, hypothermia, pinpoint pupils, and a UDS positive for benzodiazepines and opiates despite no orders for those meds. Interviews and the facility investigation pointed to a possible mix-up by an agency LPN who reported being overwhelmed, did not know the residents well, and may have given meds to the wrong resident.
A long-term care facility failed to implement proper infection control measures, including transmission-based precautions for a resident with C-DIFF, cleaning of shared equipment, and appropriate use of PPE for residents under COVID-19 observation. Staff entered isolation rooms without required PPE, and shared equipment was not sanitized between uses, increasing the risk of infection spread.
The facility failed to ensure a qualified Infection Preventionist had sufficient time to manage the Infection Prevention and Control Program. The IP was behind on critical tasks, including administering COVID-19 vaccinations to 10 residents during an outbreak, due to being assigned additional duties such as working as a floor nurse. The Nursing Home Administrator confirmed the IP's inability to fulfill her responsibilities.
The facility failed to offer COVID-19 vaccinations to 10 eligible residents who had consented, due to the Infection Preventionist being behind on responsibilities and a misunderstanding about vaccine ordering requirements. Despite a COVID-19 outbreak, no vaccinations had been provided in months, increasing the risk of infection spread.
A resident identified as a high risk to wander exited the facility through a staff exit door and was found 30 feet away in the courtyard. The incident occurred because a CNA turned off the door alarm without checking if a resident had exited, contrary to the facility's elopement policy. The Nursing Home Administrator identified the root cause as the CNA's failure to follow the policy.
The facility failed to provide SNF-ABN and NOMNC forms to two residents upon discharge from Medicare A coverage. One resident had heart failure, anxiety disorder, and dementia, while another had spinal stenosis with surgical aftercare. The admission coordinator, responsible for issuing these forms, was unfilled, leading to the oversight.
A resident in a persistent vegetative state did not receive consistent, meaningful activities as outlined in her care plan. Despite being dependent on staff, she was often left in bed without interaction or stimulation. Staff interviews revealed a lack of clarity and consistency in activity provision, and family members were not consulted for preferences. The deficiency highlights a failure to meet the resident's needs for engagement and stimulation.
The facility failed to ensure the Medical Director attended QAA meetings quarterly, as required by their policy. The Medical Director missed meetings in several months, leading to potential gaps in addressing quality deficiencies. The NHA was aware of the requirement but could not secure the former Medical Director's attendance.
A resident with rhabdomyolysis and acidosis experienced a decline in health, including a swollen arm and low blood pressure. Despite protocols requiring immediate action, the facility delayed contacting medical providers and transferring the resident to a hospital. The resident was eventually diagnosed with septic shock and died shortly after. Staff interviews revealed a failure to follow procedures for urgent medical situations.
A resident with a stage 4 pressure ulcer and functional quadriplegia experienced worsening of their condition due to inadequate repositioning and ineffective wound vac use. Despite staff awareness of the resident's refusal to be repositioned due to pain, this was not documented, and the care plan lacked specific interventions. The resident's condition deteriorated, leading to hospitalization for evaluation and treatment.
A facility failed to create a comprehensive care plan for a resident with a stage 4 pressure ulcer, leading to the worsening of the ulcer and additional wounds. The care plan lacked specific interventions for repositioning and wound vacuum use, and did not document the resident's preferences or education provided about repositioning benefits. Staff interviews confirmed the resident's resistance to repositioning, but no documentation was available to reflect this in the care plan.
A resident with a stage 4 pressure ulcer experienced a breach in infection control during a wound care dressing change. An LPN improperly handled wound wash and Dakins solution, and used unclean scissors from her pocket. The Infection Preventionist did not intervene during these actions, which could lead to cross-contamination.
Failure to Provide Ordered Wound Vac Therapy and Consistent Wound Care Resulting in Septic Shock
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered wound care and monitor a complex stage IV sacral pressure ulcer, resulting in deterioration of the wound and subsequent hospitalization for septic shock and osteomyelitis. The resident was admitted with multiple wounds, including a stage IV sacral ulcer and a right buttock wound, and required assistance with personal care. Hospital records at admission documented deep decubitus ulcers, debridement with clean borders, placement of a wound vac, and a plan for a wound clinic follow-up in two weeks. The facility’s admission assessment noted wounds on the right iliac crest, left inner ankle, right outer ankle, and sacrum but did not include measurements or wound type descriptions for each area. The care plan identified risk for impaired skin integrity and set a goal for improvement with interventions such as pressure redistribution and reevaluation of treatment when there was no improvement. Following admission, the facility did not consistently follow wound vac orders or ensure timely dressing changes. The Treatment Administration Record (TAR) for the sacral wound vac showed missing or incomplete documentation on multiple dates, including entries marked only as “see progress note” or left blank, and a hold on the wound vac from 12/29 to 12/31. Progress notes on 12/26 and 12/29 documented that wound vac supplies were reportedly unavailable and that attempts to change the wound vac dressing could not be completed due to lack of supplies. On 12/29, when the dressing was removed, nursing staff observed the right buttock wound down to bone, necrotizing tissue between buttock wounds, and a red, hot peri-wound area with odor. The former DON instructed staff to switch to wet-to-dry dressings and contact the wound clinic, and a nurse texted the NP about changing the dressing to wet-to-dry. However, there was no documented provider order authorizing the change from wound vac to wet-to-dry, and the NP later stated she had not recommended changing the wound vac orders and expected the wound vac to continue. Throughout this period, wound assessments and treatments were inconsistently documented and some wounds lacked any treatment orders. Wound measurements on 12/24 and 12/31 showed stage IV wounds to the right buttock and sacrum with granulation, slough, odor, rolled edges, tunneling, and undermining, but there were no treatment orders in the TAR for the right ankle, left ankle, or right leg wounds. TAR entries for other wound locations, such as the left hip and right posterior ribs, also had missing documentation or notes that did not explain why treatments were held. One LPN documented “No wound care this shift” on 12/31 to remove the task from her list and acknowledged that she commonly skipped treatments due to workload, with no way to verify if another nurse completed the care. Another LPN documented only a period in progress notes where treatment status should have been recorded and could not recall whether treatments were missed. Staff interviews revealed that nurses believed they were out of wound vac supplies, while the clinical care coordinator and former DON stated supplies were available in storage. The medical records staff and several clinical leaders were unaware of the hospital’s order for a wound clinic follow-up on 1/1, and the resident did not attend that appointment; the facility instead submitted a referral on 12/31 and scheduled a later clinic date. During this time, multiple staff and the resident’s family observed a decline in the resident’s condition, including increased confusion, combativeness, need for more assistance, and inability to feed himself. The family member reported noticing confusion at a care conference, being told the facility would follow up, and later being informed by a nurse that the sacral dressing had not been changed because the facility was waiting on supplies. The family continued to voice concerns about the resident’s decline and the worsening wound, and a nurse called the family to report that the wound looked worse and that the wound vac was off while waiting for the wound doctor. Progress notes documented increased drainage, foul odor, surrounding warmth, and edema of the sacral wound on multiple dates, as well as green/yellow drainage and increased tenderness on 1/6. The NP acknowledged being aware of concerns about bone in the sacral area and an abnormal CRP but stated she was not told the wound was hot to touch. On 1/8, the NP noted the resident did not look good and was not eating and ordered transfer to the hospital for altered mental status and possible infection. Hospital records from that date described septic shock from a necrotic sacral ulcer with osteomyelitis, bacteremia, and a large unstageable coccyx/sacral wound with exposed bone, necrotic tissue, circumferential undermining, erythema, and odor, along with additional unstageable or deep tissue injuries on the legs and ankle, confirming the deterioration that occurred while the resident was under the facility’s care.
Annual CNA Performance Evaluations Not Completed
Penalty
Summary
The facility failed to ensure annual performance evaluations for certified nursing assistants were completed. The deficiency was identified through interview and record review and was tied to the facility's process for tracking staff evaluations through its scheduling and talent profile system, as well as the QAPI report reviewed by HR and the DON. The report states that performance reviews were intended to be tracked after orientation and then monitored through QAPI, but the facility did not ensure the evaluations were actually completed for all CNAs. During interviews, the Staffing & Scheduling Manager stated staff were placed into the facility system upon hire to build permanent schedules and talent profiles, and HR stated orientation included the electronic education system and floor competency training, with orientation packets uploaded afterward. One CNA reported not having had an annual performance review for several years, another reported being asked to sign up for annual evaluations the prior week, and review of one CNA's employee file showed the last annual performance evaluation was completed on 3/21/24. HR was unable to locate an annual performance evaluation for one CNA and stated that the QAPI report was used to identify who was due, with the DON checking off completed evaluations in the report and system.
Cold Meals and Beverages Served to Residents
Penalty
Summary
Food and drink were not provided at a palatable temperature for 2 of 22 residents reviewed. Resident #32, who had diagnoses including Parkinson’s disease, muscle weakness, and dementia, had a BIMS score of 13/15 and was documented as cognitively intact. During an observation, the resident’s lunch tray was delivered to the room and left on the bedside table with a hard plastic cover. When the resident removed the cover and began eating, he stated the cauliflower was lukewarm at best and too tough to eat, and then said the loaded baked potato was colder than the cauliflower. The resident expressed dissatisfaction with the meal and stated he was not going to eat, adding that the palatability of the food had been a concern for several months and that he purchased nutritional drinks himself to help ensure adequate calorie intake. Resident #72 had a BIMS score of 9/15, indicating moderately impaired cognition. The resident stated that coffee was cold and that food served in the room was cold, and that it did not matter whether meals were eaten in the main dining room, small dining room, or room. During survey observations of lunch service, residents in the dining room began being served after lunch start time, no heated bases or heated plates were used, and a test tray was plated as one of the last meals coming from the steam table. The tray was later checked with a rapid-read thermometer and showed temperatures of 140F for one piece of chicken, 118F for the other piece of chicken, and 121F for the mashed potatoes.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area after surveyors observed multiple food storage and sanitation issues during kitchen observations and interviews. The Certified Dietary Manager stated that staff typically date items for a three-day discard and use the day an item was made or opened to label it. Surveyors found a half-empty gallon of milk dated 1/26/26 in a two-door reach-in refrigerator, an open package of polish sausages in the walk-in cooler with no discard date, and in the Front Street refrigeration unit two containers of cottage cheese with best-by dates of 2/2/26, an open gallon of milk with a best-by date of 1/28/26, and a pitcher of thickened water dated 1/28/26. Surveyors also found sealed packages of single-serve macaroni and cheese in the walk-in cooler even though the product label stated it should be kept frozen, and open containers of lemon juice and soy sauce in dry storage even though the labels stated refrigerate after opening. Additional observations showed sanitation concerns throughout the kitchen equipment and utensil storage areas. Surveyors observed increased accumulation of food crumb and black debris on the seals and gaskets of both four-door freezers, dried brown and black splatter debris under the coffee unit, and brown and white crusted debris inside the ice scoop holder. The can opener blade had debris and red staining, the mechanical scoop drawer contained four scoops with stuck-on food debris and food crumb debris in the bottom, and the clean utensil containers under the cookline were dirty and dingy with crumb debris inside. The CDM stated the utensil drawers should be cleaned nightly by the PM cook, and also stated the facility did not have chlorine test strips to test the dish machine.
Incomplete wound and catheter care documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for 2 of 22 residents reviewed. For Resident #121, the record showed multiple wound care orders, including negative pressure wound therapy to the sacral wound, dressing changes for a right buttock/sacral wound, a left hip ulcer, and open areas on the right posterior ribs. The Treatment Administration Record (TAR) did not document whether several ordered treatments were completed or missed on multiple dates, and some entries only stated "See progress note" without a corresponding progress note explaining the treatment status. Resident #121 was admitted with diagnoses including a stage 4 sacral pressure ulcer and need for assistance with personal care. The TAR showed missing documentation for wound care treatments on several dates, and progress notes dated 12/21/25, 12/25/25, 12/26/25, 12/31/25, and 1/2/26 did not contain the required wound care details. One nurse documented only a period in the progress note instead of indicating whether the treatment had been completed or missed, and later stated he did not know why he had not documented whether the treatment was completed and could not recall whether any treatments were missed. Facility staff also confirmed that the documentation did not show when or if a provider was notified about changes in the resident's wound or how long the wound vac was off. For Resident #19, the TAR showed orders for wound care to the left 5th met, multiple toes, heel, lateral foot, and ankle, as well as Foley catheter care and drainage bag output recording every shift. The record did not show whether several of these treatments were completed or missed on multiple dates. During interview, the CCC reviewed the TAR and confirmed that documentation was missing to indicate whether the resident's treatments had been completed, and stated that nurses were expected to complete all charting on care that residents did or did not receive.
Infection Control Failures With Delayed Isolation, Soiled Shared Equipment, and Unclean Tube Feeding Area
Penalty
Summary
The facility failed to maintain effective infection control practices for residents with respiratory symptoms and confirmed COVID-19. Resident #90 and Resident #76 were both reported positive for COVID-19, and signage outside Resident #90’s room indicated Enhanced Barrier Precautions. Resident #32 had cold symptoms and altered mental status, tested positive for COVID, and a CNA stated the signage outside the room still reflected a former resident rather than the current isolation status. The Infection Prevention Manager confirmed that residents with symptoms of acute respiratory illness should be placed in transmission-based precautions immediately and tested for COVID, and acknowledged there was a delay in implementing isolation precautions and testing for symptomatic residents during the outbreak. Resident #8 and Resident #13 shared a room and both had signs and symptoms of illness. Resident #8 was documented with fever, hoarse voice, congestion, emesis, and a wet cough, and Resident #13 reported nasal congestion, fatigue, and increased shortness of breath. During observations, no transmission-based precautions signage was posted outside their room, and the LPN caring for them confirmed that no transmission-based precautions were in use during care and did not know whether either resident had been tested when symptoms began. Resident #13 was later documented as having a cough and congestion and tested positive for COVID, while Resident #8 had been symptomatic for several days before testing was documented as negative. The facility also failed to keep shared equipment and resident care areas clean. Mechanical lift devices observed outside resident rooms were heavily soiled with dust, debris, and dried white liquid on the base, knee guard, footrests, and other surfaces. The Infection Prevention Manager stated shared medical equipment, including mechanical lifts, was expected to be cleaned immediately after each use and that every surface should be disinfected after use. In addition, Resident #27’s room contained dried tan/brown material splattered on the wall behind the bed, dried material on the tube feeding pole and base, dried material on the floor and bed frame, and a suction machine covered in dust and debris. The resident’s room was observed multiple times with the same conditions, and an LPN acknowledged the dried material on the wall, pole, floor, and bed frame and stated housekeeping should have addressed it.
Unsafe and Unclean Resident Rooms
Penalty
Summary
The facility failed to ensure a safe and sanitary environment for two residents. For Resident #4, who had vascular dementia, left-sided hemiplegia, and a history of cerebral infarct, surveyors observed a small oscillating fan on the bedside dresser with the cover missing, exposed blades covered in dust, and the cover lying under personal items on another stand. A pedestal fan in the room was also covered in dust. Resident #4 was observed in bed with the small fan turned on and rotating without a cover in place, and she stated the fan had been broken for a long time and that she had asked for it to be fixed. The housekeeper reported fans were cleaned as needed, while the Maintenance Director stated fans were to be cleaned monthly and that the broken fan should have been replaced and the pedestal fan cleaned. For Resident #103, who had heart failure, COPD, dementia, Alzheimer's disease, anxiety, and depression, surveyors observed a fall mat next to the bed covered with crumbs, dirt, and debris. The floor around and under the bed had scattered dirt, debris, and crumbs, and the nightstand and items on top of it were covered in dust. On a later observation, the room remained unkempt and still needed to be dusted, swept, and mopped. The report stated that, using the reasonable person concept, a person in this situation would likely feel a decreased sense of self-worth and frustration.
Failure to Protect a Resident From Sexual Abuse by a Staff Member
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from sexual abuse by a staff member. The resident was an adult male with multiple sclerosis, neurogenic bladder with a suprapubic catheter, muscle wasting and atrophy, depression, anxiety, chronic pain, and a documented need for assistance with ADLs such as dressing and eating. His care plan reflected altered functional mobility and dependence on staff for personal care. Despite this, a staff member in the role of Infection Preventionist (IP) developed a personal, non-work-related relationship with him that progressed to sexual activity. According to interdisciplinary documentation, the resident reported that he and the IP arranged to meet at a local hotel during an approved overnight LOA. He stated he left the facility with vape pens, money, and other belongings, and that the IP met him at the hotel shortly after his arrival. He alleged they spent the night together and engaged in unprotected sex, then left separately the next morning. He later noticed $300 and his vapes missing and reported that, during a video chat, he saw the IP using his vapes. He also reported ongoing communication with the IP via a social media platform, including messages, videos, and at least one image of the IP’s buttocks in thong underwear. Facility staff, including a CNA and the Activities Director, reported seeing on his phone the IP’s name, profile picture, and an image of her in thong underwear, along with numerous messages between them. The resident further reported to staff that the IP had been coming into his room frequently, that she had "used" him, and that he believed she had stolen items from him, including a Nike hoodie and possibly money. A CNA observed the IP entering and exiting his room more often than expected and leaving with large clear trash bags containing linens, though the CNA did not witness any sexual acts or theft directly. The resident also expressed concern that he might have contracted an STD from the IP and reported that she questioned him about his request for STD testing and about whether he would tell anyone about their relationship. A Deputy Sheriff who investigated stated that the IP acknowledged she had fallen in love with the resident, agreed to meet him at the hotel, and admitted there was sexual activity, and that hotel surveillance footage showed them together in a manner that appeared to go beyond a nurse–resident relationship. These events demonstrate that a staff member engaged in a sexual relationship with a resident, constituting sexual abuse and a failure by the facility to ensure the resident’s right to be free from abuse.
Failure to Recognize and Respond to Resident’s Decline and Worsening Infected Sacral Wound
Penalty
Summary
The deficiency involves the facility’s failure to identify and respond appropriately to an acute change in condition for one resident with a stage 4 sacral pressure ulcer, despite multiple signs of wound infection and functional decline. The resident was admitted with a sacral wound requiring a wound vac and had a care plan identifying risk for acute condition changes related to cardiopulmonary, metabolic, or infectious complications, with interventions including assessment, prompt practitioner notification, and effective communication among staff. Documentation of sacral wound symptoms showed repeated findings of increased drainage, foul odor, surrounding warmth, and edema on multiple dates, which were noted as indications of wound infection. Progress notes documented that the wound became larger, with necrotizing tissue and bone exposure, and that the peri-wound area was red and hot to touch. On 12/29, an LPN attempted to change the wound vac dressing and observed the wound down to bone, necrotizing tissue between wounds, and a red, hot peri-wound area. The former DON was made aware and instructed the nurse to discontinue the wound vac, apply wet-to-dry dressings, and call the wound clinic. The LPN left a message with the wound clinic and also left a message for the NP for further instructions, and documented that the wound vac remained on hold pending further wound care evaluation. However, the NP’s 12/31 progress note indicated to continue the wound vac and follow up with a wound clinic appointment scheduled for mid-January, without documentation that the NP had been informed of the wound being hot to touch or of the full extent of the wound changes described by nursing staff. The clinical care coordinator later reported that the facility did not initially realize the resident was supposed to follow up with a wound clinic on 1/1 and that a referral was not submitted until 12/31, with an appointment scheduled for 1/14. During this period, staff and the resident’s family repeatedly observed and reported the resident’s decline. The family member reported noticing increased confusion at a care conference, later finding the resident pale and ill, and being told that the sacral dressing had not been changed due to waiting on supplies. The family stated they continued to voice concerns about the resident’s decline, including that he could hardly talk and seemed confused or sedated, and that they contacted the social worker about these concerns. CNAs and LPNs reported that the resident, initially alert and requiring assistance of one for ADLs, became more confused, combative, unable to feed himself, and required more assistance. Nursing staff acknowledged that the wound looked worse, with black tissue and brownish slough, and that the resident’s drainage, odor, and tenderness increased, but there were gaps in documentation of these changes and uncertainty about whether and when the NP was notified. One LPN discovered an untreated right leg wound only when the resident was being sent to the hospital and did not believe there were treatment orders for it. The NP reported being aware of general concerns about the resident’s decline and stated that around New Year’s she ordered labs, which were largely unremarkable except for an elevated CRP that she did not find concerning given the presence of a wound. The clinical support nurse’s internal review found that the facility had been made aware of family concerns about decline on 12/24, that the NP did not see the resident until 12/31, and that labs were not ordered until 12/30. The clinical support nurse also confirmed finding several missing treatments and missing documentation of the resident’s change in condition. On 1/8, when the NP saw the resident and noted that he did not look well and was not eating, she ordered transfer to the emergency room for altered mental status and possible infection. Hospital records documented that the resident arrived with altered mental status, a worsening sacral wound with erythema, fluctuance, purulence, and was diagnosed with septic shock from a necrotic sacral ulcer with osteomyelitis and bacteremia, along with additional pressure injuries and skin breakdown. The facility’s Change in Resident Condition policy required prompt practitioner notification when there is a significant change in physical, mental, or psychosocial status, or when treatment needs to be significantly altered, and required objective observations of changes to be recorded in the record. In this case, despite repeated signs of wound infection, documented wound deterioration, functional and cognitive decline, and ongoing family and staff concerns, there were delays and gaps in practitioner notification, incomplete or missing documentation of changes, uncertainty about responsibility for contacting the NP and wound clinic, and missed or delayed wound treatments. These actions and inactions led to a delay in treatment for the resident, who was ultimately sent to the hospital and diagnosed with altered mental status and septic shock from a necrotic sacral ulcer with osteomyelitis.
Failure to Issue SNF-ABNs When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) to 3 residents reviewed for proper notification related to Medicare Part A coverage and facility care costs. Resident #123 had diagnoses including chronic kidney disease stage 3, and the SNF Beneficiary Protection Notification Review form showed Medicare Part A services ended on 12/19/25; the Nursing Home Administrator documented that no SNF-ABN was provided because the resident started custodial care under Medicaid and Medicare Part B coverage. Financial Services staff reported the form was not issued due to the transition to custodial care, and the facility could not provide a documented SNF-ABN before survey exit. Resident #124 had a diagnosis of malignant neoplasm of overlapping sites of the right female breast, and the SNF Beneficiary Protection Notification Review form showed Medicare Part A services ended on 10/30/25; the Nursing Home Administrator documented that no SNF-ABN was provided because the resident started hospice care under hospice-Medicaid coverage. Resident #125 had a diagnosis of traumatic subdural hemorrhage without loss of consciousness, and the SNF Beneficiary Protection Notification Review form showed Medicare Part A services ended on 09/09/25; the Nursing Home Administrator documented that no SNF-ABN was provided because the resident was discharged from the facility and did not receive non-covered services. Financial Services staff stated she did not fully understand when SNF-ABN forms should be issued for residents transitioning from Medicare Part A coverage, and the Corporate Financial Service representative stated all 3 residents should have received a SNF-ABN when Medicare Part A services were being stopped.
Failure to Report Resident Elopement Incident
Penalty
Summary
The facility failed to report an incident of potential neglect involving a resident who exited the building and was found outside by the main entrance while the door alarm was sounding. The resident was wearing a winter coat backwards, winter boots, and pajama pants, and stated that she had gone outside, smoked a cigarette, and came back in, although she later denied leaving the building by herself and said she went out only with the daughter of another resident when she visits. The resident’s face sheet stated she was allowed to go outside and leave the facility only with that resident’s daughter or a named senior services staff member per her guardian, and her wandering risk assessment noted she was not a wandering risk but wore a wander guard and wanted to go outdoors to smoke in unsafe undesignated areas. The incident report documented that the resident exited the building when the main entrance alarm was sounding, but the incident was not witnessed. An activity aide stated she did not know the resident had gone outside until another resident told her, and she then notified an LPN. The LPN stated he would keep an eye on the resident while she was outside smoking and was aware of her going outside on previous occasions. The social worker later documented staff reports that the resident had been outside smoking, while the resident denied smoking in over a month. The activity aide reported she told the activity director about the resident leaving the building the next day.
Unapproved facility-initiated discharge without required discharge plan
Penalty
Summary
The facility failed to ensure proper procedure for a facility-initiated discharge for Resident #120, a male admitted with acute osteomyelitis of the left ankle and foot and an MDS BIMS score of 9/15, indicating moderate cognitive impairment. Documentation showed staff attempted to discuss a safe discharge plan and offered boxes for the resident to pack belongings, but the resident became aggressive and stated that nobody was going to send him and that he would leave in his van. The resident had been issued a 30-day discharge notice, and the notice stated he did not have a guardian or resident representative, listed no state reason, and indicated the resident no longer needed services provided by the facility. The notice also indicated the resident had a recent level of care determination that negatively affected his ability to receive Medicaid-covered services in the facility, but a final determination had not been issued by MDHHS, and the notice stated that an involuntary transfer or discharge could not be issued until that final determination was issued. The notice was signed by the NHA, who reported she filed it and believed the resident agreed to leave in 30 days and would discharge to his van. However, email communication from BCHS-Involuntary Transfer stated the involuntary discharge was never approved because the facility never submitted a discharge plan for the resident, and the process was initiated later with a statement that the resident agreed to discharge to an AFC. The NHA later reported she did not complete the facility involuntary transfer/discharge plan because the resident did not have an actual discharge location, and the facility could not provide the required discharge plan prior to survey exit. The admission record showed the resident was discharged to a private home/apt. with no home health services.
Failure to Implement Comprehensive Care Plan for Resident with Contractures and Tube Feeding
Penalty
Summary
The facility failed to implement Resident #27’s comprehensive care plan for 1 of 22 residents reviewed for care planning, resulting in a lack of service for the resident to maintain her highest practicable physical, mental, and psychosocial well-being. Resident #27 was a female with diagnoses including stroke, contractures of the right elbow, right hand, and right ankle, contractures of the left elbow, hand, and ankle, abnormalities of breathing, epilepsy, and tube feeding due to a persistent vegetative state. Her care plan, revised on 11/12/24, identified that she was dependent on staff for all ADL care related to her persistent vegetative state and had contractures to bilateral upper extremity joints and bilateral ankles, with interventions including a low bed in the lowest position except with direct care and comfort rounds to assess positioning and assist with repositioning. During multiple observations on 02/04/2026, 02/05/2026, and 02/06/2026, Resident #27 was observed lying in bed with the bed not in the lowest position; at times it was at transfer height. On one observation, she was supine with an arm contracted upward while the bed remained at transfer height rather than the lowest position. During an observation and interview, an LPN reported the resident had a suction machine as a tube feeding resident, became congested with mucus during her menstrual cycle, coughed actively, and had seizures, so staff checked her positioning so she was not close to the side of the bed. In interview, a CNA stated CNAs could review interventions for each resident and that changes were communicated by nurses, and the CCC reported the CCCs were responsible for maintaining resident care plans and that the team discussed residents and any changes.
Failure to Supervise Exit-Seeking Resident and Maintain Fall Precautions
Penalty
Summary
The facility failed to adequately supervise residents and reduce hazards when a resident with anxiety, PTSD, bipolar disorder, mild cognitive impairment, depression, and a BIMS score of 10 exited the building without staff observation or knowledge. The resident had a wander guard and was documented as not being a wandering risk, but she was also identified as wanting to go outdoors to smoke in unsafe undesignated areas. Her facesheet and care plan stated she was only allowed to go outside or leave the facility with a specific resident’s daughter or a named senior services staff member, and her guardian confirmed she was not to go outside by herself. On the evening of the incident, the main entrance door alarm sounded and the resident was found outside sitting on the sidewalk between the main entrance and office entrance, wearing a winter coat backwards, winter boots, and pajama pants. Staff accounts showed that the alarm was turned off, the resident was allowed to remain outside smoking, and no one immediately ensured she had left or returned under observation. One staff member stated she did not know the resident had gone outside until another resident told her, another stated he would keep an eye on her from inside while continuing medication pass, and a housekeeper stated she turned off the alarm to let the resident back in when she was done smoking. The incident was not reported to management until the next day, and the resident stated she did not leave by herself, while the guardian stated she could smoke outside only with approved persons. The facility also failed to maintain fall precautions for a resident with Parkinson’s disease, muscle weakness, and dementia who required moderate assistance for transfers and had a care plan calling for a fall mat at bedside and nonslip material on the wheelchair. During multiple observations, the resident was seen in bed or standing alone without the fall mat in place and without nonslip material on the wheelchair. A staff member passed by while the resident stood in regular socks and did not stop to assist or encourage shoes. Later, the resident was found on the floor after trying to clean out his closet, had been more confused that night, and sustained a hematoma to the left forehead before being sent to the emergency department for evaluation.
Failure to Monitor Hydration, Intake, and Weight Trends
Penalty
Summary
The facility failed to maintain sufficient hydration and consistent nutritional status monitoring and re-evaluation by a nutrition professional for residents at risk for altered hydration and nutritional status. The deficiency involved 3 of 4 residents reviewed for hydration/nutrition and was associated with potential dehydration, weight loss, and unmet resident needs. Survey findings included observation, interview, and record review showing gaps in fluid monitoring, meal intake documentation, weight follow-up, and nutrition reassessment. For one resident with diabetes, dementia, paralysis, and stroke history, the record showed abnormal lab values consistent with dehydration, including elevated sodium, creatinine, and BUN with low eGFR. The resident also had urinary complaints and a positive urine culture treated with antibiotics, with increased oral fluids encouraged. During observations, the resident was repeatedly found with water present but not consumed, sometimes without fluids available at the table, and at meals she was observed not eating most of the food and using her hands to eat because utensils were not readily used. Staff interviews indicated fluid intake was not tracked consistently, and the last nutritional assessment for this resident had been completed months earlier. For another resident with dementia and an umbilical hernia, the food acceptance record had no documentation for a 16-day period. The resident lost weight from 173.5 lbs to 164 lbs, a 5.48% loss, with no reweight obtained during that interval. The last nutrition assessment noted prior weight loss and ongoing monitoring, but later documentation stated the resident had not been eating well and had mouth pain. For a third resident with Parkinson’s disease, muscle weakness, and dementia, the care plan identified risk for altered nutrition and ordered weights three times weekly, but weights were documented in only 25 of 37 opportunities over a 12-week period. The resident reported difficulty feeding himself when staff did not provide enough setup assistance and said he did not receive the large spoon needed for meals. A nutritional assessment also documented a lower recent weight, and the resident reported relying on his own nutritional drinks because he felt he could not consume enough calories during meals.
Missing Pre-Dialysis Assessments and Communication Documentation
Penalty
Summary
Safe, appropriate dialysis care/services were not provided for a resident with end stage renal disease and muscle weakness when nursing staff failed to complete and document pre-dialysis assessments before the resident left the facility for hemodialysis. The resident’s care plan identified the need for hemodialysis and included interventions for assessing fluid volume excess, routine weights, JVD, breath sounds, peripheral and sacral edema, and pain or numbness distal to the access site. Review of the Hemodialysis Communication Forms showed that a pre-dialysis assessment was not documented on multiple dates, including 11/21/25, 11/23/25, 12/1/25, 12/20/25, 1/14/26, 1/26/26, and 2/6/26. During interviews, an LPN and the CCC stated that nursing staff were responsible for assessing the resident before dialysis, including checking the fistula site and obtaining pre-dialysis weight and vital signs, and for documenting the assessment on the hemodialysis communication form sent with the resident to the dialysis center. The CCC confirmed that the forms were missing required pre-dialysis documentation on several dates and stated that the facility relied on these forms to communicate changes in the resident’s condition or dialysis treatment orders. Medical records also showed the resident refused dialysis on 1/7/26, 1/14/26, 1/23/26, and 2/9/26, and the CCC stated those refusals should have been documented on the hemodialysis communication form.
Delayed Physician Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the physician documented review of pharmacy recommendations in a timely manner for one resident who was admitted with diagnoses including depression, delusions, bipolar disorder, dementia, and chronic pain. The resident’s active orders included olanzapine 5 mg daily for bipolar disorder and sertraline 50 mg daily for major depressive disorder, and the resident had a BIMS score of 10 out of 15, indicating moderately impaired cognition. Monthly pharmacy reviews identified concerns with the resident’s medications, including recommendations related to olanzapine and sertraline on 9/10/2025 and a duplicate calcium carbonate order on 10/12/2025. The physician did not sign agreement with the first two pharmacy recommendations until 2/10/2026, the day of survey exit, and the duplicate calcium carbonate recommendation was signed on 2/9/2026 during the survey. The DON stated the pharmacist sent recommendations to her, she printed them for the physician mailbox, and changes were made after the physician signed, but she was unable to locate earlier pharmacy recommendations.
Unnecessary Adderall Use Without Supporting Diagnosis
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary drugs when Resident #114 was prescribed Adderall without an appropriate diagnosis documented in the record. The resident’s admission record listed multiple sclerosis, need for assistance with personal care, suprapubic catheter, muscle wasting and atrophy, depression, anxiety, and chronic pain, but the record review found no diagnosis of ADHD to support the original order for Adderall 20 mg twice daily for ADHD. The resident’s record showed ongoing concern about the medication’s appropriateness. A health care provider note documented agitation, marijuana use, and discussion of the safety of using Adderall with marijuana, and the provider reduced the Adderall dose because of increased agitation and labile mood. Psychiatry later documented that the resident did not meet diagnostic criteria for ADHD and that behavioral therapy was more appropriate, with a gradual wean off stimulant medication discussed. Interdisciplinary documentation also stated that the resident had been admitted with a prescription for Adderall and no appropriate diagnosis, and that attempts to reduce or discontinue the medication had failed because the resident refused gradual dose reduction. Further record review showed that the Adderall order was later changed to indicate use for MS and chronic fatigue, although the neurologist’s progress note did not document support for continued Adderall use. Staff interviews reflected that the resident remained resistant to stopping the medication, and the NP reported she believed Adderall was contributing to irritability, profanity, argumentativeness, and emotional outbursts. The NP also stated the resident did not have an appropriate diagnosis to continue Adderall and that she, the MD, and behavioral health providers agreed the medication was not appropriate.
Failure to Assess, Monitor, and Document Skin and Wound Care
Penalty
Summary
The facility failed to properly assess, monitor, document, and provide treatment for a resident with significant skin and wound care needs. The resident, who had diagnoses including diabetes, edema, and hypertension, was admitted with bilateral lower extremity edema and was at risk for skin integrity issues. Despite care plan interventions requiring regular assessment and documentation of edema and skin condition, there were lapses in following these protocols. Notably, the resident developed worsening edema, with observations of weeping fluid and open areas on the lower legs, but documentation and assessment were inconsistent. Orders were in place for daily weights to monitor edema and for specific wound care treatments, including cleansing and dressing changes. However, records revealed that daily weights were not documented after the order was written, and there was no evidence that weekly skin assessments were completed as scheduled. The treatment administration record did not reflect the daily weights order, and a required skin assessment was missed on the resident's assigned day. Additionally, when an open area developed on the resident's shin, there was no wound assessment documented in the medical record as required by facility policy. Interviews with nursing staff and the DON confirmed that documentation and assessments were not completed according to policy and physician orders. The facility's own policy required regular skin inspections, prompt reporting of abnormal findings, and communication among team members, but these procedures were not consistently followed for this resident. These failures resulted in a lack of timely assessment, monitoring, and documentation for the resident's skin and wound care needs.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds and Indwelling Devices
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control protocols for two of three residents reviewed, specifically in relation to Enhanced Barrier Precautions (EBP) as outlined by the CDC. For one resident with diabetes and severe, weeping edema in both lower extremities, there was a physician order for EBP during high-contact care activities. However, the resident's care plan did not include a focus on EBP, and there was no EBP signage or PPE holder on the door. Observations confirmed the resident had dressings and bandages on his legs, but staff did not have the necessary reminders or equipment available to follow EBP protocols during care, despite ongoing symptoms of weeping edema and a history of sepsis. Another resident with a Foley catheter and wounds on his lower extremity had a care plan that included EBP during direct contact with ADL care. During an observed transfer using a Hoyer lift, one CNA donned gloves but not a gown, and another CNA did not use any PPE. Both CNAs assisted with high-contact activities such as transferring, changing clothing, and handling the resident's catheter without following EBP requirements for gown and glove use. The staff later acknowledged that EBP protocols should have been followed due to the resident's catheter and wounds. The facility's policy required clear signage, availability of gowns and gloves outside resident rooms, and adherence to EBP for residents with wounds or indwelling devices. Despite these requirements, observations and interviews revealed lapses in both staff knowledge and practice, as well as missing care plan interventions and lack of proper signage and PPE accessibility. These failures resulted in noncompliance with infection control standards for residents at increased risk of multidrug-resistant organism transmission.
Significant Medication Error With Wrong Resident Medication Administration
Penalty
Summary
The facility failed to prevent a significant medication error for a resident with dementia, dysarthria, memory deficit following stroke, Alzheimer’s disease, diabetes, metabolic encephalopathy, and cognitive communication deficit. The resident was found unresponsive during morning rounds after having gone to bed after dinner the prior evening. Staff called a code blue, the DON responded, and the resident had a very low pulse and irregular respirations. EMS transported the resident to the hospital. Hospital records showed the resident had pinpoint pupils, bradycardia, decreased respirations, hypothermia, and an unresponsive state. Narcan was given without significant effect. A urine drug screen was presumptively positive for benzodiazepines and opiates, and the hospital documented that the resident had no orders for those medications. The discharge summary stated the resident was found unresponsive at the SNF, had a UDS positive for diazepam without a prescription, and APS was involved because benzodiazepines were present without an order. The investigation identified that another resident on the same unit had orders for diazepam and morphine, and staff interviews raised concern that an agency LPN may have mixed up residents and medications. One resident reported being brought crushed pills that were not hers, and another resident reported the nurse tried to give insulin to the wrong resident. The agency LPN stated she had many residents, did not know them well, pulled medications for both residents in each room, and later said she had made a mistake and may have charted under the wrong chart. The facility’s investigation summary stated the resident ingested medications not ordered by the physician and that the discrepancy endangered the resident’s life or welfare.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper transmission-based precautions for a resident diagnosed with Clostridium difficile (C-DIFF), a highly contagious germ. The resident's room lacked appropriate signage indicating isolation precautions, and there was no personal protective equipment (PPE) cart available outside the room. Staff entered the room without donning PPE, and it was later confirmed that the PPE cart and sign had been removed in error, leading to a lapse in following isolation protocols. Shared equipment, specifically mechanical lift devices, was observed to be soiled with dust, debris, and dried liquids. These devices were not cleaned between resident uses, as confirmed by a Certified Nursing Assistant (CNA) who was unsure of the cleaning protocol and reported a lack of available sanitizing wipes. The Infection Preventionist emphasized the importance of sanitizing shared equipment to prevent cross-contamination, but the facility failed to ensure this practice was followed. The facility also failed to ensure proper use of PPE for residents under observation for COVID-19 exposure. Staff members, including a Licensed Practical Nurse (LPN) and an Activity Aide, entered rooms without the required PPE, such as N95 masks, gowns, gloves, and face shields. Additionally, several staff members were observed wearing surgical masks improperly, with their noses exposed, despite the facility's requirement for proper mask usage in hallways and common areas. These lapses in PPE usage and adherence to isolation protocols increased the risk of infection spread within the facility.
Inadequate Time for Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was working at least part-time and was provided sufficient time to fulfill the responsibilities of the Infection Prevention and Control Program. The facility's policy, dated March 2020, mandates a systematic approach to infection control, guided by OSHA and other regulations. However, the IP, identified as IP J, reported being behind on several critical tasks, including offering COVID-19 vaccinations to residents, tracking antibiotic use, and completing staff fit testing for respirators. At the time of the report, 10 residents were eligible and had consented to receive the COVID-19 vaccination, but the vaccinations had not been administered due to the IP's time constraints. This was particularly concerning as the facility was experiencing a COVID-19 outbreak. IP J indicated that her role was initially intended to be solely dedicated to infection prevention, but she was later assigned additional duties based on the facility's census. This included working as a floor nurse nine times in recent weeks and being on-call multiple times per week, which interfered with her ability to manage her infection prevention responsibilities effectively. The Nursing Home Administrator confirmed that IP J had been working as a floor nurse and acknowledged that some requirements of the Infection Control program were not in compliance, as IP J was unable to complete all her responsibilities as the Infection Preventionist.
Failure to Offer COVID-19 Vaccinations to Eligible Residents
Penalty
Summary
The facility failed to ensure COVID-19 immunizations were offered to 10 residents who were eligible and had consented to receive the vaccine. The Infection Preventionist (IP) reported being behind on responsibilities, including offering COVID-19 vaccinations. Although a round of vaccinations was offered in October 2024, there was no follow-up for residents who could not receive the vaccine at that time or who were admitted afterward. The IP confirmed that approximately 10 residents were eligible and had consented to receive the vaccination, but the necessary steps to provide the vaccinations had not been completed. The delay in providing vaccinations was attributed to the IP's misunderstanding that a minimum of 10 doses had to be ordered at a time, which was later contradicted by the Pharmacy Representative, who stated there was no minimum order requirement. The facility did not have any COVID-19 vaccinations available onsite, and the IP confirmed that no vaccinations had been provided to residents in a few months, despite the facility experiencing a COVID-19 outbreak. This inaction resulted in an increased risk of infection and potential spread of COVID-19 to other residents, staff, and visitors.
Failure to Prevent Resident Elopement Due to Policy Non-Compliance
Penalty
Summary
The facility failed to prevent the elopement of Resident #238, who was identified as a high risk to wander. Despite having a wander guard device, Resident #238 managed to exit the facility through a staff exit door and was found 30 feet away in the courtyard by a CNA returning from break. The incident report indicated that the resident was outside in her wheelchair and had exited the building following a staff member who was going on break. The deficiency occurred because CNA LL, who was at the nurses' station near the exit door, heard the alarm but assumed it was triggered by a staff member leaving for a break. CNA LL turned off the alarm without checking if a resident had exited, which was against the facility's elopement policy. The policy required staff to visually check the exit area and ensure no residents had left before resetting the alarm. Interviews with staff confirmed that the alarm was turned off without proper verification, and the facility's elopement policy was not followed. The Nursing Home Administrator identified the root cause as the failure of CNA LL to adhere to the policy, which led to Resident #238's elopement. The facility's policy clearly outlined the steps to be taken when an alarm is triggered, including checking the exit and conducting a resident count if necessary.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) and Notice of Medicare Non-Coverage (NOMNC) to two residents, identified as Resident #26 and Resident #291, who were reviewed for proper notification related to Medicare A insurance coverage. Resident #26 had diagnoses including chronic combined systolic and diastolic heart failure, anxiety disorder, and dementia, while Resident #291 had spinal stenosis of the cervical region with surgical aftercare. During the survey, it was revealed that these residents did not receive the necessary forms indicating the end of their Medicare A coverage upon discharge. Interviews conducted during the survey revealed that the responsibility for providing these forms was assigned to the admission coordinator, a position that was currently unfilled. Financial Services personnel and the Nursing Home Administrator acknowledged the oversight, with the latter confirming the absence of the SNF-ABN and NOMNC forms for the two residents. An Administrative Assistant, who temporarily filled the admission coordinator role, was unaware of the requirement to provide NOMNC forms for planned discharges, further contributing to the deficiency.
Inadequate Activity Engagement for Resident in Vegetative State
Penalty
Summary
The facility failed to provide consistent, meaningful, and person-centered activities for Resident #29, who was in a persistent vegetative state. Despite being dependent on staff for all activities, Resident #29's care plan included interventions such as music, manicures, and reading, but these were not consistently provided. Observations over several days showed that Resident #29 was often left lying in bed awake without any music or television playing, and there was a lack of interaction from activity or facility staff. Interviews with various staff members, including LPNs, CNAs, and the Activities Director, revealed a lack of clarity and consistency in providing activities for Resident #29. Staff reported that Resident #29 was mostly bed-bound and only got up for showers or during the summer for activities. There was no clear reason provided for why Resident #29 was not more frequently engaged in activities or why she was not regularly placed in her geri chair, despite therapy staff indicating it was appropriate for her. Family members were not contacted to determine specific activity preferences for Resident #29, and there was a disconnect between the activities provided and those that would be meaningful to her. The Activities Director acknowledged the benefits of activities for residents with cognitive deficits but admitted that the expectations for 1:1 visits were not always met. The lack of consistent engagement and personalized activities for Resident #29 resulted in a deficiency in meeting her needs for interaction and stimulation.
Medical Director's Absence from QAA Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director attended the Quality Assessment and Assurance (QAA) meetings at least quarterly, as required by their Quality Assurance Performance Improvement Program policy. The policy, last revised in January 2015, mandates that the Medical Director be actively engaged in the QAA process, which includes attending meetings to identify opportunities for improvement and address gaps in systems or processes. However, the Medical Director did not attend the QAA meetings for several months, specifically in April, May, June, August, and September 2024, resulting in a failure to meet the quarterly attendance requirement. During an interview, the Nursing Home Administrator (NHA) acknowledged the absence of the Medical Director from these meetings and confirmed awareness of the requirement for quarterly attendance. Despite attempts to secure the former Medical Director's participation, the facility did not achieve compliance during the specified months, leading to the potential for the Medical Director to be uninformed about quality deficiencies within the facility.
Delayed Response to Resident's Change in Condition
Penalty
Summary
The facility failed to ensure a timely assessment and response to a change in condition for a resident, leading to a delay in communication with a provider, transfer to an acute care setting, and treatment. The resident had diagnoses including rhabdomyolysis, gait abnormalities, and acidosis. Despite being cognitively intact, the resident experienced a significant decline in health, with symptoms such as a swollen, red, and warm left arm, dizziness, and low blood pressure. These symptoms were documented by a contract nurse, who attempted to contact a doctor but was unable to reach them, leaving a voicemail and noting the issue in the doctor's book. The situation escalated as the resident's condition worsened, with additional symptoms of pallor, diarrhea, and further swelling and warmth in the left arm. Despite repeated low blood pressure readings, the resident was not transferred to the hospital until much later. Interviews with various staff members, including a nurse practitioner, registered nurse, and infection preventionist, revealed that the facility's protocol required immediate action in such situations, including contacting the on-call provider or nurse practitioner directly if the initial contact was unsuccessful. However, these protocols were not followed, resulting in a significant delay in the resident's transfer to the hospital. The resident was eventually sent to the hospital, where they were diagnosed with septic shock, cellulitis, and a urinary tract infection, among other conditions. The delay in treatment contributed to the resident's critical condition upon arrival at the hospital, where they later died. Interviews with staff highlighted a lack of adherence to established procedures for handling urgent medical situations, including the failure to persistently contact medical providers and escalate the situation to management when necessary.
Failure to Prevent Worsening of Pressure Ulcer
Penalty
Summary
The facility failed to prevent the worsening of a pressure ulcer in a resident, leading to the resident being sent to the hospital for evaluation and treatment. The resident had a stage 4 pressure ulcer on the sacral region, osteomyelitis, and functional quadriplegia, making them dependent on staff for care. Despite having a wound vac applied as per hospital orders, the wound measurements indicated deterioration over time, with new areas of concern developing. The resident also exhibited symptoms such as nausea, fever, chills, and sweats, raising concerns about potential sepsis. Interviews with facility staff revealed that the resident did not like to be repositioned due to pain, which contributed to the worsening of the wound. Staff members, including a CNA, LPN, and NP, acknowledged that the wound vac was not effective and that the resident's refusal to be repositioned was not adequately documented. The Clinical Care Coordinator confirmed that the resident's wound deteriorated and that the resident was not repositioned as frequently as necessary. The care plan for the resident lacked specific interventions related to turning schedules, repositioning, wound vac use, and the resident's preferences or refusals regarding mobility. Despite staff awareness of the resident's refusal to be repositioned, there was no documentation to support this in the medical chart. The Nursing Home Administrator and Clinical Care Coordinator were unable to provide documentation of the resident's refusal to be repositioned, highlighting a deficiency in the facility's care planning and documentation processes.
Failure to Develop Comprehensive Care Plan for Pressure Ulcer Management
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with a stage 4 pressure ulcer, osteomyelitis, and functional quadriplegia. Despite the resident being cognitively intact, the care plan lacked specific interventions for turning and repositioning, wound vacuum use, and consideration of the resident's preferences regarding mobility and positioning. The absence of these interventions contributed to the worsening of the existing pressure ulcer and the development of additional pressure wounds. Interviews with facility staff revealed that the resident preferred to remain on her back and resisted repositioning, yet there was no documentation of these preferences or any education provided to the resident about the benefits of repositioning. The care plan did not reflect the resident's refusal to be repositioned or the use of a wound vacuum, and staff were unable to provide documentation of any resident-specific interventions or preferences related to positioning and wound care.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices during a wound care dressing change for a resident with a stage 4 pressure ulcer in the sacral region, osteomyelitis, and muscle weakness. The resident was cognitively intact, as indicated by a BIMS score of 15/15. During the dressing change, the LPN used improper techniques, such as spraying wound wash directly into the wound and placing the bottle back into the clean supply area, handling the Dakins solution with gloved hands instead of using a medication cup, and using scissors from her pocket without cleaning them first. The Infection Preventionist present during the procedure did not intervene when the LPN placed the Dakins solution back into the clean supply field. The LPN admitted to not knowing the correct procedure for using wound wash and acknowledged the mistake of using unclean scissors from her pocket. The Infection Preventionist confirmed that the LPN should have used medication cups for the solutions and should not have used the scissors without cleaning them first and performing hand hygiene.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 536 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Niles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Healthwin Health & Rehabilitation | 2.3 mi | ★★★★★ | 34 | 0 |
| Majestic Care Of South Bend | 2.7 mi | ★★★★★ | 56 | 0 |
| Wellbrooke Of South Bend | 3.5 mi | ★★★★★ | 19 | 0 |
| Holy Cross Rehabilitation And Wellness | 4 mi | ★★★★★ | 5 | 0 |
| Niles Care Center, Llc | 4 mi | ★★★★★ | 33 | 2 |
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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.