Niles Care Center, LLC

Inspectors wroteBased on interview and record review the facility failed to ensure a safe transfer of a resident in 1 (Resident #103) of 3 residents reviewed for falls resulting in a fall by Resident #103.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate medical records for 2 (Resident #100 and #101) of 3 residents reviewed for accurate medical records, resulting in an inaccurate reflection of the residents' medication administrations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the published menu was served as planned and residents were consistently informed in advance of any menu changes affecting all residents consuming food from the kitchen resulting in resident dissatisfaction with their meal experience and feelings of frustration related to meals.

Inspectors wroteBased on interview and record review the facility failed to honor resident food choice preferences in 1 resident (Resident #37) of 3 residents reviewed for food preferences and didn't have enough food supply according to 2 residents (Resident #16, Resident #19) resulting in the increased likelihood for decreased food acceptance and frustration in not getting what they wanted to eat.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Quality Assessment and Process Improvement (QAPI) meetings had the Medical Director (MD) and the Infection Preventionist (IP) as mandatory attendees at least quarterly resulting in the potential for the MD and the IP to not be notified of quality deficiencies occurring in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the necessary infection control measures for residents at risk based on physician orders and standards of infection control for 4 residents (Resident #63, #55, #15 and #13) of 7 residents reviewed for infection control practices, resulting in the potential for transmission of MDRO (multidrug-resistant organisms) and an increased risk of infections to a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to promote dignity for 1(Resident #13) of 1 resident reviewed for dignity resulting in a potential for feelings of decreased self-worth and embarrassment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a transfer/discharge notice for 1 resident (Resident #49) of 2 residents reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the reason for transfer.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan that reflected the minimum healthcare information necessary to properly care for a resident based on admission orders and physician orders including, indwelling foley catheter (tube inserted into the bladder to drain urine) and cardiac pacemaker (mechanical device implanted under the skin that regulates heart rate) for 1 resident (Resident #63) of 1 resident reviewed for baseline care planning, resulting in the potential for unmet care needs and residents not maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards of care and provide adequate incontinence care in 1 resident (Resident #55) of 1 resident, reviewed for bowel and bladder incontinence, resulting in an increased risk for UTI (urinary tract infection) and the potential for skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records for 1 resident (Resident #55) of 14 residents reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents.

Inspectors wroteThis citation pertains to Intake #2682078. Based on observation, interview, and record review, the facility failed to ensure that 1 resident (Resident #3) received physician ordered pain medication for effective pain management in 1 of 3 residents reviewed for medication management resulting in uncontrolled pain for 11 days and unmet needs.

Inspectors wroteThis citation pertains to Intake #2682078. Based on observation, interview, and record review, the facility failed to follow professional standards of practice by following up on physician ordered medication that wasn't available in 1 resident (Resident #3) of 3 residents reviewed for medication management, resulting in physician ordered pain medication not being administered and resident having uncontrolled pain and unmet needs.

Inspectors wroteThis citation pertains to intake #2588471 and #2594155. Based on interview and record review, the facility failed to ensure residents received care in accordance with professional standards and advance directives were honored in 1 resident (Resident #101) of 4 residents reviewed for quality of care, resulting in an immediate jeopardy when, beginning on [DATE] at approximately 3:00 PM the resident had a serious acute change of condition (shortness of breath) and staff failed to assess, monitor and act promptly by notifying emergency services, resulting in death from cardiac arrest. This deficient practice placed all residents at risk for serious harm, injury and/or death.

Inspectors wroteThis pertains to intake #2592743. Based on observation, interview and record review the facility failed to prevent an elopement and ensure safety in 1 resident (Resident #104) of 4 residents reviewed for safety/supervision, resulting in an Immediate Jeopardy when on 8/15/25 at approximately 7:00 P.M., Resident #104 (who was a known elopement risk) exited the facility unbeknownst to facility staff through an emergency exit door and was discovered outside by another resident and EMS (emergency medical services) who notified facility staff. Resident #104 was approximately 350 feet from the facility driveway walking alongside the main road, when he was first attended by facility staff at approximately 7:15 PM. This deficient practice placed 6 residents, identified as at risk for elopement, at risk for serious harm, injury, and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. implement infection control practices during resident care for 5 (Resident #2, #4, #12, #11, and #299) of 12 residents reviewed for infection control, 2. maintain an ongoing infection control surveillance program, and 3. have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the increased risk of transmission of pathogenic organisms and cross contamination between residents.

Inspectors wroteBased on interview, and record review, the facility failed to maintain staff documentation of COVID-19 screening, education, offering and current COVID-19 vaccination status of one of one staff reviewed, resulting in increased risk for COVID-19 infections. This deficient practice has the potential to impact all residents within the facility.

Inspectors wroteBased on observation and interview the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting all residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a medication error rate less than 5% (total error rate of 20%) in 4 residents (Resident #15, Resident #25, Resident #30, Resident #43) of 9 residents reviewed for medication administration resulting in improper injection location, late oral medication administration, missed dose of medication, and the potential for reduced medication effectiveness.

Inspectors wroteBased on observations, and interviews, the facility failed to maintain an effective pest control program resulting in presence of live pests (ants), resulting in the potential for food infestation and resident discomfort.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper assessment for self-administration of medication was completed for 1 (Resident #300) of 1 resident reviewed for self-administration of medications resulting in the potential for a resident to not receive medications as ordered.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure professional standards of nursing were maintained during administration of an enteral feeding (also known as a tube feeding- the delivery of nutrients through a feeding tube directly into the stomach) for 1 (Resident #4) of 1 resident reviewed for professional nursing standards, resulting in an inaccurate administration of daily nutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assistance with activities of daily living (ADL) were provided for 3 residents (Residents #46, Residents #27, Resident #38) of 4 residents reviewed for ADL care potentially resulting in dissatisfaction with care and hygiene concerns.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that enteral feeding (also known as a tube feeding- the delivery of nutrients through a feeding tube directly into the stomach) was administered as ordered to 1 (Resident #4) of 1 resident reviewed for enteral feeding, resulting in the potential for weight loss, dehydration, and/or an overall deterioration of wellbeing.

Inspectors wroteBased on interview and record review the facility failed to ensure that gradual dose reductions (GDRs) for the ongoing use of psychotropic medications were completed for 1 (Resident #12) of 5 residents reviewed for unnecessary medications.

Inspectors wroteThis citation pertains to Intake: MI00147456 & MI00146518 Based on observation, interview and record review the facility failed to: 1. minimize the risk of scalding and burns by allowing hot water to exceed 120 degrees F (degrees Fahrenheit) and not monitoring hot water temperatures consistently resulting in an increased risk of injury among residents who reside in the facility, and 2. prevent an elopement for 1 resident (Resident #101) of 5 residents reviewed for elopement, resulting in Resident #101 exiting from the facility without staff knowledge and the potential for injury.

Inspectors wroteThis citation pertains to Intake Number MI00147372 Based on interview and record review, the facility failed to prevent resident to resident abuse in 1 of 5 residents (Resident #104) reviewed for abuse, resulting in Resident #104 experiencing physical abuse from Resident #103.

Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one resident (Resident #102) of five residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan related to skin integrity for one resident (Resident #1) of three residents reviewed for admission, transfer, and discharges resulting in ineffective skin care to be provided to the resident.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough assessment upon admission, follow-up on a skin concern and communicate findings to Hospice for one resident (Resident #1) of three residents reviewed for admission, transfer, and discharges, resulting in a rash under the breast not being treated for 4 days, worsening to occur and a lapse in the continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and resolve grievances for one (resident #1) of three residents reviewed for grievance resolution, resulting in unresolved concerns and unmet needs.

Inspectors wroteBased on interview and record review, staff failed to report an allegation timely to the Nursing Home Administrator and as a result to the State Agency, to law enforcement, and failed to report a concern/allegation to the State Agency for one resident (Resident #1) of three residents reviewed for abuse resulting in delayed reporting, an incomplete investigation and the resident not being protected from abusive individuals.

Inspectors wroteBased on interview and record review, the facility failed to assure that a Registered Nurse was on duty for eight consecutive hours a day seven days a week resulting in the potential for inadequate coordination of emergent or routine care with negative clinical outcomes affecting all 38 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively clean and maintain the food production kitchen physical plant effecting 38 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively clean and maintain the physical plant effecting 38 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively maintain domestic hot water temperatures between 105 - 120 degrees Fahrenheit in 9 (207, 209, 211, 212, 215, 216, 303, 304, 307) of 12 sampled resident restrooms effecting 38 residents, resulting in the increased likelihood for resident discomfort and/or personal injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adaptive dining equipment was provided per physician order in 1 (Resident #30) of 1 sampled resident reviewed for nutrition, resulting in the potential for difficulty with self-feeding and continued weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of infection control practices related to ensuring resident shared equipment was sanitized between uses, resulting in the potential for the transmission/transfer of pathogenic organisms and cross contamination for vulnerable residents.

Inspectors wroteThis citation pertains to intake # MI00139483 Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance during cares for 1 (Resident #100) of 3 reviewed for falls, from a total sample of 5, resulting in Resident #100 sustaining a fall, fractured femur, decreased functional abilities, increased pain, and emotional distress.

Inspectors wroteThis citation pertains to intake: MI00134983, MI00138043 Based on interview, observation, and record review, the facility failed to ensure adequate staff to meet resident needs for 4 (Resident #100, Resident #102, Resident #101, Resident #103) of 5 residents reviewed for staffing, resulting in residents being transferred unsafely, residents receiving personal care unsafely, missed showers and lack of nail care.