Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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 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.
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 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.
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.
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We read the 318 citations issued within 25 miles in the last 12 months — including the 3 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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 | — | 0 | 0 |
| Majestic Care Of South Bend | 2.7 mi | — | 26 | 0 |
| Wellbrooke Of South Bend | 3.5 mi | — | 19 | 0 |
| Holy Cross Rehabilitation And Wellness | 4 mi | — | 3 | 0 |
| Niles Care Center, Llc | 4 mi | — | 31 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.