Niles Care Center, Llc

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

was initiated for Licensed Nurses, CENAs, Dietary and Housekeeping, Activities, Maintenance and Administrative staff members. Education will be completed by the DON or a designated nurse manager and included the following topics: Change of Condition, Life Threatening Change, Change of ConditionMonitoring, Change of Condition- Reporting, Alert Charting Process, Stop and Watch, Facility Call List, Rounding- beginning of shift and periodically throughout the shift, DNR/Advance Directives [DATE REDACTED]. (As of [DATE REDACTED] 6 out of 15 Licensed Nurses have been educated. Any staff member who has not received the education, will receive before the start of their next shift. They will not be allowed to work until education has been completed), EMS/Hospital Transfer (As of [DATE REDACTED] at 430PM, 27 out of 71 staff members have received the education. Any staff member who has not received the education, will receive before the start of their next shift. They will not be allowed to work until education has been completed.)Medical Director was notified of these findings on [DATE REDACTED].

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Niles Care Center, LLC

911 S 3rd St Niles, MI 49120

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

interview on 8/20/25 at 12:21 PM, DON B and Corporate Nurse Consultant (CNC) U reported that the wanderguard intervention was on Resident #104's current care plan and they did not see what the concern was. This surveyor reviewed a copy of Resident #104's care plan that revealed, DON B had created a new intervention on 8/20/25 that indicated, Check Wander guard for placement q shift and function per policy.

CNC U acknowledged the discrepancy/error and reported that the intervention for Resident #104's wanderguard alert bracelet had accidentally been removed from his care plan on 8/16/25 and had been recreated on 8/20/25 to reflect the resident's current status. The Immediate Jeopardy that began on 8/15/25 was removed on 8/20/25 when the facility took the following actions to remove the immediacy.1. Resident #104:8/15/2025 Resident returned to the facility.8/15/2025 Skin assessment completed and no injuries noted.8/15/2025 Neuro check completed and resident remains at baseline.8/15/2025 Wander Risk Scale UDA completed.8/20/2025 Resident #104's Care plan reviewed and updated.8/15/2025 Physician notified of event and order for one on one supervision. 8/15/2025 D.O.N and Administrator were notified.8/15/2025 Attempted to notify emergency contact #1 and #2, message was left 8/15/2025 All doors/alarms were checked to ensure they are properly secured and functioning. It was determined all doors were properly secured and functioning at that time.8/16/2025 Facility has contacted Securitas to come out and service wanderguard system.8/18/2025 Facility will have a staff member at the nursing station monitoring the facility doors that go outside during non-business hours to ensure any resident at risk for wandering with a wanderguard in place do not exit the doors to the outside. During business hours the receptionist will monitor doors. This will be in place until the wanderguard system is serviced.8/19/2025 service was completed- it determined all doors were properly secured and were functioning and in working order. The front door needed the sensitivity increased, which was completed by the technician during his visit.8/16/2025 Signage was placed at door for family and visitors to stop at nursing station for assistance.2.

On 8/15/2025 the facility completed a head count of residents to ensure no other residents were affected. 52 out of 52 residents were accounted for.3. 8/16/2025 All residents were reviewed to ensure a wander assessment was completed in the last 90 days and residents at risk for wander/elopement were reviewed to ensure resident safety and proper plan of care in place.4. On 8/15/2025, education was initiated for All Staff which includes Licensed Nurses, CENAs, Dietary, Housekeeping, Activities, Maintenance and Administrative staff members.a. Education will be completed by the DON or a designated nurse manager and included the following topics: 1. Elopement Policy and Procedures, Door Alarm and Wanderguard Alarm. 2. Verbal education provided on redirecting residents with exit seeking behaviors. 8/19/2025 facility added additional education on exit seeking behaviors- redirection includes offering snacks, walking with resident, calling family, seeing if personal needs are met (i.e. need to use bathroom, ensuring they are not too warm or cold, tired, looking for their room etc.), place on 15 minute supervision to keep in line of sight.b.

As of 8/19/2025 at 1000AM, 47 out of 62 staff members have received the education.Any staff member who has not received the education, will receive before the start of their next shift. They will not be allowed to work until education has been completed.5. Medical Director was notified of these findings on 8/15/2025.6. 8/18/2025 QAA Committee has reviewed the plan and will continue to review the audits to ensure adherence to scope of practice, specifically elopement policy and procedures.7. On 8/20/2025 Errors were identified for resident 104, therefore, all residents at risk for elopement had care plans reviewed and updated.

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