Niles NSG & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Niles NSG & Rehab CTR, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 21, 2025

  Based on interview and record review, the facility failed to assess side effects and adjust medication for one resident (R2) out of three residents reviewed for medication adjustment based on blood level result. This failure resulted to R2 being hospitalized on [DATE] with diagnosis of altered mental status and lithium toxicity. Findings include: On 3/19/2025 at 1:34, V12 (Registered Nurse-RN) said V12 was the nurse for R2 on 2/28/2025. V12 said that she received the lithium blood test result of 1.53 mEq/L (milliequivalent/Liter). V12 said that the normal range of lithium blood level is between 0.6 - 1.20 mEq/L. V12 said lithium level of 1.53 is high. V12 said that V12 notified the V15 (Medical Nurse Practitioner/NP) that was making rounds on the residents. […]

• Actual harm, isolatedF684Feb 24, 2022

  Based on interview and record review the facility failed to follow their change in condition policy by not calling 911 for a resident with acute change in condition unstable vital signs. This failure affected 1 resident (R1) of 3 residents reviewed for change in condition. This failure resulted in a delay in receiving hospital treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: On 2-22-22, at 1:15 PM, concerned party said he believes the facility should have called 911 for emergent transfer rather than calling ambulance for ETA transfer of 40 minutes. On 2-22-22 at 12:16 PM, V2 (DON) said primary nurse was aware of 2 episodes of loose bowel movements, B/P (blood pressure) was 89/57 (lower than base line) and HR was 110 (greater than baseline). […]

• Actual harm, isolatedF689Feb 6, 2022

  Based on interview and record review the facility failed to follow the plan of care intervention of utilizing 2 person assist for bed mobility while repositioning 1 of 3 (R1) residents reviewed for staff assisted bed mobility. This failure resulted in R1 sustaining a commuted fracture of the 4th left finger and required treatment at the local hospital. Findings Include: R1 face sheet shows R1 has diagnosis of [CONDITION(S)], muscle wasting and atrophy right upper arm, [CONDITION(S)] and [CONDITION(S)] following unspecified [CONDITION(S)] disease affecting unspecified side, need for assistance for personal care, lack of coordination, weakness, intellectual disabilities. […]

• Actual harm, isolatedF600Jul 15, 2021

  Based on observation, interviews and record reviews, the facility failed to keep a resident free from experiencing verbal aggression from staff (V3, certified nursing assistance). This applies to one of one resident (R3) observed receiving verbal aggression by staff. As a result, R3 expressed being not safe in the facility, feeling intimidated and threatened. Findings Include: R3 is a [AGE] year old male with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/12/2021 at 2:00pm, surveyor observed R3 had his call light on. Surveyor and V5 RN (Registered Nurse) entered into R3's room. R3 stated he had his light on because he wanted a shower. […]

• No harm, potential for more than minimal, patternF585Nov 16, 2023

  Based on observation, interview, and record review the facility failed to follow their policy and procedures for making efforts to ensure resident's grievances regarding late mealtimes were resolved promptly and to the resident's satisfaction. This failure affects three of three residents (R80, R165 and R22). This failure has the potential to affect all 283 residents in the facility who receive meals. Findings include: Per facility census provided during the course of this survey, there are currently 283 residents in the facility. The Facility's Meal Schedule documents lunch times for 4th and 5th floors are from 12:10 PM - 12:30 PM. On 11/13/23 from 12:30 PM - 1:29 PM Observed several residents waiting in the 4th floor dining area for lunch to be served. […]