Cycle 1
Health 2024-12-05 · Fire 2024-12-05
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Niles, MI
Niles Care Center, LLC
2-star overall rating with 1-star inspections with Special Focus status with $82,810 in total fines with 16 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
911 S 3rd St, Niles, MI
(269) 684-4320
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
50
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avon Healthcare
Operator or chain grouping
Approved since
1978-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing
LPN hours / resident day
0.92
Licensed practical nurse staffing
Aide hours / resident day
2.00
Nurse aide staffing
Weekend hours
3.00
Weekend nurse staffing
RN turnover
100%
Annual RN turnover
Total nurse turnover
100%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
95.0%
0.9 pts better
|
93.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.6% |
95.0%
0.6 pts better
|
95.5%
0.1 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.1%
2.8 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
4.1%
1.1 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.3% |
5.5%
1.8 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.0% |
19.6%
1.4 pts worse
|
19.6%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 19.6% |
16.5%
3.1 pts worse
|
16.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.0% |
13.9%
5.9 pts better
|
16.3%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.2% |
11.7%
0.5 pts worse
|
14.9%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.6% |
20.4%
4.2 pts worse
|
19.8%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
5.6%
3.5 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.2% |
82.8%
6.4 pts better
|
81.7%
7.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
11.5%
11.5 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.3%
1.9 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.0% |
79.5%
0.5 pts better
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
24.2%
1.5 pts worse
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-25 · Fire 2023-10-25
13 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-12-20 · Fire 2022-12-20
23 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-05
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-12-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-12-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-12-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-12-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-12-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-12-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-12-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-12-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-31
E · Potential for more than minimal harm
2024-10-24
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2024-11-13
E · Potential for more than minimal harm
2024-10-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-13
F · Potential for more than minimal harm
2023-10-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-23
E · Potential for more than minimal harm
2023-10-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-11-23
E · Potential for more than minimal harm
2023-10-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-23
F · Potential for more than minimal harm
2022-12-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-12-20
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-12-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-10
F · Potential for more than minimal harm
2022-12-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-12-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-12-20
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-12-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-12-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-12-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-12-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-12-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-23
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2026-02-23
G · Actual harm
2025-12-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-12-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-22
J · Immediate jeopardy
2025-08-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-21
J · Immediate jeopardy
2025-08-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-21
F · Potential for more than minimal harm
2024-12-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-03
F · Potential for more than minimal harm
2024-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-03
F · Potential for more than minimal harm
2024-12-05
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-12-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-01-06
E · Potential for more than minimal harm
2024-12-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-03
E · Potential for more than minimal harm
2024-12-05
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-12-05
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-03
D · Potential for more than minimal harm
2024-12-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-12-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-12-05
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-12-05
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-02-12
E · Potential for more than minimal harm
2024-10-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-12
D · Potential for more than minimal harm
2024-10-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-12
D · Potential for more than minimal harm
2024-10-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-12
D · Potential for more than minimal harm
2024-07-03
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-07-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-06
D · Potential for more than minimal harm
2024-06-20
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-07-16
D · Potential for more than minimal harm
2024-06-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-16
F · Potential for more than minimal harm
2023-10-25
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-10-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-10
F · Potential for more than minimal harm
2023-10-25
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-11-10
E · Potential for more than minimal harm
2023-10-25
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-25
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-10
G · Actual harm
2023-10-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-24
G · Actual harm
2023-10-04
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-24
J · Immediate jeopardy
2022-12-20
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-01-23
G · Actual harm
2022-12-20
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-12-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-03-10
F · Potential for more than minimal harm
2022-12-20
F945 · Infection Control Deficiencies
Health
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-12-20
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-03-10
E · Potential for more than minimal harm
2022-12-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-12-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-10
E · Potential for more than minimal harm
2022-12-20
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-12-20
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-03-10
D · Potential for more than minimal harm
2022-12-20
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-20
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-20
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-20
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-10
D · Potential for more than minimal harm
2022-12-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-10
D · Potential for more than minimal harm
2022-12-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-12-20
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-01-23
Penalties and ownership
What sits behind the stars
$0
2024-12-05
Payment Denial
Payment Denial · denial start 2025-01-11 · 51 days
51 day denial
$82,810
2023-10-04
Fine
Fine · fine $82,810
Fine
$0
2023-10-04
Payment Denial
Payment Denial · denial start 2023-10-26 · 28 days
28 day denial
Ownership
Freund, Eliyahu
5% Or Greater Direct Ownership Interest · Individual
Gottlieb, Moshe
5% Or Greater Direct Ownership Interest · Individual
Cain, Cynthia
Operational/Managerial Control · Individual
Niles Avon Management
Operational/Managerial Control · Organization
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