Cycle 1
Health 2025-01-09 · Fire 2025-01-09
9 health deficiencies
Top issue: Infection Control (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Niles, MI
West Woods of Niles
3-star overall rating with 3-star inspections with $16,800 in total fines with 9 recent health deficiencies
1211 State Line Rd, Niles, MI
(269) 684-2810
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
121
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Peplinski Group
Operator or chain grouping
Approved since
2000-07-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.55
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,398
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.14
Composite VBP score used to determine payment impact.
Payment multiplier
0.9931
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.01
Baseline 17.41% · Performance 19.57% · Measure score 4.01 · Achievement 4.01 · Improvement 0
Healthcare-associated infections
4.22
Baseline 6.01% · Performance 6.57% · Measure score 4.22 · Achievement 4.22 · Improvement 0
Total nurse turnover
5.03
Baseline 48.72% · Performance 43.14% · Measure score 5.03 · Achievement 5.03 · Improvement 1.84
Adjusted total nurse staffing
2.80
Baseline 3.53 hours · Performance 3.87 hours · Measure score 2.80 · Achievement 2.80 · Improvement 1.01
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.75% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 110 · Observed rate 10.91% · Lower 95% interval 7.54% |
| Discharge to community | 46.76% |
50.57%
3.8 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 42.11% · Lower 95% interval 36.21% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.61% |
95.27%
3.3 pts better
|
Numerator 71 · Denominator 72 |
| Falls with major injury | 1.39% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 72 |
| Discharge self-care score | 67.27% |
53.69%
13.6 pts better
|
Numerator 37 · Denominator 55 |
| Discharge mobility score | 56.36% |
50.94%
5.4 pts better
|
Numerator 31 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 8.33% |
2.29%
6 pts worse
|
Numerator 6 · Denominator 72 · Adjusted rate 7.05% |
| Healthcare-associated infections requiring hospitalization | 6.57% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 5.33% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 126 |
| Staff flu vaccination coverage | 31.15% |
42%
10.9 pts worse
|
Numerator 38 · Denominator 122 |
| Discharge function score | 67.27% |
56.45%
10.8 pts better
|
Numerator 37 · Denominator 55 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 24 · Denominator 24 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 28.21% |
25.2%
3 pts better
|
Numerator 11 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 2.1 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.5
0.8 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.0%
5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
3.1%
2.5 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
4.1%
3.7 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 16.9% |
5.5%
11.4 pts worse
|
5.4%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 20.6% · Q3 20.3% · Q4 13.4% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
19.6%
10 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 11.4% · Q3 6.6% · Q4 10.7% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
16.5%
3 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 12.3% · Q3 15.0% · Q4 15.9% · 4Q avg 13.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.8% |
13.9%
13.9 pts worse
|
16.3%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.6% |
11.7%
4.9 pts worse
|
14.9%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 10.3% · Q3 23.9% · Q4 8.6% · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.9%
0.8 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.3% · Q3 2.5% · Q4 1.5% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
1.7%
1.5 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 9.3% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.3% |
20.4%
8.9 pts worse
|
19.8%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 32.0% · Q3 33.8% · Q4 25.7% · 4Q avg 29.3% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
5.6%
1.4 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 7.1% · Q3 10.5% · Q4 7.9% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
82.8%
10 pts better
|
81.7%
11.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.4% · Q2 89.6% · Q3 92.3% · Q4 94.6% · 4Q avg 92.8% |
| 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 · Adjusted 0.0% · Observed 0.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.3%
0.3 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.3% · Q3 3.5% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.5% |
79.5%
11 pts better
|
79.7%
10.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
24.2%
1 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 23.3% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-29 · Fire 2023-11-29
13 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-17 · Fire 2022-11-17
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-12-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-16
G · Actual harm
2025-11-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-04
F · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-12
E · Potential for more than minimal harm
2025-01-09
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-02-12
E · Potential for more than minimal harm
2025-01-09
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 2025-02-12
D · Potential for more than minimal harm
2025-01-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-02-12
D · Potential for more than minimal harm
2025-01-09
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 2024-10-10
D · Potential for more than minimal harm
2025-01-09
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-10-08
G · Actual harm
2024-07-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-26
G · Actual harm
2024-07-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-07-03
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-07-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-26
G · Actual harm
2024-03-14
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 2024-04-10
D · Potential for more than minimal harm
2024-03-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-10
D · Potential for more than minimal harm
2024-02-01
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 2023-12-21
D · Potential for more than minimal harm
2023-11-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-29
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 2023-12-22
D · Potential for more than minimal harm
2023-11-29
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 2023-12-22
D · Potential for more than minimal harm
2023-11-29
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 2023-12-22
D · Potential for more than minimal harm
2023-11-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-22
D · Potential for more than minimal harm
2023-11-29
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 2023-12-22
D · Potential for more than minimal harm
2022-11-17
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 2022-12-20
D · Potential for more than minimal harm
2022-11-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-12-20
D · Potential for more than minimal harm
2022-11-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-20
D · Potential for more than minimal harm
2022-11-17
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-12-20
D · Potential for more than minimal harm
2022-11-17
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 2022-12-20
Penalties and ownership
What sits behind the stars
$8,400
2024-07-03
Fine
Fine · fine $8,400
Fine
$8,400
2024-07-03
Fine
Fine · fine $8,400
Fine
Ownership
Peplinksi Holdings, Inc.
5% Or Greater Direct Ownership Interest · Organization
Ackerman, Amy
5% Or Greater Indirect Ownership Interest · Individual
Ackerman, Ricky
5% Or Greater Indirect Ownership Interest · Individual
Baumgarten, Michael
5% Or Greater Indirect Ownership Interest · Individual
Baumgarten, Therese
5% Or Greater Indirect Ownership Interest · Individual
Peplinski, Sheli
5% Or Greater Indirect Ownership Interest · Individual
Peplinski, Todd
5% Or Greater Indirect Ownership Interest · Individual
Schade, Jeffery
5% Or Greater Indirect Ownership Interest · Individual
Schade, Tamara
5% Or Greater Indirect Ownership Interest · Individual
Thompson, Brian
5% Or Greater Indirect Ownership Interest · Individual
Thompson, Shelly
5% Or Greater Indirect Ownership Interest · Individual
Ackerman, Ricky
Operational/Managerial Control · Individual
Ackerman, Ricky
Corporate Officer · Individual
Peplinski, Todd
Corporate Director · Individual
Peplinski, Todd
Corporate Officer · Individual
Plante & Moran Pllc
Operational/Managerial Control · Organization
Schade, Jeffery
Operational/Managerial Control · Individual
Schade, Jeffery
Corporate Director · Individual
Schade, Jeffery
Corporate Officer · Individual
Sears, Monica
Operational/Managerial Control · Individual
Solarewicz, Maciej
Operational/Managerial Control · Individual
Thompson, Brian
Operational/Managerial Control · Individual
Thompson, Brian
Corporate Director · Individual
Thompson, Brian
Corporate Officer · Individual
Winkels, Kathy
Operational/Managerial Control · Individual
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