Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 Chesaning Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found persistent strong urine and body odors, uncovered urinals left near drinking cups, cluttered rooms, and improper storage of medical equipment in both resident rooms and the therapy area. The therapy room was used for excess equipment storage, obstructing therapy activities, and had a non-functioning air conditioner. Staff and family reported ongoing cleanliness issues, and infection control practices were not consistently followed.
A deficiency was cited when a resident’s drug regimen included unnecessary medications, either lacking clinical indication, being excessive in duration, or duplicative, without proper documentation to justify their use.
Two residents with feeding tubes did not receive proper care due to missing or unclear physician orders, lack of documentation of tube feedings and water flushes, and incomplete care plans. Nursing staff were unaware of or did not follow orders for tube maintenance, resulting in inconsistent care and, in one case, severe abdominal pain requiring hospital transfer.
A resident with a Mediport for chemotherapy did not have physician orders, documentation, or care plan interventions addressing the central line. Facility nurses were not monitoring the site for complications, and the only policy available addressed flushing and removal, not ongoing management.
A resident with chronic kidney disease and a dialysis fistula did not have physician's orders or care plans addressing dialysis services or access site monitoring. Facility staff failed to complete required pre- and post-dialysis assessments and left most dialysis communication forms incomplete, contrary to facility policy.
A long-term care facility failed to implement effective COVID-19 preventive measures during an outbreak, resulting in 11 residents and 10 staff members testing positive. The facility did not fit-test staff for N95 masks, used expired test kits, and failed to isolate COVID-positive residents properly. Staff were observed wearing only surgical masks, and there was inadequate education on preventive measures. Resident #7, with multiple health conditions, was hospitalized with COVID-19. The facility's lack of adherence to its policies and CDC guidelines contributed to the outbreak.
The facility failed to update the Resident Roster Matrix (CMS-802) to reflect COVID-positive residents during an outbreak. Despite isolation signs, residents were observed in communal areas. An LPN confirmed the oversight, leading to potential unmet care needs.
The facility failed to update care plans for several residents, leading to unmet care needs. A resident with a UTI and Covid was hospitalized without proper care plan interventions. Another resident with severe cognitive impairment lacked monitoring for infection signs. Two residents experienced significant weight changes without care plan updates. These deficiencies show a lack of comprehensive and current care plans.
The facility failed to prevent and manage urinary tract infections for several residents, leading to potential health risks. A resident was hospitalized with multiple infections, including a UTI, after completing antibiotic treatment. Another resident received antibiotics before a urine culture, which later showed no specific organism, and did not meet infection surveillance criteria. Multiple antibiotics were administered to another resident without meeting criteria or identifying organisms. Staff education on perineal and catheter care was outdated.
The facility failed to maintain clean and properly stored medication carts, with crushed pills and dust found in drawers. Staff were unclear about cleaning responsibilities. Unlocked treatment carts contained undated medications, and insulin lacked open dates. Medication administration errors included unidentified meds in a cart and incorrect documentation of a declined nasal spray.
The facility failed to maintain sanitary conditions and proper food safety practices in the kitchen, affecting 35 residents. Issues included a malfunctioning hand washing sink, dirty equipment, and undated food items. Staff interviews revealed a lack of oversight due to the Dietary Manager's absence and ongoing cleanliness concerns noted by the Dietitian.
The facility did not analyze monthly infection data for July and August, missing critical analysis of infection rates and related factors. Additionally, during wound care for a resident with a chronic wound, staff failed to use enhanced barrier precautions, despite signage indicating the need for such measures. This oversight increased the risk of cross-contamination and infection spread.
The facility failed to monitor and justify antibiotic use for four residents, leading to inappropriate administration and potential health risks. A resident experienced recurrent UTIs and was given antibiotics without organism identification. Another resident with severe cognitive impairment received antibiotics despite not meeting infection criteria. Multiple antibiotics were administered to a third resident without proper culture or organism identification. A fourth resident was treated for UTIs despite urine cultures showing mixed flora. The facility lacked adherence to infection criteria and did not provide ongoing staff education on care practices.
A diabetic resident experienced a change in condition with stomach pain and was on antibiotics for a UTI. Despite completing the antibiotic therapy, the resident's condition worsened, leading to hospitalization where she was diagnosed with COVID-19 and a UTI, with low sodium and critically low glucose levels. The facility failed to monitor or document glucose levels during this acute change, delaying treatment for low blood glucose.
The facility failed to ensure timely weight monitoring for two residents, leading to a lack of follow-up on significant weight changes. One resident experienced weight fluctuations without updates to their care plan, while another had inconsistent weight recordings with no triggered changes in the electronic medical record. Staff interviews revealed inconsistencies in weight measurement methods and a lack of timely re-weighing, contributing to the deficiency.
A facility failed to document and monitor a resident's behavioral health care, leading to a deficiency. The resident, with multiple mental health diagnoses, had an undated care plan noting attention-seeking behaviors. However, there was no evidence of monitoring or documentation of interventions in the resident's records. Interviews revealed a lack of a behavioral program and policy, and staff were not trained on the provided behavioral policy.
A resident was administered Abilify, Trazadone, and Ativan without obtaining the necessary consents from the responsible party. The facility's policy requires education on risks and benefits of psychotropic drugs, but this was not followed. The social worker's attempts to obtain consent were unsuccessful due to incorrect email addresses, leaving the consents unsigned.
The facility failed to ensure a clean and safe environment, with issues such as extreme odors, stained curtains, and dirty fans observed in resident rooms. Hazards like missing wood and bent heater edges were noted, along with unsanitary conditions like uncovered toothbrushes and urinals with urine. Staff interviews revealed a lack of awareness and responsibility for maintaining cleanliness, and the facility's policy on environmental quality was not followed.
A cognitively impaired resident, requiring assistance with all ADLs, did not receive the scheduled showers as per the facility's policy, despite adequate staffing. The resident, with a history of stroke, seizures, and Alzheimer's, only received two showers and refused one, with no documented follow-up. This failure increased the likelihood of negative outcomes such as offensive odors and skin issues.
Environmental Cleanliness and Safety Deficiencies in Resident and Therapy Areas
Penalty
Summary
Surveyors identified multiple deficiencies related to the facility's failure to maintain a clean, safe, and homelike environment in both resident rooms and the therapy area. Observations included persistent strong urine and body odors in several rooms and hallways, urinals left half-full and uncovered on nightstands or floors near drinking cups, and cluttered rooms with personal items and medical equipment improperly stored. In one instance, a resident's breakfast tray with perishable food remained untouched for approximately four hours, and urinals were left on the floor. Additionally, oxygen tubing and nasal cannulas were not stored in protective bags as required, and tubing was not changed according to facility policy. The therapy room was found to be used for storage of excess equipment, including wheelchairs, walkers, and lifts, which obstructed access to therapy areas such as parallel bars and the plinth. Staff reported having to move equipment before and after therapy sessions, and the room was described as cluttered and dirty by both staff and family members. The air conditioning unit in the therapy room was not functioning, and a ceiling vent was observed to have rust. Staff interviews confirmed ongoing issues with environmental cleanliness and equipment storage, with some staff stating that complaints had been made to management without timely resolution. Additional observations included a resident returning from outside with a urinary catheter bag dragging on the floor, uncovered and wet, which was acknowledged by staff as inappropriate. Housekeeping practices were found to be lacking, with no formal checklist for room checks and the supervisor responsible for multiple roles. Social work staff reported receiving frequent complaints from residents and families about odors and cleanliness. Infection control rounds were documented monthly, but issues persisted in both resident and therapy areas.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated, excessive in duration, or duplicative, without adequate justification documented in the medical record.
Failure to Ensure Accurate Orders and Maintenance for Feeding Tubes
Penalty
Summary
The facility failed to ensure accurate physician orders and proper maintenance of feeding tubes for two residents who required enteral nutrition. For one resident with a history of stroke, oral and throat cancer, and a PEG tube, there were overlapping and unclear orders for tube feeding and water flushes. Documentation was lacking regarding the administration of prescribed tube feedings and water flushes, with no records of Jevity 1.5 or water flushes being provided or refused for several days. Additionally, the order for water flushes was not properly entered into the Medication Administration Record (MAR) or Treatment Administration Record (TAR), resulting in nurses not being prompted to perform or document the required care. The resident experienced severe abdominal pain during an attempted bolus feeding, leading to a hospital transfer and tube replacement. Nurses also expressed confusion about the appropriate volume for flushing the tube and were unaware of the specific orders, further contributing to inconsistent care. For the second resident, who had multiple diagnoses including Parkinson's disease, diabetes, and a feeding tube, physician orders specified tube feeding and hydration but did not include instructions for water flushes to maintain tube patency. Review of the MAR/TAR showed that while tube feedings were documented, there was no documentation of water flushes being performed. Observation revealed that the resident had two PEG tube sites, with the old site showing signs of redness and drainage, and the dressing was not properly dated or initialed. The care plan for this resident addressed nutritional concerns but did not include interventions for maintaining the feeding tube, such as water flushes. Interviews with nursing staff revealed a lack of familiarity with the orders for flushing the PEG tubes and confusion about the documentation process. The facility's policy required that feeding tubes be maintained according to physician orders, including the frequency and volume of flushes, and that care plans address strategies to prevent complications. However, these requirements were not met for either resident, as evidenced by missing or unclear orders, lack of documentation, and incomplete care planning related to feeding tube maintenance.
Failure to Monitor and Document Central Line (Mediport) Care
Penalty
Summary
The facility failed to follow accepted standards of practice for the management and monitoring of a Central Venous Catheter (Mediport) for a resident receiving chemotherapy and radiation therapy for cancer. The resident, who had a history of stroke, left-sided weakness, tongue and throat cancer, feeding tube, chronic pain syndrome, depression, weakness, hypertension, and atrial fibrillation, was admitted and readmitted to the facility. Despite having a Mediport placed for chemotherapy, there were no physician orders addressing the Mediport, no documentation in the Medication Administration Records (MAR) or Treatment Administration Records (TAR) regarding its presence, location, or monitoring, and no specific care plan interventions related to the Mediport. Progress notes only briefly mentioned the placement and stability of the Mediport, with no ongoing assessments or documentation of the site or dressing. Interviews with nursing staff confirmed that the Mediport was only accessed and maintained by the Cancer Center staff, and that facility nurses were not monitoring the site for signs of complications such as dressing integrity, bleeding, redness, pain, or warmth. Review of the care plans showed only general skin integrity interventions, with no updates or specificity regarding the Mediport after its placement. The facility provided a policy for flushing, locking, and removing a central line, but did not have a policy for ongoing management and monitoring of a central line, including surveillance for adverse effects.
Failure to Ensure Safe and Appropriate Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with chronic kidney disease who required regular dialysis treatments. Specifically, there were no physician's orders for dialysis services or for the monitoring and assessment of the resident's dialysis access site. The resident, who had a history of chronic kidney disease, diabetes, hypertension, and other conditions, had a dialysis fistula that was not documented in the physician's orders, Medication Administration Records, or Treatment Administration Records. Additionally, the resident reported issues with bleeding at the dialysis center, but there was no evidence that the facility had orders or protocols in place to monitor or assess the access site upon return. The facility also failed to complete required dialysis communication forms, with most pre- and post-dialysis assessments left incomplete or blank. Out of ten reviewed forms, nine were incomplete and eight lacked any post-dialysis assessment by a nurse. The resident's care plan did not address dialysis services or the presence and monitoring of the dialysis access device. Only one progress note documented a post-dialysis assessment during the review period. These deficiencies were contrary to the facility's own policy, which required ongoing assessment and monitoring before and after dialysis treatments.
Failure to Implement COVID-19 Preventive Measures
Penalty
Summary
The facility failed to implement timely and effective COVID-19 preventive measures during an outbreak, resulting in 11 residents and 10 staff members testing positive for COVID-19. The facility's Pandemic COVID-19 policy, dated 2020, outlined measures such as training staff and isolating infected residents, but these were not adequately followed. The Infection Control Nurse revealed that staff were not fit-tested for N95 masks, and there was no documentation of visitor education on transmission-based precautions. Observations showed that COVID-positive residents were not isolated in private rooms, and staff were not consistently wearing appropriate PPE. During the outbreak, several residents, including those on the Rehab and Long-Term Halls, were not properly isolated, with room doors left open, allowing potential virus spread. Staff members were observed wearing only surgical masks instead of N95 masks, and there was a lack of education on COVID-19 preventive measures. The facility used expired COVID-19 test kits, leading to false positives and delayed identification of actual cases. The Infection Control Nurse admitted to not having documentation of current staff COVID immunizations, and only a portion of the staff had been educated on preventive measures. Resident #7, who required assistance for all activities of daily living and had multiple health conditions, was hospitalized with COVID-19, among other diagnoses. The facility's failure to follow its own policies and CDC guidelines contributed to the rapid spread of COVID-19 among residents and staff. Interviews with staff and administration revealed a lack of communication and adherence to infection control protocols, with the Director of Nursing and Administrator acknowledging that precautions were not followed as they should have been.
Inaccurate Resident Information During COVID Outbreak
Penalty
Summary
The facility failed to ensure accurate resident information on the Resident Roster Matrix (CMS-802) for five residents, which included those who were COVID-positive. This deficiency was identified during a survey when the facility's Social Worker informed the surveyors of a COVID-positive outbreak upon their entrance. Observations during the entrance tour revealed that isolation signs were posted, but the type of isolation was not specified. Additionally, residents were observed moving about and eating in the main dining room, despite the outbreak. The CMS-802 form provided by the facility, dated 10/14/2024, did not indicate any COVID infections, despite the outbreak beginning on 10/10/2024. An interview with the LPN responsible for the Minimum Data Set (MDS) and infection control confirmed that the form was not updated to reflect the COVID-positive status of the residents. This oversight resulted in the likelihood of unmet care needs for the affected residents.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were updated and revised appropriately with new interventions for four residents, leading to unmet care needs. Resident #7 experienced a urinary tract infection (UTI) and was treated with antibiotics, but her care plan did not include interventions for monitoring signs and symptoms of infection or adverse reactions to antibiotic treatment. She was later sent to the hospital with multiple infections, including a UTI and Covid, which were not addressed in her care plan. Resident #8, who has severe cognitive impairment, was treated for a UTI with antibiotics, but her care plan lacked interventions for monitoring infection signs and symptoms or adverse reactions to the treatment. Similarly, Resident #17 experienced significant weight fluctuations, but the care plan was not updated to reflect these changes or address potential nutritional problems. The care plan was last updated before a notable weight loss, indicating a lack of timely revision. Resident #27 also experienced inconsistent weight changes, with a significant weight gain not triggering any updates in the care plan. The care plan for potential nutritional problems was last updated before the weight gain, showing a failure to revise the care plan in response to the resident's changing condition. These deficiencies highlight the facility's failure to maintain comprehensive and current care plans for residents, resulting in unmet care needs.
Failure to Prevent and Manage Urinary Tract Infections
Penalty
Summary
The facility failed to prevent facility-acquired urinary tract infections and appropriately follow up on contaminated urine samples for four residents, leading to potential health risks. Resident #7, who was urinary incontinent, experienced symptoms of dysuria and fatigue, and was treated with Rocephin for a urinary tract infection. Despite completing the antibiotic course, the resident was later hospitalized with acute metabolic encephalopathy due to multiple infections, including a urinary tract infection and COVID. Resident #8, with severe cognitive impairment, was administered Macrobid for a urinary tract infection before a urine culture was conducted, which later showed Proteus Mirabilis. However, the resident did not meet the McGeers criteria for infection surveillance, indicating a possible misdiagnosis or inappropriate treatment. Similarly, Resident #9 received multiple antibiotics for urinary tract infections over several months, but the McGeers criteria were not met, and no organisms were identified in some instances, suggesting potential overuse or misuse of antibiotics. Resident #31 was treated with antibiotics for urinary tract infections despite urine cultures showing mixed skin/genital flora with no specific organism identified. The facility's Director of Nursing and Infection Preventionist were questioned about staff education on perineal and catheter care, which was last provided in March 2024, indicating a lack of ongoing training to address the high rate of urinary tract infections.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper storage of medication carts, as observed on two separate occasions. The medication carts on the Rehab Hall and Long-Term Hall were found to have dirty drawers containing crushed pills, dust, and loose papers. Interviews with nursing staff revealed confusion about who was responsible for cleaning the carts, with some nurses unsure and others believing it was their duty. The Director of Nursing confirmed that nurses were responsible for cleaning the carts. The facility's Medication Storage policy emphasized the importance of proper sanitation and storage, but these standards were not met. Additionally, the treatment cart on the Rehab Hall was found unlocked and contained several opened and undated medications, including Nystatin powder, Eucerin cream, and Iodosorb gel. This lack of proper dating and security of medications poses a risk of contamination and improper medication administration. Furthermore, insulin and other medications were found without open dates, contrary to the facility's pharmacy guidelines, which require medications to be dated upon opening to ensure they are used within safe timeframes. There were also issues with medication administration practices. Medications were found in a plastic cup in the medication cart without identification of the resident they belonged to, and a medication tablet was mishandled during administration. A resident declined a nasal spray medication, but it was still marked as administered in the Medication Administration Record. These incidents highlight lapses in medication handling and documentation, which could lead to medication errors and compromised resident safety.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain food preparation and kitchen equipment in a sanitary and good working condition, as well as ensure that partially opened food items had an open and use-by date. During a kitchen walkthrough, several issues were identified, including a hand washing sink that was not draining properly, a dirty kitchen floor, and equipment such as a cupboard mixer, toaster, and microwave that were found with dried food particles and crumbs. Additionally, the thickener, hotdog buns, and various food containers in the vegetable refrigerator were found without use-by dates. Eggs were found in the dairy refrigerator without a container or dates. Interviews with staff revealed that the Dietary Manager had been on vacation, and there was a lack of double-checking of food items. The Dietitian noted that recent walk-throughs had revealed undated food items and cleanliness concerns. These deficiencies affected all 35 residents who consumed oral nutrition from the facility kitchen and ice machine, increasing the likelihood of foodborne illness and cross-contamination.
Failure to Analyze Infection Data and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to analyze monthly infection data for July and August, despite having documented infection rates and total numbers of infections. There was no analysis of infection rates, employee call-ins, antibiotic usage, or immunizations. During an interview, the Infection Control Nurse and the Director of Nursing confirmed that no analysis had been conducted from the monthly data collected in the Infection Control program. The facility's Infection Prevention and Control Program and the Infection Preventionist job description both indicated that data analysis was a required component of the infection control program, yet this was not performed. Additionally, the facility did not implement enhanced barrier precautions during wound care for a resident with a chronic wound. During an observation, a wound care nurse and a CNA were seen attending to a resident with a sacrum wound without wearing the required enhanced barrier gowns, despite signage indicating the need for such precautions. The resident had a wound on her bottom, and during the care, blood was noted from a tear at the top of the buttocks crease. The lack of adherence to enhanced barrier precautions increased the risk of cross-contamination and infection spread.
Inadequate Monitoring and Justification of Antibiotic Use
Penalty
Summary
The facility failed to adequately monitor and justify the administration of antibiotics for four residents, leading to inappropriate antibiotic use and potential health risks. Resident #7 experienced recurrent urinary tract infections (UTIs) and was administered antibiotics without proper identification of the causative organism. In September 2024, Resident #7 received Rocephin for a UTI caused by Proteus Mirabilis, and in October 2024, Ampicillin was administered without an organism being identified. This lack of proper monitoring and justification for antibiotic use contributed to the resident's recurrent infections and subsequent hospitalization. Resident #8, who has severe cognitive impairment, was administered Macrobid for a UTI despite not meeting the McGeers criteria for infection surveillance. The urine analysis showed Proteus Mirabilis, but the culture was conducted after the antibiotic treatment had already begun. Similarly, Resident #9 received multiple antibiotics for UTIs that did not meet the McGeers criteria, including Keflex, Ceftin, Nitrofurantoin, and Amoxicillin, without proper culture or organism identification. This resident also received Diflucan for a fungal infection/UTI without an identified organism, indicating a pattern of antibiotic use without clinical rationale. Resident #31 was treated with Macrobid and Cipro for UTIs despite urine cultures showing mixed skin/genital flora and no identified organism. The facility's Infection Preventionist and Director of Nursing acknowledged the lack of adherence to McGeers criteria and the absence of a urine dip policy, which contributed to the inappropriate use of antibiotics. The facility's failure to provide ongoing staff education on perineal and catheter care further exacerbated the issue, as the last documented training occurred in March 2024, prior to the summer months when UTI incidents increased.
Failure to Monitor and Document Glucose Levels in Diabetic Resident
Penalty
Summary
The facility failed to ensure proper assessment, monitoring, and timely provision of care for a resident, leading to a lack of documentation and glucose monitoring during a change in the resident's condition. The resident, an elderly female with a cognitive status of 14 out of 15 on the Brief Interview of Mental Status (BIMS) and a medical diagnosis of diabetes, experienced stomach pain and was on antibiotics for a urinary tract infection (UTI). Despite the completion of antibiotic therapy, the resident continued to feel unwell, and her condition worsened, resulting in her being sent to the hospital. At the hospital, the resident was diagnosed with COVID-19 and a UTI, and her hospital records indicated a sudden change in mental status, low sodium, and critically low glucose levels. The facility's records showed no glucose monitoring or checks at the time of the resident's acute change in condition, which was a significant oversight given her diabetic status. This lack of monitoring and documentation contributed to a delay in identifying and treating her low blood glucose level, which was a critical aspect of her care.
Failure in Timely Weight Monitoring for Residents
Penalty
Summary
The facility failed to ensure timely weight monitoring for two residents, resulting in a lack of follow-up on abnormal weight changes. The facility's 'Weight Monitoring' policy requires a weight monitoring schedule upon admission, with specific guidelines for recording and analyzing weight changes. However, the facility did not adhere to these guidelines, as evidenced by inconsistent weight recordings and a lack of timely re-weighing for significant weight changes. Resident #17 experienced several weight fluctuations in July 2024, including a 7.2-pound loss and a 5-pound gain, without any mention in the physician's progress notes. The resident's care plan, which included potential nutritional problems related to diabetes, dysphasia, Alzheimer's, and chronic kidney disease, was not updated following a significant weight loss. Additionally, the last dietary assessment for this resident was completed in May 2024, indicating a lack of ongoing nutritional evaluation. Resident #27 also exhibited inconsistent weight recordings, with a notable 5.8-pound loss and an 11.2-pound gain. Despite these changes, there was no triggered change in weight generated from the electronic medical record, and the resident's care plan was not updated following the weight gain. Interviews with staff revealed inconsistencies in the method of obtaining weights and a lack of re-weighing within 24 hours for significant weight changes, contributing to the deficiency in weight monitoring.
Failure to Document and Monitor Resident's Behavioral Health Care
Penalty
Summary
The facility failed to ensure proper documentation and monitoring of a resident's behavioral health care, leading to a deficiency in care. The resident, who is unable to make healthcare decisions independently, has a history of epilepsy, intellectual disabilities, schizophrenia, adjustment disorder, major depression, dementia, and delusional disorders. The resident's behavioral care plan, which was undated, noted issues such as yelling, being sexually inappropriate, and attention-seeking behaviors. Despite these documented behaviors, there was no evidence of monitoring or documentation of interventions and their effectiveness in the resident's electronic records. Interviews with the facility's social worker revealed that there was no consistent documentation of the resident's behaviors or interventions in the progress notes. The social worker admitted to the absence of a behavioral program and a lack of policy to monitor such behaviors. Additionally, the facility's Use of Psychotropic Medication policy emphasized the need for assessing underlying conditions and identifying causes, yet there was no evidence of adherence to this policy. The facility administrator later provided a behavioral policy, but it was noted that staff had not been trained on it, indicating a gap in the implementation of behavioral health care protocols.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain appropriate consents for the administration of antipsychotic medications to a resident, identified as Resident #8. The resident was administered Abilify, Trazadone, and Ativan without the necessary consent forms being signed and dated by the responsible party. The facility's policy requires that residents or their representatives be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments, but this was not adhered to in the case of Resident #8. The social worker attempted to obtain consent by emailing the guardian, but the emails were sent to the wrong address, and the consents remained unsigned. Resident #8 had a diagnosis of dementia, depression, agitation, and sundowning, and was prescribed these medications to manage these conditions. The social worker noted that the resident's guardian was aware of the medication changes, but no formal consent was obtained prior to the administration of Abilify, which replaced Risperdal. The lack of signed consent forms and risk-versus-benefit analysis documentation indicates a failure to comply with the facility's policy on psychotropic medication use, potentially increasing the likelihood of serious side effects and adverse reactions for the resident.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by multiple observations during a survey. In several resident rooms, there were issues such as extreme odors of urine, used tissues on the floor, stained bedside curtains, and dripping sinks with corrosion. Additionally, there were hazards like missing wood on closet bottoms, bent heater edges, and lifting veneer on room doors. The presence of dirty electric fans, uncovered toothbrushes, and urinals with urine further highlighted the unsanitary conditions. The survey also revealed that some rooms had non-labeled razors, personal items like blankets and pillows on the floor, and opened food bags left unattended. The walls and doors in these rooms had black scuff marks and chipping paint, while the baseboards were lifting. In one room, a CPAP mask was left uncovered, and urinals with urine were placed on the floor. These conditions were observed during two separate walkthroughs, indicating a lack of timely corrective action. Interviews with staff, including a housekeeper and the Director of Nursing (DON), revealed a lack of awareness and responsibility for maintaining the cleanliness of privacy curtains and the overall environment. The facility's hallways and sitting areas also showed signs of neglect, with worn-off finishes and exposed wood. The facility's policy on maintaining a safe and sanitary environment was not adhered to, as evidenced by the observations and the undated daily cleaning sheet that outlined the expected cleaning tasks.
Failure to Provide Scheduled Showers to Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident, who was cognitively impaired and required assistance with all activities of daily living (ADLs), received the necessary care, specifically showers, as per the facility's policy. The resident, who had a history of stroke with severe cognitive impairment, seizures, anxiety disorder, Alzheimer's Disease, mood disturbance, and diabetes, was supposed to receive two showers a week. However, records showed that the resident only received showers on two occasions and refused one, with no documentation of staff re-approaching the resident or implementing interventions after the refusal. Interviews with the Director of Nursing and staff confirmed that there was adequate staffing to provide the required showers, yet the resident did not receive the scheduled care. The facility's ADL care plan and Resident Showers policy emphasized the importance of maintaining hygiene and preventing skin issues, but these were not adhered to in this case. The lack of documentation and follow-up on the resident's refusal to shower contributed to the deficiency, increasing the likelihood of negative outcomes such as offensive odors, skin issues, and decreased self-esteem with isolation.
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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.
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Nursing homes near Chesaning
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Montrose Inc | 12.7 mi | — | 25 | 0 |
| Pleasant View Shiawassee County Medical Care Facil | 12.7 mi | — | 0 | 0 |
| Memorial Healthcare Center | 12.8 mi | — | 1 | 0 |
| Majestic Care Of Flushing | 16.6 mi | — | 2 | 0 |
| Optalis Health And Rehabilitation At St. Francis | 16.8 mi | — | 24 | 0 |
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