Chesaning Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1). have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), 2). ensure 2 of 2 residents' (Resident's #3 and #35) meet the facility criteria for infections, and 3) do infection control environmental rounds of the main dining room, resulting in the potential for increased risk of respiratory infection among all residents in the facility, an increased unnecessary use of antibiotic therapy, and an unsafe dining room environment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect residents' rights to be free from neglect for 3 residents ( #7, #14, #49) of 18 residents reviewed for dignity and the confidential Resident Council group, resulting in verbalizations from the council group of anger regarding call lights not being answered timely, frustration regarding not being able to reach call lights, and a heavy smell of urine in the back hall. Findings Include:Review of the facility's Maintaining Dignity policy, dated 12/25, stated It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances quality of life. Respond to requests for assistance in a timely manner. Call Light Availability and Response Time: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedures for 1) Medication labeling and storage in 2 of 2 medication carts, 2) Storage and handling of medications for one medication room of one reviewed, and 3) Consistently monitor the medication refrigerator temperature in accordance with acceptable pharmaceutical standards of practice, for 11 residents (R3, R8, R10, R12, R19, R28, R35, R37, R40, R42, R50) of 11 sampled residents

Inspectors wroteBased on interview and record review, the facility failed to implement Mood/Behaviors care plan interventions for 1 resident (Resident #14) of 18 residents reviewed for care plans, resulting in lack of documentation of any interventions for mood or behaviors and a lack of follow-up with intervention effectiveness. Findings Include:Resident #14:Review of the Face Sheet, MDS (dated 5/25), and care plans (dated 4/25), revealed Resident #14 was 63 years-old, admitted to the facility on [DATE], alert and interviewable with a BIMS of 10 (cognitive assessment, interviewable), and required total assistance with all Activities of Daily Living/ADL's. The residents' diagnosis included, sepsis, back pain, muscle weakness, seizures, difficulty walking, epilepsy, respiratory failure, traumatic brain injury with explosive disorder and hemiplegia of left side (weakness). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to update care plan interventions for one resident (Resident #2) of 4 sampled residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of Stage II pressure ulcer for one resident (Resident #2) of 1 resident reviewed for pressure ulcer/injury, resulting in Resident #2 developing a facility-acquired Stage II pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the enteral tube feeding (TF) solution was labeled with the resident's name, date, and rate of infusion for one resident (Resident #6) of 1 sampled resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and monitor a post-dialysis pressure dressing for 1 resident (Resident #3) of 1 sampled resident, resulting in Resident #3 to be observed with a pressure dressing to the fistula access sites with no date on the dressing or documented nursing assessment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Infection Control Preventionist Licensed Practical Nurse F completed an annual nursing skills competency evaluation for 1 of 2 nurses reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify targeted behaviors, medication classifications, and the duration of therapy on the informed consents for 3 residents (R5, R6, R22) of 5 sampled residents.

Inspectors wroteThis citation pertains to intake Number 2585037. Based on observation, interview and record review, the facility failed to ensure a clean, safe, and homelike environment involving the Therapy room and 5 residents' rooms (Rooms 2, 3, 4, 14, and 19) of 20 rooms in total, resulting in the protentional for injury (therapy equipment stored in the therapy area, increases risk of tripping and falling), resident and family complaint's regarding the environment, anger, dissatisfaction and depression. Findings Include: Self-tour of facility on 8/19/2025 at 9:30AM noted Strong urine odors in the back hall noted coming from room [ROOM NUMBER]. Noted 2 male residents to reside in room, Resident #106 the bed by the window was noted with urinal on nightstand with yellow urine noted with no top on it, half full, next to white Styrofoam drinking glass with a straw. [...]

Inspectors wroteThis citation pertains to intake Numbers: 2590687, 2577760, and 2581464. Based on observation, interview and record review, the facility failed to prevent a decline in the quality of life for one resident (Resident #101) of 6 residents reviewed, resulting in Resident #101 having a change in demeanor of a decrease in activity with an increase in depression of tearfulness.

Inspectors wroteThis citation pertains to Intake Numbers 2590687, 2577760, and 2581464. Based on observation, interview and record review, the facility failed to get a signed informed consent for anti-anxiety medication prior to administering it for one resident (R101), resulting in Resident #101 receiving the medication with no written or verbal consent.

Inspectors wroteThis Citation Pertains to Intake Number MI00151360. Based on observation, interview and record review, the facility 1) Failed to ensure accurate orders for a feeding tube and 2) Failed to ensure maintenance of the feeding tube, including water flushes, for 2 residents (Resident #1 and Resident #2) of 2 residents reviewed for feeding tubes. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: History of a stroke, left sided weakness, tongue and throat cancer, feeding tube, chronic pain syndrome, depression, weakness, hypertension and atrial fibrillation. [...]

Inspectors wroteThis Citation Pertains to Intake Number MI00151360. Based on observation, interview and record review, the facility failed to follow accepted standards of practice for obtaining a physician's order, assessment and monitoring of a Central Venous Catheter/CVS Mediport IV for one resident (Resident #1) of 1 resident reviewed for IV catheters. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: History of a stroke, left sided weakness, tongue and throat cancer, feeding tube, chronic pain syndrome, depression, weakness, hypertension and atrial fibrillation. Resident #1 was receiving chemotherapy and radiation therapy for the cancer. [...]

Inspectors wroteThis Citation Pertains to Intake Number MI00151360. Based on observation, interview and record review, the facility failed to ensure that 1) Physician's orders for dialysis services; 2) Post- Dialysis assessment and monitoring were completed and 3) Dialysis communication forms were complete and included pre-dialysis and post-dialysis assessment, including location and assessment of the dialysis access site for one resident (Resident #4) of 1 resident reviewed for Dialysis care. Findings Include: Dialysis Resident #4: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Chronic kidney disease, receives dialysis, Diabetes, obesity, anemia, gout, hypothyroidism. Hypertension and bipolar disorder. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of care regarding implementation of COVID preventive measures in a timely manner during a COVID outbreak emergency, resulting in 11 residents (Resident's #6, #7, #14, #16, #23, #24,#25, #28, #35, #90) and 10 staff members (Nursing Assistant/CNA O, CNA P, CNA Q, CNA R, CNA S, Nurse, LPN G, Social Worker E, Dietary Aide N, Nurse, CNA H, and Dietary Manger A) testing positive for COVID, resulting in one resident's (Resident #7) hospitalization, resulting in rapid spread of COVID throughout the facility and staff members with the likelihood for the continued spread of COVID, resident and staff illness and the hospitalization of (Resident #7. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that accurate resident information was completed on the Resident Roster Matrix (802) for five residents (Resident #1, Resident #14, Resident #16, Resident #26, Resident #140) of 12 sampled residents, resulting in COVID-positive residents and the likelihood of unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that care plans were updated and revised appropriately with new interventions for four residents (Residents #7, Resident #8, Resident #17, Resident #27) of 12 sampled residents, resulting in revision and interventions necessary for care and services not being care planned with the likelihood for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent facility-acquired urinary tract infections and follow up on contaminated urine samples for four residents (#7, #8, #9, #31), resulting in the likelihood for urinary tract infections and/or organisms to be unidentified and untreated, bladder injury, pain and decline in overall health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 2 medication carts (Rehab Hall and Long-Term Hall medication carts) were clean and sanitized, free of crushed pills, pieces of loose papers and dust in the drawers, and proper medication storage, resulting in the likelihood of cross contamination, low medications count with increased cost and missed resident medications. Findings Include: Observation of facility medication carts done on 10/14/24 at 10:30 a.m., revealed the following: Medication Cart on the Rehab Hall was found to have the second, and third drawers dirty with crushed meds, dust, and papers on the bottom of the carts. During an interview done on 10/14/24 at 10:30 a.m., Nurse, LPN V stated I don't know who is supposed to clean it, maybe third shift. [...]

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to maintain food preparation and kitchen equipment in a sanitary and good working condition, and 2) Failed to ensure that partially opened food items had a open and use-by date on them, resulting in an increased likelihood for food borne illness with hospitalization, and cross contamination affecting 35 residents who consumed oral nutrition from the facility kitchen and ice machine of a total census of 35 residents. Findings Include: Review of the Public Health Service 2009 Food Code, adopted by the Michigan Food Law, effective October 1, 2012, Chapter 4-501.14 directs that equipment cleaning frequency is to be throughout the day at frequency necessary to prevent recontamination of equipment and utensils. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to 1) Ensure resident monthly infection data was analyzed for 7/24 and 8/24 for a census of 35 residents, and 2) Ensure enhanced barrier precautions were used during wound care, resulting in the likelihood for cross contamination, resident, and staff illness, antibiotic usage with possible hospitalization. Findings Include: Infection Control Data Analyzing: Review was done of 7/24 and 8/24 facility monthly data reports. Both reports had documentation of infection rates, and the total numbers of each infections. No documentation of any analysis done regarding the infection rates, employee call-ins, antibiotic usage or immunizations was found. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor and justify the administration of antibiotic medications for four residents (#7, #8, #9, #31), resulting in Resident #7 and Resident #31 to have recurrent urinary tract infections, Resident #8 and Resident #9 to be receive antibiotic without clinical rational and the likelihood of antibiotic resistance due to an inappropriate usage, resistance or the development of opportunistic organisms, and hospitalizations.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure assessment, monitoring and timely provision of care, per professional standards of practice for one resident (Resident #7), resulting in a lack of documentation and glucose monitoring with a change of condition with the likelihood for a lack of change of condition and delay in the treatment of low blood glucose level.

Inspectors wroteBased on interview and record review, the facility failed to ensure weight monitoring timely for two residents (Resident #17, Resident #27) of 4 residents reviewed, resulting in a lack of weight monitoring/follow-up of abnormal weights, and the likelihood for unidentified nutritional deficiencies and decline in overall health.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one resident's (Resident #22) behavior's were documented and monitored, resulting in the likelihood for increased resident behaviors with no documentation of interventions done or effectiveness, lack of follow-up regarding care plan's, and medication reviews not being accurate. Findings Include: Resident #22: Review of the Face Sheet, care plans and nursing notes dated 10/11/24 though 10/14/24, revealed Resident #22 was 57 years-old, not able to make his own healthcare decisions, and required staff assistance with Activities of Daily Living/ADL. Review of the residents diagnosis included, epilepsy, intellectual disabilities, schizophrenia, adjustment disorder, major depression, Dementia, and delusional disorders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain consents for antipsychotic medication usage for one resident (Resident #8), resulting in Resident #8 being administered antipsychotic medications without appropriate consent and risk-versus-benefit analysis or medications explained to the resident/responsible party and the increased likelihood for serious side effects and adverse reactions.

Inspectors wroteThis Citation pertains to Intake Number MI00145893. Based on observation, interview and record review, the facility failed to ensure a clean and safe environment for 11 residents' rooms, 2 main hallways, and 1 residential sitting area, resulting in the likelihood for resident injury (bug and spider bites and hand splinters), anger and frustration from family members and residents, cross contamination with illnesses with increased use of antibiotics. Findings Include: During a walk-through of the facility done on 9/12/24 starting at 10:00 a.m., accompanied by the Administrator, the following concerns were observed: -room [ROOM NUMBER]: Extreme odor of urine near bed 2; resident in bed at the time. -room [ROOM NUMBER]: Several used tissues were observed on the floor near bed 1, the walls had numerous areas of chipping paint and black scuff marks from wheelchairs. -room [ROOM NUMBER]: [...]

Inspectors wroteThis Citation pertains to Intake Number MI00145893. Based on interview and record review, the facility failed to ensure that one resident (Resident #103), had the required Activities of Daily Living (ADL) care (showers) of 6 residents reviewed for ADL's, resulting in an increased likelihood for offensive odors, skin issues, and decreased self-esteem with isolation. Findings Include: Resident #103: Review of the Face Sheet, Care Plans dated 6/22, and shower sheets (dated 7/3/24, 7/16/24 and 7/23/24), revealed Resident #103 was 69 years-old, admitted to the facility on [DATE] and re-admitted on [DATE], was cognitively impaired and unable to make healthcare decisions, and required staff assistance with all ADL's. The residents diagnosis included, stroke with severe cognitive impairment, seizures, anxiety disorder, Alzheimer's Disease, mood disturbance, and diabetes. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00138042. Based on observation, interview and record review, the facility 1) Failed to provide care following professional standards of practice and facility policy to prevent the development of avoidable pressure injuries, 2) Failed to accurately measure and stage residents' pressure injuries, and 3) Failed to promptly identify and provide necessary treatment for a deteriorating pressure injury for four residents (Resident #192, Resident #6, Resident #13, and Resident #26) reviewed for pressure injuries, resulting in R192 requiring emergent surgical intervention for sepsis and acute osteomyelitis of a Stage 4 sacral wound. [...]

Inspectors wroteThis Citation pertains to Intake Numbers MI00135195 and MI00138197. Based on observation, interview, and record review, the facility failed to follow professional standards of nursing practice for medication administration vital sign assessments for 6 residents (Resident #2, Resident #10, Resident #26, Resident #21, Resident #14, and Resident #3) reviewed for provision of nursing services, resulting in medications administered late, medications administered outside of physician-ordered parameters, medication errors without management follow through, incomplete laboratory testing, and the potential for less than therapeutic effects of medications, decreased effectiveness of medications, and the potential for a delay in treatment and the worsening of medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, monitor, and care for a resident receiving enteral tube feedings for one resident (Resident #6) reviewed for enteral tube feedings, resulting in the potential for aspiration pneumonia and an overall deterioration of health status.

Inspectors wroteBased on observation, interview, and record review, the facility 1) Failed to implement an effective and current system of surveillance of staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak, 2) Failed to perform incontinence care using infection control practices, and 3) Failed to ensure that staff were educated on and wore the appropriate recommended Personal Protective Equipment (PPE) while providing care for residents. This deficient practice placed all residents residing in the facility at risk for the potential for the development and spread of disease and infection and the potential for an outbreak to go undetected.

Inspectors wroteBased on interview and record review, the facility 1) Failed to implement, and operationalize an antibiotic stewardship program and 2) Failed to ensure accurate monitoring and documentation of an antibiotic for three residents (Resident #13, Resident #19, Resident #30) reviewed for antibiotic use, resulting in the potential for inappropriate antibiotic utilization and the potential for antibiotic resistance.

Inspectors wroteBased on observation and interview, the facility failed to treat one resident (Resident #14) with dignity during care resulting in the potential for diminished feelings of self-worth.

Inspectors wroteBased on interview and record review, the facility 1) Failed to ensure that residents received complete and comprehensive wound assessments and 2) Failed to ensure the effectiveness of treatments and interventions based on wound assessments for one resident (Resident #13), reviewed for quality of care, resulting in the lack of assessment, monitoring, documentation, and the potential for the worsening of a wound and a delay in treatment.

Inspectors wroteBased on interview and record review, the facility failed to accurately document administration of controlled substances for three residents (Resident #13, Resident #22, and Resident #11) resulting in the potential for overdose and/or ineffective management of pain, and the potential for drug diversion of controlled substances.

Inspectors wroteThis citation pertains to intake #MI00138565. Based on interview and record review, the facility failed to, 1) ensure a complete and accurate nursing assessment was done after a significant change involving 1 resident (Resident #701), and 2) ensure the facility had a policy to follow for assessment regarding signs/symptoms of infection (not feeling well, increased temp, tiredness, nausea), resulting in hospitalization with a diagnosis of urinary tract infection (UTI) and sepsis (extensive infection), antibiotic given, and the likelihood for serious injury. Findings Include: [...]