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F0921
E

Environmental Cleanliness and Safety Deficiencies in Resident and Therapy Areas

Chesaning, Michigan Survey Completed on 08-20-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

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