Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 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.
Improper sanitizer concentration was identified in the food service area when the rag sanitizer bucket tested at zero during lunch observation. The CDM stated the bucket needed to be changed out and that it is changed when visibly soiled or every 2 hours, while also stating the solution should be 200 ppm. The report notes that wiping cloths must be held in a chemical sanitizer solution at the required concentration and that the solution must be changed as needed to maintain proper concentration.
Infection prevention and control deficiencies were identified involving water management, antibiotic use, and dining room oversight. Two residents were given antibiotics even though McGeer criteria were not met and documentation of signs or symptoms, risk-versus-benefit review, and antibiotic time-out details was absent. The facility also lacked documented Legionella control measures such as dead-leg policy and chlorine residual testing, and the IP did not document dining room rounds while chairs were observed damaged and unstable and a stove in the dining room had torn plastic wrapping.
Call lights were not kept within reach or answered timely for multiple residents, and a heavy urine odor was noted in a back hallway. One resident with chronic lung disease, HF, and delusions said second- and third-shift staff sometimes took an hour or more to answer his call light; another resident with a BIMS of 10 and total ADL dependence was observed with the call light on the floor; and a hospice resident who was confused and totally dependent was twice observed with the call light clipped to a privacy curtain and out of reach. In Resident Council, residents complained that call lights were not answered timely, and one resident reported an incontinence episode because no one responded.
Opened and used meds were found in multiple carts and a medication refrigerator without required dates, including insulin, inhalers, nasal sprays, injections, and topical products. An unlocked treatment cart contained undated creams and ointments, and the med room refrigerator had missing temp log entries plus opened, undated vaccines and a controlled med vial. Staff and the DON acknowledged that carts should be locked when not in use and that opened multi-dose products require dating.
A resident with TBI, explosive disorder, epilepsy, hemiplegia, and total ADL dependence had a behavioral care plan requiring staff to monitor and document observed behaviors and interventions. The record showed repeated movements, yelling, abusive language, rejection of care, screaming, and threatening behaviors, but there was no documentation of interventions or follow-up in the behavior log or progress notes, and the DON and Social Service Director confirmed the lack of documentation.
Failure to update the care plan for a resident with significant functional dependence and multiple medical conditions led to a deficiency. The resident had a new sacral/coccyx wound with packing, surrounding fungal-appearing redness, and a wound infection noted on the CMS 802 form, but the skin impairment care plan had not been revised with new interventions; the DON confirmed the resident had developed a stage II sacral wound/skin tear, while turning q2h and limited time out of bed were not reflected in the care plan.
A resident with major functional dependence, impaired cognition, and an indwelling catheter developed a recurrent Stage II sacral pressure ulcer after earlier coccyx/sacrum skin breakdown. The chart showed missing nursing documentation, no timely care plan updates for the new or reopened wound, and inconsistent wound care, including use of dry gauze instead of ordered dressings and failure to follow a strict q2h turning schedule. Survey observation found the resident flat on the back with the sacral dressing peeling back and packing falling out, while the DON acknowledged the wound and that key interventions were not on the care plan.
Unlabeled Enteral Feeding Solution at Bedside A resident with a PEG tube had an empty Glucerna feeding bottle and tubing at the bedside that lacked the resident’s name, date, time, and rate of infusion. An RN and hospice RN both observed the unlabeled setup, and the RN stated the feeding was hung by night shift and ran all night. The MAR showed a continuous PEG feeding order for dysphagia, and facility policy required the resident’s name, date, and dosing on the feeding bag and bottle.
A resident receiving HD had post-dialysis pressure dressings to the left upper arm fistula site that were observed without a date, and no nursing assessment was documented for the dressing. The resident said she removes the dressings herself and alerts nursing if bleeding starts again. Later, the dressing was found with a backdated date, and an LPN stated she forgot to date it; the chart had no nursing progress note or documented assessment of the dressing site, and the LPN’s competency checklist did not include dialysis pre/post therapy assessment or pressure dressing monitoring.
Missing Annual Nursing Competency for LPN/ICP: The facility failed to ensure an LPN who also served as the ICP/Wound Care nurse completed a 2025 annual nursing skills competency evaluation. HR could not locate the checklist in the employee file, and the DON stated she did not know why it had not been done until the survey inquiry. The DON later presented a dated competency form and said the LPN also worked the resident care floor when needed.
Incomplete psychoactive medication consents for multiple residents. Three residents receiving psychotropic medications had consent forms that did not identify targeted behaviors, medication classifications, clinically significant side effects, or expected benefits. The records showed residents with diagnoses including depression, anxiety, psychotic disorder, dementia, and other chronic conditions, while behavior monitoring documented repeated movement, grabbing, pushing, crying, yelling, swearing, and rejection of care. The facility policy required residents or representatives to be informed of benefits, risks, alternatives, and black box warnings for antipsychotics before psychotropic initiation or dose increase.
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.
Improper Sanitizer Concentration in Food Service Area
Penalty
Summary
The facility failed to maintain best practices in the food service area when the rag sanitizer bucket solution tested at zero with Hydrion QT-40 test strips during lunch observation with the Certified Dietary Manager. During the same observation, the CDM stated the bucket needed to be changed out and said it is changed when visibly soiled or every 2 hours. When asked about the required chemical range, the CDM stated it should be 200 ppm. The report states that cloths used for wiping counters and other equipment surfaces must be held in a chemical sanitizer solution at the concentration specified under the Food Code, and that the sanitizing solution must be changed as needed to minimize organic material and sustain proper concentration.
Infection Prevention Program, Antibiotic Use, and Dining Room Environmental Oversight Deficiencies
Penalty
Summary
The facility failed to maintain an active and ongoing infection prevention and control program for reducing the risk of Legionella and other opportunistic pathogens in premise plumbing, and it also failed to complete infection control environmental rounds of the main dining room. During an environmental tour, a water softener in the basement was observed to be not in use, with the valves shut off, and the Maintenance Director stated there was no dead-end plumbing policy. He also stated the facility had never done chlorine residual testing, although pH testing was performed. The facility’s Water Management Plan stated that control measures, monitoring, weekly and bi-annual testing, visual inspections, and environmental testing for pathogens were to be used, but the infection control data reviewed for 10/25 contained no documentation of a plan to address concerns or issues found. Resident #3, a 67-year-old resident with diabetes, unsteadiness, weakness, and MRSA wound infection, was prescribed Bactrim for a wound infection. The facility infection timeline and McGeer infection surveillance documentation showed the resident did not meet the facility’s infection criteria, and the McGeer checklist was left blank with no documentation of signs or symptoms of a wound infection. The Antibiotic Time Out form also had no documentation from the prescribing NP or the Infection Preventionist explaining why the antibiotic was given when the resident did not meet criteria, or documenting a risk-versus-benefit review. The NP progress note stated the left ankle wound was stalled due to infection, the wound culture was positive for MRSA, and Bactrim was started, but no signs or symptoms of wound infection were documented. Resident #35, an 89-year-old resident with dementia, chronic lung disease, and a history of UTIs, was prescribed Macrobid for a UTI without documented signs or symptoms of infection. The facility infection control tracking sheet showed no signs or symptoms of a UTI, and the McGeer checklist documented that the resident did not meet criteria. The Infection Preventionist stated the family had dipped the urine at home and said it was positive, the facility did not re-dip, and there was no facility policy for dipping urine. The Antibiotic Time Out form contained no documentation from the prescribing NP or Infection Preventionist explaining why the antibiotic was used when the resident did not meet criteria or documenting a risk-versus-benefit review. In the main dining room, several resident chairs were observed with rust, chipped paint, and instability, and a large stove in the corner was covered with tearing plastic wrapping with yellow spots on top; the Infection Preventionist stated she did not document dining room walk-throughs and said the stove had been in the dining room for months.
Call lights not within reach or answered timely; urine odor noted in hallway
Penalty
Summary
The facility failed to protect residents’ rights to be free from neglect for 3 residents and during the confidential Resident Council group, residents voiced anger about call lights not being answered timely, frustration about not being able to reach call lights, and a heavy smell of urine in the back hall. The facility’s policies stated that resident rights and dignity were to be protected, requests for assistance were to be answered in a timely manner, and call lights were to be within reach and accessible to residents in bed. Resident #7, who had chronic lung disease, heart failure, muscle wasting, delusions, and required assistance with ADLs and supervision for behaviors, stated that second- and third-shift staff sometimes took an hour or more to answer his call light. Resident #14, who had a BIMS of 10, required total assistance with all ADLs, and had diagnoses including sepsis, seizures, epilepsy, respiratory failure, traumatic brain injury, and hemiplegia, was observed with the call light on the floor and not within reach. Resident #49, who was confused, on Hospice, and totally dependent for bed mobility, bathing, and dressing, was observed twice with the call light clipped to the privacy curtain about 4 feet from the low bed and out of reach; an LPN stated staff clip call lights to the curtains, and the DON stated staff should not put the call light on the curtain. During the Resident Council meeting, 2 of 6 residents complained that call lights were not answered timely on second and third shifts, one resident reported an incontinence episode because no one answered the call light, and prior council notes also documented call lights taking up to an hour to be answered. A heavy urine smell was also observed in the back hallway, and the DON confirmed the odor.
Medication Labeling, Storage, and Refrigerator Monitoring Failures
Penalty
Summary
The facility failed to follow its medication labeling and storage procedures in two medication carts, a treatment cart, and a medication refrigerator. During observation of the cart for rooms 1 through 12, R42’s Lantus vial had the seal off and no date on the vial or box, R50’s albuterol inhaler was not dated and had no pharmacy label, R19’s Trelegy Ellipta inhaler was not dated, and R28’s ketorolac injection bottle was open and returned to the cart with no open date. In the cart for rooms 13 through 20, R3’s Lyumjev insulin vial had the top removed with no date on the vial or box, R35’s Stiolto Respimat inhaler and a Ventolin HFA inhaler were not dated, opened blood sugar sticks were not dated, R8’s albuterol inhaler was not dated, and R10’s ipratropium nasal spray and R40’s fluticasone nasal spray were opened without dates on the bottle or box. The treatment cart was observed unlocked in the hallway, allowing access to ointments and creams. Inside were opened and used products including R36’s diclofenac topical gel, R12’s hydrocortisone cream, and R20’s mupirocin ointment, all without open dates on the tubes or boxes. Staff stated the treatment cart is usually open and used by nurses, while the DON acknowledged that the treatment cart should be locked when not in use. The DON also stated that multi-dose vials, pens, and containers should be dated when opened because they must be discarded within 30 days or earlier per pharmacy recommendations or manufacturer guidance. In the medication room refrigerator, the temperature log had missing entries for 12/8/25 and 12/9/25, despite the facility’s log requiring temperatures to be checked and recorded at least twice daily. The refrigerator also contained multiple opened and undated items, including floor stock Afluria influenza vaccine, R37’s lorazepam injectable vial with the seal off and no date on the vial or bag, and an opened pneumonia vaccine syringe with the cap removed and no date. The DON could not provide a date for when R37’s lorazepam vial had been opened and used, and record review showed the medication had been received in 11/2024 and last signed out in 2/2025, yet remained in the refrigerator opened and used for over a year. The facility’s multi-dose vial policy stated that opened vials are to be relabeled with a beyond-use date 28 days after opening and include the initials of the nurse who opened the vial.
Failure to Document Behavioral Interventions and Follow-Up
Penalty
Summary
The facility failed to implement Mood/Behavior care plan interventions for Resident #14, a 63-year-old resident admitted with diagnoses including sepsis, back pain, muscle weakness, seizures, difficulty walking, epilepsy, respiratory failure, traumatic brain injury with explosive disorder, and left-sided hemiplegia. The resident was alert and interviewable with a BIMS score of 10 and required total assistance with all ADLs. The care plan for aggressive/behavioral issues directed staff to monitor and document observed behavior and attempted interventions in the behavior log on the ADL sheets. Review of the resident’s Mood/Behavior ADL documentation for the month showed repeated movements, yelling, abusive language, rejection of care, screaming, and threatening behaviors, but there was no documentation of interventions or follow-up for those behaviors. Review of progress notes for the same period also found no documentation of interventions or effectiveness. During the record review with the DON and Social Service Director, both confirmed there was no documentation of behavioral interventions for the targeted behaviors, and the DON stated nurses should have documented interventions and effectiveness while Social Service stated no one documented what they did about the behaviors.
Failure to Update Care Plan for New Sacral Wound
Penalty
Summary
The facility failed to update the care plan interventions for a resident with a complex medical history, including anemia, seizure disorder, bipolar disorder, indwelling catheter, colostomy, and significant functional dependence. The resident’s quarterly MDS dated 11/7/2025 identified moderately impaired cognition, poor decision-making, dependence for eating, oral hygiene, toileting, bathing, dressing, and personal hygiene, and non-weight-bearing status with mechanical lift assistance for mobility. Although the resident was identified on the CMS 802 form as having a wound infection and family reported a new pressure area with redness in the lower buttock area, the skin impairment care plan had not been updated with new interventions; the last skin-related intervention added was dated 12/9/2024. During observation on 12/12/2025, the resident was found lying flat in bed with a sacrum/coccyx dressing dated 12/11/2025. When the dressing was peeled back, wound packing fell out, and the wound was observed as approximately 2 cm long by 1 cm wide with visible depth and a beefy red base. Surrounding skin was noted to have a red area with fungal appearance and irregular borders. The DON reviewed the care plans and stated the resident had developed a stage II sacral wound, which the wound nurse was calling a skin tear, but the care plan still did not include added interventions for the new skin injury. The DON also stated that staff had begun limiting the resident to about 6 hours out of bed daily and that a physician order for strict turning every 2 hours was on the treatment record, but neither was included in the care plan.
Failure to Prevent and Properly Manage a Recurrent Sacral Pressure Ulcer
Penalty
Summary
The facility failed to prevent the development and recurrence of a Stage II pressure ulcer for one resident with significant functional dependence, impaired cognition, non-weight-bearing status, and an indwelling catheter and colostomy. The resident’s records showed no unhealed pressure ulcers on the 11/7/2025 MDS, but the resident had a history of skin breakdown at the coccyx/sacrum area earlier in the year, including a March 2025 skin tear with measurements of 1.6 cm by 0.5 cm by 0.1 cm and a photo showing old scar tissue at the coccyx/sacrum region. The record also showed that the sacral wound was later documented as reopened in July 2025 and identified by the NP as a Stage II pressure ulcer to the coccyx that was deeper and larger than before. The record review showed gaps in documentation and care planning when the sacral wound first appeared and when it recurred. For the March 2025 wound, there were no nursing progress notes identifying the sacrum wound, no measurements, no treatment documentation, and no notification of the physician or responsible party. The skin impairment care plan did not include new interventions for treatment or prevention of sacrum wound development. The wound was later documented as resolved on 3/25/2025. When the wound reopened in July 2025, the chart again lacked nursing progress notes identifying the recurrence, measurements, treatment, or notification of the physician or responsible party, and the skin impairment care plan still did not show new interventions for treatment or prevention of sacrum wound development. The resident’s wound course continued through the fall with repeated NP notes describing an open sacral wound that was not improving, then reopening and worsening, with orders for specific wound treatment and a strict turning schedule every 2 hours. The record stated that nursing was only putting on dry gauze and could not find the ordered treatment dressings even though they were in the wound cart and accessible. Later NP notes documented that the wound was not improving, that the resident was not being turned according to schedule, and that the wound culture was positive for MRSA, requiring antibiotics. On 12/12/2025, survey observation found the resident lying flat on the back with a sacrum/coccyx dressing that peeled back and packing that fell out of the wound; the wound was estimated at 2 cm by 1 cm with a visible beefy red base and surrounding red fungal-appearing skin. The DON reviewed the care plans and stated that the resident had developed a Stage II sacral wound, that the wound nurse was calling it a skin tear, and that the strict turning order and limited time out of bed were not on the care plan.
Unlabeled Enteral Feeding Solution at Bedside
Penalty
Summary
The facility failed to ensure that enteral tube feeding solution was labeled with the resident’s name, date, and rate of infusion for Resident #6. During observation on 12/09/2025 at 9:24 AM, Resident #6 was lying in bed with an empty Glucerna 1.5 cal. bottle/container and tubing at the bedside. The bottle and tubing had no resident name, rate, time, date, or duration of infusion. The hospice RN in the room stated that hospice does not hang feeding tube solution, and when the surveyor asked her to observe the bottle and tubing, she confirmed that it was empty and did not identify whose it was or how long or at what rate it was to run. At 9:26 AM, an RN was brought into the room and also observed the hanging Glucerna 1.5 cal. feeding tube solution, which was empty and lacked a date, time, resident name, and rate of infusion. The RN stated that the feeding tube solution is hung by the night shift and runs all night long. Record review showed that on 12/8/2025 in the evening, Glucerna 1.5 cal. oral liquid was ordered to be given via PEG tube for dysphagia as a continuous feeding from 7:00 PM to 5:00 AM with water to run concurrently at 100 ml/hr. Facility policies reviewed by the surveyor stated that enteral tube feeding medications and feeding tubes should have the resident’s name, date, and dosing present on the feeding bag and tube feeding bottle, and that feeding tubes are to be used according to physician orders including the kind of feeding, caloric value, volume, duration, mechanism of administration, and frequency of flush.
Dialysis Dressing Not Assessed or Dated
Penalty
Summary
The facility failed to assess and monitor a post-dialysis pressure dressing for one resident who received hemodialysis on Monday, Wednesday, and Friday. During an observation, the resident was seated in a wheelchair in her room and had two pressure dressings to the left upper arm fistula access site with folded 4x4 gauze and tape, and no dates were noted on the dressings. The resident stated that she removes the dressings herself and tells nursing staff if the site starts bleeding again, at which time nurses apply a dressing. Later the same day, the dressing was observed with a piece of tape dated 12/8/2025 and initials, which was backdated to the dialysis treatment day. The LPN who was brought to the room stated she forgot the date and reviewed the resident’s nursing progress notes, stating the nurse should have assessed the dialysis dressing site and dated the dressing for 12/8/2025. Record review showed the dialysis communication form documented the left upper arm shunt location, bruit/thrill present, and no bleeding, but there were no nursing progress notes for that day and no documented assessment of the left upper arm pressure dressings. The LPN’s competency checklist also had no skills related to dialysis pre/post therapy assessments or dialysis pressure dressing monitoring post treatment.
Missing Annual Nursing Competency for LPN/ICP
Penalty
Summary
The facility failed to ensure that the Infection Control Preventionist/LPN F completed an annual nursing skills competency evaluation for 2025. During staffing and record review, Human Resource staff member N stated that the annual competency checklist for LPN F was not available and that she did not know why it was missing. The record review of the employee file, binders, and papers in the office did not locate any annual competency for 2025 for LPN F, who had been hired in August 2023 and was expected to have one completed. On 12/12/2025, the DON presented a Licensed Nurse Orientation/Annual Competency Checklist dated 12/11/2025 for LPN F after the state surveyor asked why the annual competency evaluation had not been completed until the survey inquiry. The DON stated that LPN F also worked on the resident care floor as a nurse when needed, that she did not know why the 2025 annual skills/competency had not been done, and that no one had told her about it. The DON also stated that she had recently become DON and signed off on the new checklist, and when asked about completing all required skills on the form in one day, she replied that most of the skills/procedures were done.
Incomplete psychoactive medication consents for multiple residents
Penalty
Summary
The facility failed to identify targeted behaviors, medication classifications, and the duration of therapy on psychoactive medication informed consent forms for three residents who were receiving psychotropic medications. Resident #5 was an elderly resident with diagnoses including debility, heart failure, diabetes, anxiety, depression, bipolar disorder, and PTSD, and was receiving aripiprazole for mood stabilization and escitalopram for depression. The consent form signed by the resident did not identify which medication was for depression or mood stabilization, did not list clinically significant side effects associated with the medication classifications, left the expected benefits section blank, and did not identify targeted behaviors, even though the behavior monitoring task documented repeated movement and grabbing. Resident #6 was an elderly resident with diagnoses including a progressive neurological condition, CAD, HTN, PVD, diabetes, CVA, seizure disorder, anxiety, depression, and psychotic disorder, and was receiving risperidone and mirtazapine via PEG tube for depression, with social work documentation also noting appetite. The psychoactive medication informed consent listed duloxetine, risperidone, and mirtazapine, but the form did not identify targeted behaviors, did not identify clinically significant side effects associated with the medication classifications, and left the expected benefits section blank. The resident’s behavior monitoring task documented repeated movement, pushing, and grabbing. Resident #22 was an elderly resident with diagnoses including non-traumatic brain dysfunction, cancer, anemia, atrial fibrillation, CAD, HTN, non-Alzheimer’s dementia, anxiety, and depression, and was receiving olanzapine, trazodone, venlafaxine, buspirone, and clonazepam for psychiatric symptoms. The consent form listed mirtazapine, olanzapine, clonazepam, and trazodone, but did not identify which medication was for depression or mood stabilization, did not identify clinically significant side effects, left expected benefits blank, and did not identify targeted behaviors. The behavior monitoring task documented frequent crying, yelling and swearing, and rejection of care. The facility policy stated that prior to initiating or increasing a psychotropic medication, the resident, family, and/or representative must be informed of the benefits, risks, and alternatives, including black box warnings for antipsychotic medications, in advance of initiation or increase.
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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Illustrative
What surveyors actually found near you
We read the 214 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 28 | 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 | ★★★★★ | 6 | 0 |
| Optalis Health And Rehabilitation At St. Francis | 16.8 mi | ★★★★★ | 26 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.