Chesaning Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Chesaning Nursing and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF686Oct 17, 2023

  This 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. […]

• Actual harm, isolatedF637Sep 1, 2023

  This 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. […]

• Actual harm, isolatedF686Jul 20, 2022

  Based on observation, interview and record review, the facility failed to implement preventive measures to prevent 2 Stage II (blisters) heel pressure ulcers for 1 resident (Resident #26) of 3 resident's review for pressure ulcers, resulting in 2 bi-lateral Stage II heel pressure ulcers, pain, discomfort, agitation and wound treatments. Findings Include: Stage two pressure ulcer is partial-thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents as an abrasion, shallow center or blister. High risk residents (immobile, bed bound) should be assessed weekly, when a condition, change or as needed and preventive measures should be in place including pressure relieving devices, position changes, and dietary supplements. […]

• Actual harm, isolatedF686May 25, 2022

  This Citation Pertains to Intake Number MI 371 Based on interview and record review, the facility failed to assess, monitor and ensure appropriate interventions were ordered and provided to prevent worsening of pressure ulcers for 2 residents (Resident #100 and Resident #102) of 3 residents reviewed for pressure ulcers, resulting in Resident #100 developing a facility-acquired Stage 4 (National Pressure Injury Advisory Panel (NPIAP): Full-thickness loss of skin and tissue with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer .) pressure ulcer on the sacrum with no ordered treatment until 12 days after admission and Resident #102 was readmitted with a right buttock/sacral pressure ulcer (Stage 3: NPIAP- Full thickness skin loss in which adipose… […]

• No harm, potential for more than minimal, widespreadF812Dec 12, 2025

  Based 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. Findings include:On 12/09/2025 at approximately 11:30 AM during lunch observation with the Certified Dietary Manager E, the rag sanitizer bucket solution was tested with Hydrion QT-40 test strips, and the result was zero. On 12/09/2025 at approximately 11:30 AM during lunch observation with the CDM E, when interviewed on the chemical solution of the rag sanitizer bucket, the CDM E stated that the bucket needed to be changed out, and it is changed when it's visibly soiled or every 2 hours. […]