Clearstream Rehabilitation and Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 18, 2024

  This citation pertains to intakes: MI00146150, MI00146185, MI00146924 This citation has 2 deficient practice statements. DPS #1: Based on observation, interview, and record review, the facility failed to ensure the safety and prevent elopement for 3 (Resident#100, Resident #101, Resident #105) of 5 residents reviewed for elopement, resulting in an Immediate Jeopardy when Resident #100 and Resident #101 left the premises alone, unbeknownst to staff, for an extended period, and were later found in the community and the likelihood for serious harm and/or injury for Resident #105. […]

• Actual harm, isolatedF600Sep 18, 2024

  This citation pertains to intakes MI00146152, MI00146926 Based on interview, and record review, the facility failed to protect the residents right to be free from resident to resident abuse for 4 (Resident #102, Resident #103, Resident #107 and Resident #108) of 5 residents reviewed for abuse, resulting in Resident #102 physically assaulting Resident #103, and Resident #107 grabbing Resident #108 in a sexual manner. Findings include: Resident #102 Review of an Admission Record revealed Resident #102 was originally admitted to the facility on [DATE] with pertinent diagnoses which included: unspecified dementia (a group of thinking and social symptoms that interfere with daily functioning). […]

• Actual harm, isolatedF689Jun 25, 2024

  This citation pertains to intake #MI00143822. Based on interview and record review, the facility failed to use a sit-to-stand lift (a medical device used to assist individuals in transitioning from a seated to a standing position), as recommended by therapy and per care plan, during a transfer from the resident's bed to wheelchair in 1 (Resident #100) of 3 residents reviewed for safety, resulting in the resident sustaining a laceration requiring sutures. Findings include: Review of an Admission Record revealed Resident #100 was a female, originally admitted to the facility 3/6/24, with pertinent diagnoses which included: muscle weakness (generalized), and cognitive communication deficit. […]

• Actual harm, isolatedF689Mar 26, 2024

  Based on observation, interview, and record review, the facility failed to implement facility fall protocols and utilize gait-transfer belts/implement interventions before and after falls and provide adequate supervision for 2 residents (Resident #65 & #64) of 3 reviewed for falls/supervision resulting in a fall with a fracture needing surgical repair for Resident #65 and the potential for accidents and injuries to residents at risk for falls. Findings include: Resident #65 Review of an Admission Record revealed Resident #65, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: muscle weakness. […]

• No harm, potential for more than minimal, widespreadF804May 5, 2026

  Based on observation, interview, and record review the facility failed to provide food at a palatable temperature for 1 of 1 resident (R33), resulting in the potential for decreased food consumption for all residents who receive food from the kitchen and nutritional decline.Findings Include: Resident #33 During an interview on 5/3/2026 at 10:08 AM, Resident #33 reported ongoing concerns with cold food. Resident #33 reported she felt that the food was a bit warmer when served in the dining room, but when she ate meals in her room, the food was always cold. Resident #33 reported she had spoken with multiple facility staff members on numerous occasions about her concerns with food, but they were still serving cold food often. […]