Chesaning Nursing And Rehabilitation Center

F 0675 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

has been lying in bed since 2:30PM. He refused his 4pm med stating he doesn't care about it and refuses to get up out of bed. Refused dinner as well. Denies pain and will continue to monitor. Record review of resident #101's 8/1/2025 at 8:28 PM nursing progress note revealed: Resident has been tearful and lying in bed since 2:30PM. He refused all nighttime medications times 3. He stated he did not care. He refused dinner as well. Record review of Resident #101's 8/1/2025 Medication Administration Record (MAR) noted Ativan 1mg Intramuscular injection (IM) one time daily for 1 day. Ativan medication was administered at 8:21PM by the Nursing Home Administrator/Director of Nursing. In an interview on 8/20/2025 at 11:35 AM,

the Nursing Home Administrator/Director of Nursing about the Ativan IM injection stated that Resident #101 was just upset that he was going to get a staff member fired, and he did not like the other staff talking about it. He couldn't sleep at night, and I called (physician) and got the Ativan order for IM injection and gave it myself. Record review of Resident #101's Nurse Practitioner's note dated 8/4/2025 revealed investigation initiated 8/1/2025 for allegation of patient abuse by staff regarding patient's inappropriate relationship with a staff member. The nurse spoke with patient on 8/4/2025 in regard to the incident on 8/1/2025. He stared he was not happy staff reported this and stated he wants to get out of here as soon as possible. Patient currently working for community placement. Patient has been tearful related to incident, refusing showers, meds, and to get out of bed .Record review of the facility 'Promoting/Maintaining Resident Dignity' policy, undated, revealed it is the practice of the 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 resident's quality of life by recognizing each resident's individuality.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chesaning Nursing and Rehabilitation Center

201 South Front Street Chesaning, MI 48616

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Nursing about the Ativan IM injection stated that Resident #101 was just upset that he was going to get Staff member fired, and he did not like the other staff talking about it. He couldn't sleep at night, and I called (physician) and got the Ativan order for IM injection and gave it myself. Record review of facility 'Use of Psychotropic Medications' policy undated, revealed it is the intent of the policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms . (1.) A psychotropic drug is any drug that affects brain activities associated with mental process and behavior. Psychotropic drugs include but are not limited to the following categories: Antipsychotics, antidepressants, anti-anxiety, and hypnotics. (3.) Other medications not classified as antipsychotic, antidepressant, antianxiety, or hypnotic medications but can affect brain activity should not be used as a substitution for another psychotropic medication unless prescribed with a documented clinical indication for use consistent with accepted clinical standards of practice. (9.) Prior to initiating or increasing a psychotropic medication, the resident, family, and/or representative must be informed of the benefits, risk and alternatives for medication, including and black box warnings for antipsychotic medications, in advance of such initiation or increase. (11.) The facility will document that the resident or resident representative was informed in advance or the risk and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use. (e.g , written consent form, narrative note, etc.)Record review and interview on 8/20/2025 at 11:55AM with the Social Worker G reviewed Resident #101's point click care medical record of Resident #101's consent dated 8/19/2025 for Ativan IM was not dated and placed into the PCC on 8/19/2025. The Social Worker G stated that she should have dated the consent form; the nurse administered the medication. Record reviews of progress notes revealed that there was no verbal consent documented, and no written consent documented. The Social worker G stated that Ativan is an antianxiety medication and not used for sleep aid.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chesaning Nursing and Rehabilitation Center

201 South Front Street Chesaning, MI 48616

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

hallway with his urinary catheter bag and tubing uncovered (not in a privacy bag) and dragging on the floor.

The catheter bag was wet from being outside dragging on the ground and got the floor wet, also it was not

in the privacy bag that was hanging on his wheelchair.

During an interview done on 8/19/25 at 11:58 a.m., Nursing Assistant/CNA J stated “yes, I see it (the catheter dragging on the floor), he just came in from outside, it should not be on the floor.”

During a phone interview done on 8/19/25 at 11:14 a.m., Family Member #1 stated My dad said the Therapy room is dirty and smells, he said it was disgusting. The halls smell and the place is dirty.

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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