Medilodge of Clare

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure professional standards of practice were followed regarding 1) administration of blood pressure medication with parameters and 2) treatment of hypoglycemic episodes for 2 residents (R6 and R85) of 7 residents reviewed. Findings include: Resident #6 (R6) Review of a Face Sheet revealed R6 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and congestive heart failure. Review of R6's active Physician's Orders on 4/13/2026 revealed midodrine HCI tablet 2.5 mg (a medication that increases blood pressure), started 3/19/2026, give 1 tablet by mouth every 8 hours as needed for hypotension (low blood pressure) give if SBP (systolic blood pressure, the top number in the reading that measures the maximum pressure in your arteries when your heart beats) is less than 100 mmHg (millimeters of mercury). Further review of the Electronic Medical Record (EMR) revealed that R6's blood pressure had not been checked three times a day…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #2978434.Based on interview and record review, the facility failed to report an allegation of abuse to the state agency within 2 hours for 2 residents (R9 and R25) of 3 residents reviewed for abuse.Findings include:Review of a Face Sheet revealed R9 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and anxiety.Review of a Face Sheet revealed R25 admitted to the facility on [DATE] with pertinent diagnoses which included dementia and anxiety.Review of the facility reported incident (MI-FRI #63868) revealed R25 struck R9's left arm with the back of his open hand on 3/11/2026 at 10:20 AM. Further review revealed this incident was reported to the state agency on 3/11/2026 at 1:52 PM.In an interview on 4/14/2026 at 10:15 AM, the NHA reported this allegation of abuse was not reported to the state agency within 2 hours because the day was very busy working through the incident.Review of facility policy/procedure Abuse Prevention Program, revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure timely follow up for the monthly drug regimen review recommendations for 1 resident (R46) of 5 residents reviewed for unnecessary medication.Findings include:Review of an Face Sheet revealed R46 admitted to the facility on [DATE] with pertinent diagnoses which included chronic obstructive pulmonary disease, chronic kidney disease, and dementia. Review of R46's Pharmacist Monthly Medication Review dated 1/5/26 revealed a recommendation to evaluate the risks versus benefits and consider a gradual dose reduction to primidone (used to treat seizures), 50 milligrams (mg) give 0.5 tablet every day for 1 week, then discontinue. Physician response noted on 1/6/26 for hospice to evaluate the recommendation. Review of R46's Order Summary on 4/15/26 revealed an active order for primidone 50 mg to give 0.5 tablet by mouth twice daily. In an interview on 04/15/2026 at 9:48 AM, the Director of Nursing (DON) stated that he was unable to confirm that hospice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living for residents. Findings include:On 04/13/2026 at 10:47AM, observed a trash can sitting under a leaking pipe in the basement area. The trash can was serving as a container and was overflowing with water; the overflow was running down the hallway towards a drain in the floor. When observation was pointed out to Certified Dietary Manager (CDM) R, CDM R stated that the maintenance department is aware of the leak, as they had told CDM R that the leak was coming from the ice machine drain line. On 04/13/2026 at 2:30PM observed that the water in the trash can, under the leaking pipe in the basement area, continued to overflow onto the floor. Maintenance Director (MD) H when asked who is responsible for emptying the water from the container, MD H responded that the maintenance department is responsible for emptying the water out. MD H proceeded to explain that the leak…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure incontinence care was provided according to professional standards of practice for 1 resident (R104) of 5 residents reviewed for incontinence care. Findings include: Review of an admission Record revealed R104 admitted to the facility on [DATE] with pertinent diagnoses which included altered mental status, urinary tract infection, and muscle weakness. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R104, with a reference date of 2/17/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 13, out of a total possible score of 15, which indicated R104 was cognitively intact. Further review of same MDS assessment revealed R104 required assistance with toileting and was incontinent of urine. Review of a current incontinence Care Plan intervention for R104, initiated 2/11/2025, directed staff to apply barrier cream…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all residents residing in the facility. Findings include: Review of the CMS PBJ Staffing Data Report FY (fiscal year) Quarter 4 2024 (July 1 - September 30)revealed the metric Excessively Low Weekend Staffing Triggered In an interview on 2/05/25 at 10:28 AM., Registered Nurse/Staff Scheduler (RN/SS) E reported there was a possibility that the Excessively Low Weekend Staffing had Triggered on the PBJ report from CMS because nurses who are salaried position often work the floor and do not punch in on a time clock. RN /SS E reported as for Certified Nurse Aides (CNA's) this could also be true, because the Activity Director (AD) and the facility Transportation staff do not punch in either to her knowledge. RN /SS E reported both of those staff members work the units as CNAs when the facility runs short. RN /SS E reported she was a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #: MI00140715 Based on observation, interview, and record review, the facility failed to accommodate the needs of 2 residents in a timely manner (Resident #178 and Resident #227) out of 3 residents reviewed for accommodation of needs, resulting in delays in care provided to residents. Findings: Review of a Face Sheet revealed R178 was a [AGE] year-old female, admitted to the facility on [DATE], with pertinent diagnoses of pneumonia, diabetes mellitus type 2, history of falls, morbid obesity, and need for assistance with personal care. R178 was her own decision maker and cognitively intact. During an observation on 01/08/24 at 12:15 PM, R178's call light was on, staff entered the room at 12:20 PM, and the call light was turned off. Staff exited the resident's room. During an observation on 01/08/24 at 1:09 PM, R178's call light was activated. During the same time, R178 stated that the call light was activated an hour ago, staff came in and turned off the light, and told R178 that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 2 of 8 residents (Resident #4 and #33), reviewed for the provision of nursing services, resulting in blood pressures not being assessed prior to medication administration and medications administered outside of the physician ordered parameters, and the potential for an unsafe elevation of blood pressure and the worsening of a medical condition. Findings: Resident #4 (R4) Review of an admission Record revealed R4 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: orthostatic hypotension (low blood pressure that happens when you stand up from sitting or lying down). Review of R4's Physician Order dated 9/15/23 revealed, Midodrine HCl Tablet 2.5 MG Give 1 tablet by mouth three times a day for vasopressor (constrict blood vessels) hold if systolic blood pressure (top number) is greater than 120. Midodrine is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #: MI00137844 Based on interview and record review, the facility failed to 1.) ensure controlled substances were accurately documented and 2.) ensure narcotic medications were administered following the physician order for 4 residents (Resident #108, #109, #110, and #111), reviewed for controlled substances, resulting in narcotic medications not being administered and the potential for drug diversion of controlled substances and pain not being adequately controlled. Findings include: Resident #108 (R108) Review of an admission Record revealed R108 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: muscle spasms. Review of R108's Physician Order dated 2/10/23 revealed, KlonoPIN Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth two times a day related to OTHER MUSCLE SPASM. Review of R108's Controlled Substance Record revealed no Klonopin was not administered on 8/16/23. Review of R108's Incident Audit Report…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.