Medilodge of Clare

In the surveyor’s words

From the most serious findings on record at Medilodge of Clare, in the surveyor’s own words.

• Actual harm, isolatedF684Aug 25, 2023

  This citation pertains to intake #: MI00135530 Based on interview and record review, the facility failed to 1.) ensure licensed nurses were competent in the provision of care for a diagnosis of [NAME] Syndrome, 2.) identify a change in condition, 3.) perform a comprehensive assessment following a change in condition, and 4.) ensure complete and accurate documentation for 1 resident (Resident #102) reviewed for quality of care, resulting in a delay in medical treatment and R102's subsequent death. Findings: Resident #102 (R102) Review of an Admission Record revealed R102 was a [AGE] year-old male, originally admitted to the facility on [DATE] and readmitted on [DATE], with pertinent diagnoses which included: [NAME] Syndrome. […]

• Actual harm, isolatedF684Jan 5, 2023

  This citation is related to intake #MI00130701 Based on interview and record review, the facility failed to provide quality care for two residents (Resident #222 and Resident #30 ) by (a) failing to identify, assess, and monitor for a change in condition for Resident #222 and (b) failing to notify the physician of, and initiate a new antibiotic order based on culture and sensitivity for Resident #30 , resulting in (a) severe septic shock and death for Resident #222 and (b) rehospitalization with pneumonia, urinary tract infection and sepsis for Resident #30. […]

• Actual harm, isolatedF689Jan 5, 2023

  This citation pertains to intake # MI00129347 Based on observation, interview, and record review, the facility failed to ensure resident safety by 1.) providing accurate assessments, 2.) implementing care planned interventions, 3.) monitoring residents, and 4.) implementing safety interventions for residents on leave, for 5 residents (Resident #8, #223, #26, #54, and #48) reviewed for accidents, hazards, and supervision, resulting in falls for Resident #223 and Resident #26, a clavicle fracture for Resident #8, and the potential for further falls, serious injury, and a deterioration in health status. […]

• No harm, potential for more than minimal, widespreadF851Feb 6, 2025

  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. […]

• No harm, potential for more than minimal, patternF658Apr 15, 2026

  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… […]