Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Clare during CMS and state inspections, most recent first.
A resident with dementia and CHF had inconsistent BP monitoring and missed documentation of midodrine administration despite multiple SBP readings below the ordered threshold, and an LPN Unit Manager said the order had been entered incorrectly. Another resident with CHF, CAD, and type II DM had a blood glucose of 39 mg/dl, received orange juice and lunch, but the required 15-minute recheck and physician notification were not documented; the LPN said the follow-up glucose was obtained but not charted and the DON confirmed the recheck should have occurred within 15 minutes.
The facility failed to ensure timely follow-up on a pharmacist’s monthly drug regimen review for a resident with COPD, CKD, and dementia. The pharmacist recommended evaluating the risks versus benefits of primidone and considering a gradual dose reduction, and the physician noted hospice should evaluate the recommendation. However, the medication remained active on the resident’s order summary, and the DON could not confirm that hospice had been notified or that the recommendation had been evaluated.
Premises Not Maintained in Clean and Repaired Condition: A trash can placed under a leaking pipe in the basement was observed overflowing with water onto the floor and toward a drain, while the MD stated maintenance knew about the leak and that the pipe needed replacement. In a separate observation, a green mold-like substance was seen on the face of a mini-split unit in the dining room, and the HM stated maintenance was responsible for cleaning the unit by removing the front panel.
The facility failed to report an allegation of abuse to the state agency within the required 2-hour timeframe for two residents with dementia and anxiety. One resident struck another resident's arm, and the NHA stated the report was delayed because the day was very busy working through the incident. Facility policy required immediate reporting, no later than 2 hours, to the state licensing/certification agency.
A resident requiring assistance with toileting did not receive incontinence care according to professional standards when a CNA failed to change gloves and perform hand hygiene between cleaning fecal and vaginal areas, and did not apply barrier cream as directed by the care plan.
Surveyors found that the facility did not provide documentation of an annual diesel fuel quality test for the emergency generator, as required by NFPA 110. The most recent test report was over a year old and showed the fuel did not meet ASTM standards.
The facility failed to accurately report PBJ information to CMS, leading to a deficiency related to staffing levels. This was due to salaried staff not clocking in when working as CNAs and a glitch in the timekeeping system during a payroll changeover.
Missed Midodrine Parameters and Incomplete Hypoglycemia Follow-Up
Penalty
Summary
The facility failed to follow professional standards of practice related to midodrine administration for a resident with dementia and congestive heart failure. The resident had an order for midodrine 2.5 mg every 8 hours as needed for hypotension when systolic blood pressure was less than 100 mmHg, but blood pressure checks were not completed three times daily from 3/19/2026 through 4/13/2026. During that period, blood pressures were checked inconsistently, sometimes once a day, sometimes twice a day, and sometimes not at all. The MAR showed midodrine was administered only once during that timeframe, and several systolic blood pressure readings below 100 mmHg were documented without corresponding documentation that the medication was given. An LPN Unit Manager reviewed the order and blood pressure readings and stated the order had been entered incorrectly and that it appeared doses of midodrine had been missed. The facility also failed to follow the ordered hypoglycemic protocol for a resident with congestive heart failure, atherosclerotic heart disease, and type II diabetes. The resident had a blood glucose of 39 mg/dl and was given orange juice and lunch, with documentation stating the blood sugar would be rechecked after lunch. The active order required orange juice, food, or glucose gel for blood sugar less than 60 mg/dl, with a recheck in 15 minutes and physician notification as needed. The EMR showed a later blood sugar of 74 mg/dl, but there was no documentation of the follow-up check or physician notification. An LPN stated the follow-up blood sugar was obtained but not documented and that the primary physician was not notified of the low blood sugar result. The DON confirmed the blood sugar should have been rechecked within 15 minutes and the physician notified if indicated.
Failure to Follow Up on Pharmacist Medication Review Recommendation
Penalty
Summary
The facility failed to ensure timely follow-up on a pharmacist’s monthly drug regimen review recommendation for one resident, R46, who was admitted with diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, and dementia. A pharmacist review dated 1/5/26 recommended evaluating the risks versus benefits and considering a gradual dose reduction of primidone 50 mg, with the medication to be given 0.5 tablet daily for 1 week and then discontinued. The physician response on 1/6/26 indicated hospice was to evaluate the recommendation, but review of the resident’s order summary on 4/15/26 showed primidone 50 mg remained an active order at 0.5 tablet by mouth twice daily. During interview on 04/15/2026 at 9:48 AM, the DON stated he was unable to confirm that hospice had been notified to evaluate the recommendation and that the recommendation had not been evaluated.
Premises Not Maintained in Clean and Repaired Condition
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises. On 04/13/2026, a trash can was observed sitting under a leaking pipe in the basement area and was overflowing with water, with the overflow running down the hallway toward a floor drain. When the observation was pointed out, the Certified Dietary Manager stated that maintenance was aware of the leak and had said it was coming from the ice machine drain line. Later that day, the water in the trash can was still overflowing onto the floor, and the Maintenance Director stated that maintenance was responsible for emptying the water from the container and that the leak was coming from a metal pipe that needed replacement. The Maintenance Director also stated that water was dripping off the metal beam next to the pipe because it was running along the block ceiling and coming out at that point.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency within 2 hours for 2 residents, R9 and R25, who were reviewed for abuse. R9 was admitted with diagnoses including dementia and anxiety, and R25 was admitted with diagnoses including dementia and anxiety. The incident report showed that R25 struck R9's left arm with the back of an open hand on 3/11/2026 at 10:20 AM, but the allegation was not reported to the state agency until 1:52 PM the same day. In interview, the NHA stated the report was delayed because the day was very busy working through the incident. Facility policy required alleged or suspected abuse to be reported immediately, and no later than 2 hours for an allegation of abuse, to the state licensing/certification agency.
Failure to Follow Professional Standards During Incontinence Care
Penalty
Summary
A resident with a history of altered mental status, urinary tract infection, and muscle weakness was admitted to the facility and assessed as requiring assistance with toileting due to urinary incontinence. The resident's care plan directed staff to apply barrier cream after incontinence care. During an observed episode of incontinence care, a CNA cleaned feces from the resident's buttocks and anus, then proceeded to clean the vaginal area without changing gloves or performing hand hygiene in between these tasks. Additionally, the CNA did not apply the prescribed barrier cream after completing incontinence care. Upon interview, the CNA stated she was unaware of the need to change gloves and perform hand hygiene between cleaning different body areas and reported she had not been taught this during her certification or at the facility. The CNA also acknowledged forgetting to apply the barrier cream. The unit manager confirmed that staff are expected to change gloves and perform hand hygiene when moving from a dirty to a clean area during incontinence care. Facility policy also requires hand hygiene when moving from a contaminated to a clean body site, and specifies that glove use does not replace hand hygiene.
Failure to Perform Annual Diesel Fuel Quality Test for Emergency Generator
Penalty
Summary
The facility failed to provide documentation that an annual diesel fuel quality test was performed for the essential electrical system (EES) generator, as required by NFPA 110. During record reviews on two separate dates, surveyors found that the last available vendor report for diesel fuel testing was dated over a year prior, and there was no evidence that a fuel quality test had been conducted within the last 12 months. Additionally, the most recent diesel fuel quality test report provided by the vendor indicated that the fuel did not meet ASTM standards. This deficiency pertains to the maintenance and testing requirements for the emergency generator system, which is critical for supplying power in the event of an electrical failure. The lack of current and compliant diesel fuel testing documentation means the facility did not meet the required standards for ensuring the reliability of its emergency power source. No specific residents or patient conditions were mentioned in relation to this deficiency.
Plan Of Correction
No specific residents were identified. The fuel sample was taken during generator repair on 2/10/2025. Fuel sample was analyzed by lab for Number 1 Diesel when we run Number 2 Diesel. Lab was contacted to re-analyze fuel sample for correct fuel type. Cummins reanalyzed previous fuel sample for Diesel number 2 with passing results. NHA and Senior Maintenance Director reviewed the Generator Testing policy, which was deemed appropriate on 2/10/2025. Administrator provided re-education regarding proper maintenance and testing of the generator to the Senior Maintenance Director and Maintenance crew on 2/10/2025. If maintenance of the generator coincides with fuel sample testing, it will be done regardless of the repairs to be made to ensure compliance. NHA/designee will audit monthly. Results will be reported to QAPI, and audits will not be discontinued until substantial compliance is achieved. NHA is responsible for compliance.
Inaccurate PBJ Reporting Due to Timekeeping Issues
Penalty
Summary
The facility failed to report accurate Payroll Based Journal (PBJ) information to CMS, resulting in a deficiency related to staffing levels. The issue was identified during a review of the CMS PBJ Staffing Data Report for fiscal year Quarter 4 2024, which revealed an 'Excessively Low Weekend Staffing' trigger. Interviews with the Registered Nurse/Staff Scheduler (RN/SS) and the Nursing Home Administrator (NHA) indicated that the deficiency may have been caused by salaried nurses and other staff, such as the Activity Director and facility Transportation staff, not punching in on a time clock when working as CNAs. Additionally, a glitch in the facility's time clock system during a payroll/timekeeping system changeover may have contributed to the inaccurate reporting.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Clare
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Woods Nursing Center | 7.7 mi | ★★★★★ | 13 | 0 |
| The Laurels Of Mt. Pleasant | 15 mi | ★★★★★ | 2 | 0 |
| Medilodge Of Mt. Pleasant | 15 mi | ★★★★★ | 6 | 0 |
| Isabella County Medical Care Facility | 15 mi | ★★★★★ | 8 | 0 |
| Gladwin Pines Nursing And Rehabilitation Center | 17.2 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.