Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 St. Clair during CMS and state inspections, most recent first.
Overflowing Dumpster Area and Improper Refuse Storage: The facility failed to properly dispose of waste and keep the exterior refuse area maintained. During observation with the Food Service Manager, dumpsters were seen overflowing with stacked trash bags piled above the top edge so the lids could not be closed. The manager stated the containers were usually overflowing after the weekend and believed they were emptied once a week.
Pest Control Program Not Maintained: The facility failed to maintain an effective pest control program by eliminating harborage conditions. The dish machine area had sludge buildup, damp flooring, accumulated items on the floor, and numerous gnats on the pipes and back wall under the soiled drain board. The Food Service Manager confirmed the gnats and stated the flooring needed a good cleaning.
Cold and unpalatable food was reported by multiple residents and resident council members. A resident council group raised ongoing concerns about food temperature and taste, and committee minutes documented repeated cold food complaints over several months. Several residents said meals were served cold in the dining room and in rooms, and one resident reported limited availability of alternate menu items and preferred breakfast foods. The NHA stated food was expected to be delivered in a timely manner to maintain temperature.
Insufficient staffing led to delayed call light response and resident care needs not being met for multiple residents. A CNA reported heavy assignments due to call-ins and lack of help from med techs, while residents reported repeated long waits for assistance, including call lights taking up to an hour to be answered. Records showed some residents needed substantial to maximal assistance with ADLs, and resident council minutes documented ongoing concerns about slow response times. During observation, one resident waited nearly 20 minutes while staff passed by, and the NHA stated the expected call light response time was within 30 minutes.
A resident was moved away from a spouse after the facility accepted a new admission and said the resident’s room was the only option. The resident reported receiving only about 10 minutes’ notice and was visibly upset and crying after the move. SS staff said they were not involved, and the NHA acknowledged it was a last-minute decision. Record review found no documentation that the resident or guardian received written notice or the reason for the room change.
PASARR screening was not completed timely for two residents. One resident with schizoaffective disorder had a hospital-exempt PASARR that required an additional Level I review after 30 days, but no updated PASARR was found in the chart and the facility reported it had not been completed. Another resident with anxiety, bipolar disorder, and major depressive disorder had a hospital Level I screening in the record, but the facility could not provide its own completed PASARR; staff said the corporate social worker was handling the forms and the process was being changed.
Failure to Administer Ordered Pain Medication: A resident with chronic pain syndrome reported not receiving prescribed oxycodone for severe pain because staff said it was out of stock, and acetaminophen was given instead. The resident later requested oxycodone again for 10/10 back and leg pain, but an LPN said it was on order and again offered acetaminophen, even though the facility’s back-up supply had the oxycodone available.
Medication availability and administration failures affected two residents. One resident reported delayed eye drops and antibiotics after admission, and the MAR showed multiple missed or undocumented doses, with pharmacy delivery occurring late. Another resident with chronic pain, urosepsis, and multiple comorbidities had delays in pain meds, including Xtampza and PRN hydrocodone/acetaminophen not being given as ordered, and staff reported the opioid was not kept in backup.
Medication Storage and Labeling Deficiencies: A resident with dementia was found asleep with a medication cup containing two pills on the nightstand, and staff did not know how long the meds had been there. In a medication cart, an LPN found an expired Humalog insulin pen that had not been discarded, an Advair inhaler that was not dated when opened, and another inhaler that was not labeled with a resident identifier. The DON stated the insulin should have been discarded and that leaving meds at the bedside was not the facility’s practice.
An LPN failed to perform hand hygiene and did not clean a glucometer, thermometer, or pulse oximeter after use during a medication pass for a resident. The LPN rechecked blood sugar, administered insulin, and used the temperature and pulse ox devices, but no hand hygiene was observed and the devices were returned to the cart without being wiped down; the LPN also reported no sanitizing cloths were available on the med cart.
A resident with severely impaired cognition and a history of escalating aggression grabbed another resident by the neck, squeezed, and pushed the resident to the floor, causing red marks on the neck and an abrasion to the knee. Staff interviews and record review showed the aggressive resident had repeated behavioral episodes, including slamming doors, breaking furniture, and threatening statements, and the behavior care plan identified physical aggression toward residents.
A facility failed to provide timely ADL assistance for three residents who required help with hygiene and toileting. One resident was found in a wet bed and said they were not changed overnight, another reported waiting over two hours to be cleaned and said staff missed scheduled showers, and a third said call lights were often answered late and showers were not always provided as scheduled. A CNA’s response suggested difficulty completing care in a timely manner, and shower refusals were documented without supporting notes or nurse follow-up.
Two residents with multiple medical conditions did not receive their prescribed medications within the required one-hour window on several occasions, as confirmed by MAR review and resident interviews. Staff and DON interviews indicated that delays were due to interruptions, staff assignments, and extended administration times, in violation of facility policy.
A resident with Peripheral Vascular Disease and impaired cognition was administered blood pressure medications without prior checks or hold parameters, leading to hypotension and a vasovagal episode. The facility's policies on medication administration were not followed, as vital signs were not checked before administering the medications, and the physician was not notified of the abnormal readings.
The facility failed to maintain a pest-free environment, leading to flies in the facility and resident complaints. Flies were observed in hallways and resident rooms, with a bent window screen allowing pest entry. A resident with limited mobility was particularly affected, and a CNA reported the issue to maintenance weeks prior, but it remained unresolved.
A facility failed to meet professional standards for medication administration when an RN administered medications to two residents consecutively without returning to the medication cart, signing off, performing hand hygiene, or separately preparing medications. The residents had significant medical conditions, including stroke and Alzheimer's for one, and head injury and depression for the other. The DON and Infection Control Nurse confirmed this practice was unacceptable.
A resident with Chronic Obstructive Pulmonary Disease and Localized Edema did not have compression stockings applied as ordered by the physician. Despite the Treatment Administration Record indicating application, observations and resident reports confirmed non-compliance over several weeks. The DON was unaware of any justification for this lapse, and facility policies lacked guidance on accurate clinical documentation.
A resident with a history of quadriplegia and other conditions had a wound misclassified as non-pressure, despite its location on a pressure point and worsening condition. The facility failed to implement consistent pressure relief measures, and documentation was inconsistent, leading to a deficiency in care.
A facility failed to provide restorative therapy for a resident and did not consistently apply immobilization devices for two residents. One resident did not receive the prescribed therapy sessions, while another was observed without an arm sling despite orders. A third resident was seen without a cervical collar, contrary to medical orders. Staff confirmed the deficiencies, and the facility's policy did not address the application of mobility devices.
A resident with chronic respiratory conditions had an extra portable oxygen tank improperly stored in their room for several days, contrary to facility policy. The tank was observed near the bathroom, and the Director of Nursing confirmed that extra tanks should be stored in a designated oxygen storage room.
Two residents with mild cognitive impairment were observed managing their nebulizer treatments without nursing supervision, contrary to professional standards. Their care plans did not reflect this independence, despite their medical histories of COPD, Obstructive Sleep Apnea, and dementia.
The facility failed to provide medically related social services for two residents. One resident wished to be discharged from hospice to pursue therapy but received no follow-up or documentation. Another resident, cognitively intact, wanted to regain guardianship and stop dialysis, but their concerns were not documented. The Social Services Designee was aware of these issues but did not document them due to discomfort with medical documentation, contrary to facility policy.
A facility failed to implement a 14-day stop date on a PRN antianxiety medication for a resident with End Stage Renal Disease and Atrial Fibrillation. The resident had an intact cognition, and the physician's order for Ativan was active without an end date, violating the facility's policy. Interviews with staff confirmed the oversight.
A medication cart was left unlocked and unattended during a medication pass by an RN, allowing potential unauthorized access. The RN admitted to forgetting to lock the cart, and the DON acknowledged the concern. Facility policy requires medications to be stored securely.
The facility failed to maintain accurate medical records for two residents. One resident had conflicting orders for a sling due to a shoulder condition, while another had outdated dialysis orders despite being on hospice care. Staff interviews confirmed the need to update these records.
A facility failed to follow infection control guidelines when a nurse administered a subcutaneous injection to a resident without wearing gloves. The ICP and DON both indicated that gloves were not necessary for subcutaneous injections, despite the facility's policy and CDC guidelines recommending glove use during procedures with potential exposure to blood or body fluids.
Overflowing Dumpster Area and Improper Refuse Storage
Penalty
Summary
The facility failed to properly dispose of waste and maintain the dumpster area to keep refuse inaccessible to insects and rodents. During observation with the Food Service Manager, the exterior trash refuse area was found with dumpsters overflowing with stacked trash bags, with bags piled above the top edge of the containers so the lids could not be closed. When asked, the Food Service Manager stated the containers were usually overflowing after the weekend and believed they were emptied once a week. The report cited 2022 FDA Food Code requirements that refuse be stored in receptacles or waste handling units so they are inaccessible to insects and rodents and that receptacles kept outside be covered with tight-fitting lids or doors after they are filled.
Pest Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an effective pest control program by eliminating harborage conditions. On 12/8/25 at 7:35 AM, the dish machine was observed with a build-up of sludge on the floor tiles underneath the soiled side drain board, and the flooring was damp. A cup and a small bowl had accumulated on the floor along the back wall, and numerous gnats were observed on the pipes and back wall under the soiled drain board. When questioned, the Food Service Manager confirmed the presence of the gnats and stated that the flooring was in need of a good cleaning. The report cited the 2022 FDA Food Code section 6-501.111 regarding controlling pests and maintaining the premises free of insects, rodents, and other pests.
Cold and Unpalatable Food Served to Residents
Penalty
Summary
Food and drink were not kept palatable, attractive, or at a safe and appetizing temperature for multiple residents. R69, who had intact cognition per the most recent MDS, stated the food was cold and did not taste good. R55 and R80 also reported that food was cold in the dining room and when served in their rooms. During a resident council meeting, eight members voiced concerns about the temperature and taste of the food served, and the meeting minutes documented ongoing palatable food and temperature concerns in July, October, November, and December 2025. R20, who had intact cognition and needed set-up assistance for eating per the MDS, reported that the facility did not order enough food and that substitute items from the alternate menu were not available. R20 stated that chips and bananas were not provided as often as before, that breakfast meat items such as sausage or bacon were rarely available, and that complaints had not led to real changes. During breakfast, R20 did not appear to eat the eggs on the tray and asked the aide to remove the tray. Food committee minutes also documented cold food concerns in July, August, and September 2025. The NHA stated the facility expectation was for food to be delivered in a timely manner to maintain temperature.
Insufficient Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to ensure sufficient staff were available to answer call lights and provide timely resident care for four residents and six group residents in a census of 120. During observation and interview, a CNA reported staffing was "horrible" and said they had twenty patients to care for over the weekend because of call-ins and med techs not helping on the floor. A resident reported that staffing was not enough about three times a week, most often on the midnight shift, and said call lights could take up to 45 minutes to be answered because aides were working shorthanded. Another resident reported waiting 15 minutes for assistance and having waited up to an hour. A third resident reported multiple call-ins and that the facility did not have enough additional staff to fill in, and also stated there had been four Administrators in the last year. Record review showed one resident required substantial to maximal assistance with bathing, dressing, and personal hygiene, and partial to moderate assistance with toileting, while another resident was dependent on staff for bathing, dressing, and personal hygiene. Resident council meeting minutes documented call light response concerns during August and September 2025. During a resident council meeting, six of eight group members said wait times for staff after activating call lights could be up to an hour. On observation in the 300 unit hallway, one resident was waiting close to twenty minutes for a call light to be answered while multiple staff members walked past the room without responding; the call light screen showed the call light activated at 3:05 PM and staff responded at 3:30 PM. When interviewed, the Administrator stated the expectation for call light response time was within thirty minutes.
Failure to Provide Advance Notice for Room Change Separating Spouses
Penalty
Summary
The facility failed to honor a resident’s right to share a room with a spouse and failed to provide written notice before changing the resident’s room. One resident reported being upset after the facility moved them away from their spouse, stating they had been married for three months and had only about three weeks together in the same room. The resident said the facility gave about 10 minutes’ notice before the room change and was observed crying and visibly upset during the interview. Social Services staff stated they were not involved in the room change and only checked on the couple the day after the move, when both residents were upset. The Nursing Home Administrator stated the facility accepted a new resident and the resident’s room was the only option, acknowledging it was a last-minute decision to move the resident away from the spouse. Record review showed a room change on 11/28/25, with no documentation that the resident or guardian was notified. The resident had been admitted and readmitted with a diagnosis of right femur fracture, and the facility policy required advance notice of room changes and inclusion of the reason for the move.
PASARR Screening Not Completed Timely for Two Residents
Penalty
Summary
The facility failed to ensure PASARR screening was completed timely for two residents. One resident was admitted with diagnoses including schizoaffective disorder, stroke, and high blood pressure. The PASARR form dated 09/24/25 documented the admission as a hospital-exempt discharge with an expectation that the resident would remain at the facility less than 30 days, which required an additional Level I PASARR after 30 days. Record review showed no additional PASARR in the medical record, and on 12/10/25 the facility reported that the additional Level I PASARR had not been completed. A second resident was admitted on 7/22/25 with diagnoses including anxiety disorder, bipolar disorder, current episode mixed, major depressive disorder, and diabetes. The resident was cognitively intact and required 2-person assist for ADLs. The medical record contained a Level I pre-admission screening form completed by the referring hospital that identified current mental illness, treatment for mental illness, and prescribed psychotropic medications, including Wellbutrin and Buspar. When the facility’s PASARR was requested, the form provided was the hospital form rather than a facility-completed PASARR. The social worker stated that the corporate social worker was completing PASARRs and that the process for completing the forms was being changed.
Failure to Administer Ordered Pain Medication
Penalty
Summary
The facility failed to administer pain medications as ordered for a resident with chronic pain syndrome, heart failure, and diabetes who was cognitively intact and required one-person assistance with activities of daily living. The resident reported that they had been dealing with pain and did not receive prescribed oxycodone the prior night because they were told it was out of stock, and that acetaminophen was given instead even though it did not relieve the pain as well as oxycodone. The resident’s care plan included administering medications per orders and observing for side effects and effectiveness, and the active physician’s order was for oxycodone 5 mg by mouth every 4 hours as needed for pain. Record review showed the resident received oxycodone on 12/7/25 for a pain level of 10, then later asked an LPN for oxycodone for 10/10 pain affecting the back and legs. The LPN checked the electronic record, stated the medication was on order, and offered acetaminophen, which the resident accepted; a pain patch was also applied to the lower back. The facility’s back-up supply medications showed the resident’s oxycodone was available in the facility, and the facility’s Medication Administration policy did not address pain management or obtaining medications from the back-up supply.
Medication Availability and Administration Failures
Penalty
Summary
The facility failed to ensure medications were available for two residents, including one resident who reported missing doses of newly ordered medications after admission and another resident whose pain medications were not available or not administered as ordered. For the first resident, the record showed admission from the hospital with diagnoses including nonrheumatic aortic valve stenosis, intact cognition, and a need for assistance with activities of daily living. The resident reported that eye drops and antibiotic medication were delayed, and the MAR showed cefazolin doses were not documented on the evening of admission and the following day, while latanoprost was coded as unavailable with a progress note stating the medication was unavailable. The resident’s November MAR also showed 18 scheduled medications that were not documented as administered. The unit manager stated the resident’s medications were not delivered timely, and the pharmacy delivery manifest showed the medications were delivered late in the evening after the resident had already been admitted earlier that day. This created a gap between the ordered medications and their availability for administration. For the second resident, the record showed admission for urosepsis, altered mental status, abdominal pain, and dysuria, with diagnoses including arthritis, left above-the-knee amputation, and depression, and an MDS showing intact cognition and severe pain frequently in the prior five days. Physician notes documented that the resident was out of pain medication and that medications were sent immediately on request, while nursing notes documented transfer to the hospital for uncontrolled pain after the resident refused non-pharmacological interventions. The MAR showed Xtampza and PRN hydrocodone/acetaminophen were not given on multiple days, the controlled substance record showed the last Xtampza dose was given several days earlier, and nursing staff reported delays in obtaining pain medications and that Xtampza was not kept in backup.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not properly stored and labeled for one resident and in one medication cart. On 12/08/2025, during a tour of the Dementia unit, R6 was observed asleep in bed with a medication cup containing two pills on the nightstand. An unidentified nurse stated the day shift had not yet begun medication pass and did not know how long the medications had been left there. R6’s record showed admission on 8/27/25 with diagnoses of Alcohol Dependence with Alcohol-Induced Persisting Dementia, Metabolic Encephalopathy, and Major Depressive Disorder, and the resident was moderately cognitively impaired and required one-person assistance with activities of daily living. The record did not show a self-administration of medications assessment. On 12/09/2025, review of the D wing medication cart with an LPN found a Humalog insulin pen for R67 with an opened date of 11/06/25 that had not been discarded, a Fluticasone Salmeterol Advair 250-50 mcg inhaler for R66 that was not dated when opened on the inhaler, and a Fluticasone-Salmeterol 250-50 mcg inhaler for R42 that was not labeled with a resident identifier on the inhaler. The DON stated the expired insulin should have been discarded and also stated that leaving medications at R6’s bedside was not the facility’s practice. The facility policy required medications to be stored according to manufacturer recommendations, and the manufacturer inserts stated the Advair inhaler should be discarded one month after opening and the Humalog pen should be discarded after 28 days.
Hand Hygiene and Device Cleaning Not Performed During Medication Pass
Penalty
Summary
The facility failed to ensure hand hygiene and medical device cleaning were completed during a medication pass for one resident. During observation on 12/10/2025 at 8:23 AM, an LPN removed five oral medications, a glucometer, a lancet, a glucose test strip, and an alcohol pad from the medication cart and entered the resident’s room to recheck blood sugar. The LPN donned gloves, handed the medication cup to the resident, used the lancet to obtain a blood sample from the resident’s left hand, doffed gloves, returned to the cart, and then prepared and administered insulin using an insulin pen into the back of the resident’s left arm. The LPN then used a thermometer to check the resident’s temperature on the left temple and a pulse oximeter on a digit of the left hand. The glucometer, thermometer, and pulse oximeter were placed back on top of the cart without being wiped down after use, and no hand hygiene was observed during the medication pass. The LPN had a bottle of hand sanitizer in a pocket but did not use it, and reported there were no sanitizing cloths for the devices on the medication cart. The DON stated the expectation was for the nurse to complete hand hygiene before and after each incidence of care. The facility policy titled Medication Administration, revised 01/17/23, stated to wash hands prior to administering medication and to wash hands using facility protocol and policy.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect one resident from physical abuse by another resident. An incident report dated 11/28/25 stated that while one resident was having a behavioral episode in the hallway, another resident walked past and was grabbed by the neck, squeezed, and then pushed to the floor, causing the resident to fall onto their knees and buttocks. An LPN intervened and redirected the aggressive resident away from other residents. The injured resident stated, "[the other resident] was choking me, almost killed me," and was observed with an abrasion on the front of the right knee and redness to the elbow. Record review showed the aggressive resident had a history of escalating behavioral episodes, including yelling, slamming doors, breaking furniture, and making statements such as "die, die, die" and "kill myself." The resident's behavior care plan identified physical aggression toward residents and directed staff to keep the resident safe during episodes of behaviors. The aggressive resident had diagnoses including Alzheimer's disease and COPD and a most recent MDS showing severely impaired cognition. The injured resident also had severely impaired cognition and diagnoses including schizoaffective disorder and dementia. Interviews with staff confirmed the aggressive resident had become increasingly aggressive over the prior two to three months, and the DON stated staff could have taken the resident to a quiet area to calm down when escalating.
Delayed ADL Assistance and Call Light Response
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living for three residents who required help with care. R19, who had moderately impaired cognition and required assistance with ADLs after a right femur fracture, was observed on 12/08/2025 with a large wet area in the middle of the bed and reported not being changed during the midnight shift. R19 also stated they sometimes had to wait a long time for assistance. R55, who had intact cognition and required assistance with ADLs due to progressive neurological conditions, reported waiting over two hours to be cleaned after having a soiled brief and said staff told them they were too busy to provide scheduled showers. R55’s shower documentation included refusals without a progress note explaining the reason or nurse follow-up. R80, who had intact cognition and required assistance with ADLs due to COPD, reported often waiting a long time for call light response and not always receiving showers as scheduled, stating the wait time had been awful since the facility switched to a pager system. A CNA gave a nonverbal response when asked about completing care for all residents in a timely manner, and the NHA was informed that call lights and ADLs were being monitored on an ongoing basis.
Failure to Administer Medications Within Required Time Frame
Penalty
Summary
The facility failed to administer physician-ordered medications within the required time frame for two residents who were cognitively intact and had multiple medical diagnoses, including hypertension, hyperlipidemia, anemia, and major depression. Review of the Medication Administration Records (MAR) for both residents over a 10-day period showed that morning and evening medications were frequently given more than one hour outside the scheduled time, contrary to facility policy. For one resident, morning medications due at 8:00 AM were administered after 9:00 AM on six out of ten days, and evening medications due at 8:00 PM were given after 9:00 PM on six out of ten days. There was also an instance where a blood pressure medication was administered at 0:40 AM instead of the scheduled 8:00 PM. The medications involved included antihypertensives, cholesterol-lowering agents, eye drops, iron, and over-the-counter medications. Interviews with the residents confirmed that medications were often late, with one resident stating they had reported the issue to their family. Staff interviews revealed that delays were attributed to interruptions from residents, nurses being assigned to multiple units, and extended medication administration times. The Director of Nursing confirmed the expectation that medications be administered within one hour before or after the scheduled time, acknowledging that delays could occur due to staff being called to other areas or resident requests. Facility policy required medications to be administered within 60 minutes of the scheduled time unless otherwise ordered by a physician.
Failure to Follow Blood Pressure Medication Hold Parameters
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration for a resident with a diagnosis of Peripheral Vascular Disease and moderately impaired cognition. The resident had active physician orders for Metoprolol Succinate ER and Losartan Potassium for hypertension, but there were no orders to check blood pressure prior to administration or parameters for holding the medication if the blood pressure was below baseline. On the morning of the incident, the resident's blood pressure was recorded as significantly low, yet the medications were administered without prior blood pressure checks. Following the administration of the blood pressure medications, the resident experienced an altered mental status and a vasovagal episode, leading to hypotension and a low pulse. The resident required assistance and was subsequently sent to the hospital for further evaluation. Interviews with the RN and DON revealed that the nurse should have held the medications and notified the physician due to the abnormal blood pressure readings. The facility's policies on medication administration emphasize the need for checking vital signs and holding medications if parameters are not met, which were not followed in this case.
Pest Control Deficiency Due to Flies in Facility
Penalty
Summary
The facility failed to maintain a pest-free environment, resulting in the presence of flies and resident complaints. On October 1, 2024, several flies were observed in the 100 hallway, and a window in a resident's room was found to have a bent screen, creating a gap that allowed pests to enter. The Maintenance Supervisor confirmed the issue but was unaware of any current fly problem. A Quality Assistance Form from April 4, 2024, noted a similar issue with a window screen in another room, indicating a recurring problem. Additionally, a resident in room 117 was observed with flies landing on them, which they found bothersome due to their limited ability to swat them away because of decreased range of motion. A CNA reported that rooms 117 and 118 had significant fly issues and had informed maintenance weeks prior, but the problem persisted.
Medication Administration Deficiency
Penalty
Summary
The facility failed to meet professional standards of care for medication administration for two residents. During an observation in the dining room, a Registered Nurse (RN) was seen administering medication to one resident from a cup containing a yellowish fruit puree. After completing this, the RN administered medication to another resident without returning to the medication cart, signing off on the first resident's medication administration, performing hand hygiene, or separately preparing the second resident's medications. The Director of Nursing and the Infection Control Nurse both confirmed that this practice was unacceptable and not in line with facility protocols. The first resident involved had diagnoses including Cerebral Infarction (Stroke), Atrial Fibrillation, Dysphagia, Aphasia, and Alzheimer's Disease. The second resident had diagnoses of Injury of Head, Fatigue, Repeated Falls, and Major Depressive Disorder. These observations and interviews indicate a deficiency in the facility's medication administration process.
Failure to Apply Compression Stockings as Ordered
Penalty
Summary
The facility failed to apply compression stockings as ordered by the physician for a resident diagnosed with Chronic Obstructive Pulmonary Disease and Localized Edema. The physician's orders specified that compression stockings should be applied to the resident's bilateral lower extremities before getting out of bed and removed at bedtime to manage pedal edema. However, observations on multiple occasions revealed that the resident was not wearing the compression stockings, and the resident reported that they had not been applied for approximately three weeks. The Treatment Administration Record inaccurately reflected that the compression stockings had been applied on specific dates, despite evidence to the contrary. The Director of Nursing was unaware of any reason for the non-application of the stockings and confirmed that the expectation was for the physician's order to be followed. There was no documentation of resident refusals or clinical justification for not applying the stockings, and the facility's policies did not address the accuracy of clinical documentation.
Failure to Properly Classify and Manage Pressure Ulcer
Penalty
Summary
The facility failed to properly classify and manage a pressure ulcer for a resident, leading to a deficiency in care. The resident, who was dependent on staff for all care, had a wound initially classified as Moisture-Associated Skin Damage (MASD) and later as a non-pressure full-thickness skin injury. Despite the wound's location on a pressure point and its characteristics consistent with a pressure ulcer, it was not reclassified as such. The wound care providers and facility staff continued to document it as a non-pressure wound, even though the wound had worsened over time. Observations and interviews revealed that the resident was often seated in a high-back manual wheelchair with inadequate pressure relief, contributing to the wound's deterioration. The resident reported discomfort and pain while seated, and the facility's care plan included interventions such as a positioning wedge and pressure-relieving boots, which were not consistently implemented. The resident's non-compliance with offloading and prolonged periods in the wheelchair were noted, but the facility did not provide alternative seating arrangements or ensure consistent use of pressure-relieving devices. The facility's documentation and communication regarding the wound were inconsistent and incorrect. The Minimum Data Set (MDS) assessments did not reflect the presence of a pressure ulcer, and the facility matrix incorrectly listed the wound as a Stage 4 pressure ulcer. The Director of Nursing and other staff members acknowledged the discrepancies and the potential for the wound to be a pressure area, yet no corrective actions were taken to address the classification and management of the wound. This lack of appropriate intervention and documentation led to the deficiency in pressure ulcer care for the resident.
Failure to Provide Restorative Therapy and Apply Immobilization Devices
Penalty
Summary
The facility failed to provide recommended restorative therapy for a resident, identified as R59, who was observed not receiving the prescribed therapy. R59 reported not walking with staff or regularly receiving restorative therapy exercises, which were supposed to occur five times a week. A review of R59's restorative therapy logs for September 2024 showed participation in walking only once out of eight opportunities and range of motion exercises once out of ten opportunities, with no refusals documented. The logs frequently noted that the sessions were not scheduled, and there was no monthly summary provided for September 2024. The Restorative Aide, CNA K, confirmed the lack of consistent therapy offerings, citing being pulled to assist with showers as a reason. The facility also failed to apply immobilization devices for two residents, R5 and R107, as prescribed. R5, who had a recurrent dislocation and pain in the left shoulder, was observed multiple times without the required arm sling while out of bed, despite physician orders stating it should be applied when out of bed. R5 had to remind staff to apply the sling, indicating a lack of adherence to the care plan. Similarly, R107, who had a nondisplaced C4 vertebral body fracture, was observed without a cervical collar while out of bed, contrary to physician orders. The collar was supposed to be worn when out of bed or sitting upright, but observations showed it was not consistently applied. Interviews with staff, including the Unit Managers and the Director of Nursing, confirmed the deficiencies in applying the prescribed devices. Staff acknowledged the requirements for the arm sling and cervical collar but failed to ensure they were consistently used as ordered. The facility's policy on physician/practitioner orders did not address the application of mobility devices, contributing to the oversight in care for these residents.
Improper Storage of Portable Oxygen Tanks
Penalty
Summary
The facility failed to safely and properly store portable oxygen for one resident, identified as R27. R27, who has diagnoses including Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure, was observed using an oxygen concentrator. A portable oxygen tank was attached to R27's four-wheeled walker, and a second portable tank was stored in a wheeled cart near the bathroom in R27's room. R27's roommate was not using oxygen, and R27 was unsure why the extra tank was placed near the roommate. The extra oxygen tank remained in the room over several days, contrary to the facility's policy, which requires that extra oxygen tanks be stored in a designated oxygen storage room. The Director of Nursing confirmed that the expectation is for extra tanks to be stored in the oxygen storage room, not in residents' rooms.
Failure to Provide Supervised Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving nebulizer treatments. Resident 61 was observed using a nebulizer without a nurse present during and after the treatment. The resident, who has a history of COPD, Obstructive Sleep Apnea, and Dyspnea, was readmitted to the facility after hospitalization. Despite having mild cognitive impairment, the resident was left to manage the nebulizer treatment independently, which was not reflected in their comprehensive care plan. Similarly, Resident 93, who has a history of COPD, COVID-19, and dementia, was observed completing a nebulizer treatment without nursing supervision. The resident, who also has mild cognitive impairment, was left to manage the treatment independently, including turning on the nebulizer and storing the equipment without proper cleaning. This practice was also not documented in the resident's care plan. Interviews with the Unit Manager and the Director of Nursing confirmed that such activities should be reflected in the care plans.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services for two residents, R23 and R73, as observed during the survey. R23 expressed a desire to be discharged from hospice services to pursue therapy for potential improvement in transfers, aiming for a possible discharge home. Despite communicating these wishes to multiple staff members, including the hospice nurse, R23 received no follow-up or documentation of their request. The Director of Nursing (DON) was aware of R23's concerns and had referred the matter to the Social Services Designee, Staff P, but no documentation was found in R23's medical record regarding their wishes. Staff P acknowledged awareness of R23's wishes but admitted to not documenting the discussions due to discomfort with documenting nursing complexities. R73, another resident, expressed a desire to regain guardianship, believing their current guardian, a family member, was only meant to act as a power of attorney if they became incapacitated. R73, who was cognitively intact, reported wanting to stop dialysis against the guardian's wishes. Despite being aware of R73's concerns, Staff P failed to document any follow-up or discussions regarding the guardianship issue or the resident's wish to stop dialysis. The DON had expected documentation of these concerns, but none was found in the medical record. The facility's policy on social services emphasizes the provision of medically related social services to help residents achieve their highest practicable well-being. However, the lack of documentation and follow-up on the residents' expressed wishes indicates a failure to adhere to this policy. Staff P admitted to not documenting the residents' concerns due to uncertainty about how to document medical issues, and this lack of documentation was not addressed with their supervisor or the DON.
Failure to Implement 14-Day Stop Date on PRN Antianxiety Medication
Penalty
Summary
The facility failed to implement a 14-day stop date on a PRN antianxiety medication for a resident, which is a requirement for psychotropic medications. The resident, who was admitted with diagnoses of End Stage Renal Disease and Atrial Fibrillation, had an intact cognition as indicated by a BIMS score of 14/15. The physician's order for Ativan, a psychotropic medication, was active with no end date specified, contrary to the facility's policy that mandates a limited duration for PRN orders. Interviews with the Social Worker and the Director of Nursing confirmed the oversight, acknowledging that there should have been a stop date on the order.
Medication Cart Left Unlocked During Administration
Penalty
Summary
The facility failed to ensure that a medication cart was locked during medication administration, as observed by a surveyor. On the morning of October 2, 2024, a Registered Nurse (RN) was seen preparing medications for a resident from the C-wing cart. After placing the medications in a pill cup, the RN entered the resident's room to administer the medications, leaving the cart unlocked and unsupervised. During this time, the surveyor observed another resident and a maintenance staff member near the unattended cart, which was accessible to both residents and staff. Upon questioning, the RN acknowledged forgetting to lock the cart and recognized the potential risk of unauthorized access to the medications. The Director of Nursing (DON) was also informed of the incident and acknowledged the concern regarding the unsecured cart. The facility's policy on medication storage, revised earlier in the year, mandates that all medications be stored in locked compartments and that during medication passes, medications must be under the direct observation of the administering personnel or locked in the storage area or cart.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in their care. For one resident, who was admitted with recurrent dislocation and pain in the left shoulder, there were conflicting physician orders regarding the use of a sling and swathe. The medical record contained two active orders, one from February and another from September, with the latter being the correct one following an orthopedic follow-up. This discrepancy was identified during an interview with the Unit Manager, who acknowledged the need to discontinue the outdated order. Another resident, admitted with end-stage renal disease and atrial fibrillation, had active physician orders for hemodialysis, despite having elected to stop dialysis due to being on hospice care. The resident expressed frustration at having to inform staff repeatedly about the cessation of dialysis. Interviews with the Unit Manager and the Director of Nursing confirmed that the orders for dialysis should have been discontinued, highlighting a lapse in updating the resident's medical records to reflect their current care plan.
Failure to Use Gloves During Subcutaneous Injection
Penalty
Summary
The facility failed to adhere to infection prevention and control guidelines regarding glove use during a subcutaneous injection for one resident. On October 2, 2024, at 7:40 AM, a registered nurse (RN) was observed administering a subcutaneous injection to a resident without wearing gloves during a community breakfast. When questioned, the Infection Control and Prevention Practitioner (ICP) stated that gloves are required for intramuscular injections but not necessarily for subcutaneous injections, such as insulin. Similarly, the Director of Nursing (DON) indicated that administering a subcutaneous injection without gloves was acceptable. A review of the facility's Infection Prevention and Control Program Policy, last revised on October 25, 2022, under the section on Standard Precautions, mandates that licensed staff adhere to safe injection and medication administration practices as outlined in relevant facility policies. The Centers for Disease Control and Prevention (CDC) guidelines recommend wearing gloves during blood glucose monitoring and any procedure involving potential exposure to blood or body fluids.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near East China
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marwood Manor Nursing Home | 12.2 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Richmond | 14.5 mi | ★★★★★ | 1 | 0 |
| The Village Of East Harbor | 16.4 mi | ★★★★★ | 1 | 0 |
| Michigan Veterans Home Of Chesterfield Township | 19.3 mi | ★★★★★ | 1 | 0 |
| Medilodge Of Port Huron | 19.9 mi | ★★★★★ | 0 | 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.