Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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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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 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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