Medilodge Sault Ste. Marie: Insulin Gap Sends Resident to ER - MI
The resident, identified in inspection records as R10, transferred from an assisted living home in October 2025. The transferring facility had not refilled her insulin prescription, so the medication didn't appear on the nursing notes sent with her. It did appear on the physician medication list, sent separately with the physician progress notes. Nobody at Medilodge caught the discrepancy.
R10's daughter, who held durable power of attorney, told inspectors she learned none of this until after her mother was hospitalized on October 16. She said she investigated on her own and pieced together what had happened. The facility's explanation was that the transferring home hadn't included insulin on its medication list.
What the daughter told inspectors was more pointed: no one at the facility asked about insulin, or about diabetes at all, from the moment of admission until EMS arrived to take her mother to the emergency room.
The facility's own diabetic protocol, provided by the administrator during the inspection, states that residents with a diabetes diagnosis should have orders for glucose monitoring, and that a bedside blood glucose test should be given to any resident showing symptoms including confusion or malaise. The facility's medication reconciliation policy calls for comparing orders against hospital records and obtaining clarification when needed.
The director of nursing told inspectors that point-of-care glucose checks were part of the standard admission order set.
R10 had a known diabetes diagnosis. Her physician's records included insulin. She went nine days without it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medilodge of Sault Ste. Marie from 2025-11-26 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Medilodge of Sault Ste. Marie in Sault Ste. Marie, MI was cited for violations during a health inspection on November 26, 2025.
The resident, identified in inspection records as R10, transferred from an assisted living home in October 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.