Medilodge Sault Ste. Marie: Insulin Missed on Admission - MI
The resident, identified in inspection records only as R10, had transferred to Medilodge on September 26, 2025, from an assisted living home. Two documents came with her: nursing notes that included a medication list, and physician progress notes that included a separate medication list. The two lists did not match. Insulin appeared on one. It did not appear on the other.
Nobody caught it.
The reason, the Director of Nursing later confirmed to inspectors, was that the previous facility had stopped refilling R10's insulin prescription, so the drug had dropped off the nursing notes medication list. But the physician's own records, sent at the same time, still showed insulin. The discrepancy was sitting in R10's admission paperwork from day one.
The Director of Nursing told inspectors on October 23 that she could not determine who had reviewed R10's referral documents. That was three weeks after R10 had already been hospitalized. The facility had investigated the incident by that point and had figured out what happened, the DON said, but she still could not name the person responsible for reviewing the records on admission.
R10's daughter, who held her mother's durable power of attorney, said she had no idea her mother was going without insulin or blood glucose monitoring before the hospitalization. She told inspectors she had looked into it herself afterward and reached the same conclusion as the facility: the transferring home had not refilled the prescription, so it never made it onto the medication list tucked into the nursing notes. But the physician's medication list, also sent on September 26, told a different story.
She was asked whether anyone at Medilodge had inquired on admission about what medications R10 was using to manage her diabetes. No inquiry about insulin, she said. No inquiry about diabetes at all. The first time the subject came up, she told inspectors, was when EMS arrived.
The facility's own diabetic protocol, provided to inspectors by the administrator, stated that residents with a diabetes diagnosis should have orders for glucose monitoring and treatment, and that a bedside blood glucose test should be performed for any resident experiencing symptoms of hyperglycemia, including malaise and confusion. The facility's medication reconciliation policy required staff to compare orders against hospital records, obtain clarification as needed, and verify that all medications on hand matched physician orders.
Neither appears to have been followed in R10's case.
The Director of Nursing, when asked whether the facility had a protocol for checking blood glucose levels for diabetic residents on admission, said that point-of-care glucose checks were included in the standard admission order set. She also confirmed, directly, that the facility should have sought clarification from R10's previous physician and her current provider when the two medication lists came in with different information.
That acknowledgment came on October 23. R10 had been admitted on September 26. The gap between those two dates, twenty days, was the window in which she received no insulin and no monitoring.
The inspection was conducted as a complaint investigation. The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a few residents.
R10's daughter did not learn any of this until after her mother was already in the emergency department.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 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 only as R10, had transferred to Medilodge on September 26, 2025, from an assisted living home.
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.