Medilodge of Grand Rapids: DNR Violation Immediate Jeopardy - MI
That gap, federal inspectors concluded, put the resident in immediate jeopardy. If that person's heart had stopped before anyone caught the error, staff would have had no documentation telling them to stand down. They would have started CPR on someone who had explicitly said no.
The January 2026 complaint inspection found that the facility had admitted a resident without securing a signed advance directive or a physician's order reflecting the person's code status in the facility's electronic health record system, called PCC. The inspection report does not name the resident. It does say they were a new admission within the previous 14 days when the problem was discovered.
The violation was cited at the immediate jeopardy level, the most serious classification federal inspectors assign, reserved for situations where a facility's failure has caused or is likely to cause serious injury, harm, or death.
Advance directives are among the most fundamental documents a nursing home handles. A do-not-resuscitate order means exactly what it says. If a resident coded and staff found no DNR in the record, their training and their legal exposure would push them toward CPR, toward cracked ribs and chest compressions and a resuscitation attempt on a person who had spent time making clear that was not what they wanted. The inspection report put it plainly: performing CPR on someone who wished to be do-not-resuscitate would cause both physical and psychosocial harm, and would directly contradict that person's medical care wishes and their life wishes.
The facility's own admission policy, reviewed and on file, said that prior to or at the time of admission, the attending physician must provide the facility with information needed for the immediate care of the resident, including care orders. The policy also required the facility to secure appropriate medical records before or upon admission. That process broke down for this resident. The signed advance directive was not uploaded into PCC. The code status was not confirmed. The physician had not been looped in to issue an order.
Nobody caught it until inspectors arrived.
Once the immediate jeopardy citation landed, the facility moved quickly. The director of nursing and the nursing home administrator reviewed the CPR and advance directive policy and determined it was still appropriate. The problem, then, was not the policy. It was that the policy wasn't being followed.
The social services director audited all 50 residents in the facility to check that every person's code status was accurately reflected in the medical record and that a signed advance directive had been uploaded into PCC. The audit found no additional problems. The director of nursing ran a separate, targeted audit of every resident admitted in the previous 14 days, reviewing 7 residents, and found no further discrepancies.
All 22 licensed nurses on staff were educated on the corrected process. Eighteen received in-person, face-to-face training. Four were reached by phone. The education covered how to complete advance directive paperwork on admission, how to involve the designated responsible party, and how to notify the physician to obtain orders and get them placed in PCC.
The new procedure works like this: the admitting nurse meets with the resident or their responsible party immediately upon admission to address code status. The completed paperwork is faxed to a preprogrammed number on the facility fax machine, which transmits the document directly to the provider's email. The provider can sign it and return it by phone to the facility fax. The nurse also calls the provider to make sure they know the document is coming. The goal is to close the window between a resident's arrival and the moment their wishes are documented and ordered.
Weekly audits, to be conducted by the director of nursing for 12 weeks, were put in place to verify that new admissions are having their code status documented by the admitting nurse. Those audits are set to continue until the facility's quality assurance and performance improvement committee determines that substantial compliance has been achieved.
The immediate jeopardy designation was removed after the facility completed those corrective steps.
What the inspection report leaves unresolved is the period before any of that happened. The resident at the center of this citation was admitted, had a code status that was not reflected in the record, and remained in that condition for some stretch of time, the exact length of which the report does not specify. During that window, the gap existed. The inspection report does not say whether anything happened to the resident during that time, whether their condition changed, whether anyone had occasion to look for a code status and found nothing there.
What it does say is that a reasonable person who wished to be do-not-resuscitate would not want CPR performed to save their life. That is not a bureaucratic formulation. It is a description of what was at stake.
Nursing homes handle advance directives badly with some regularity, and the consequences almost never surface until something goes wrong. The paperwork problem is easy to minimize, easy to treat as an administrative lapse rather than a clinical one. But the advance directive is the mechanism by which a person's end-of-life decisions survive their own incapacity. When someone is unconscious or in cardiac arrest, they cannot speak for themselves. The record speaks for them. When the record is empty, the record speaks for nobody.
Medilodge of Grand Rapids is a 50-bed facility. At the time of the inspection, all 50 beds were occupied. The audit covered every one of those residents. The facility's response was comprehensive and fast once the citation was issued. Twenty-two nurses retrained. New fax protocols established. Weekly audits scheduled.
None of that changes what the inspection found: a resident who had made a decision about how they wanted to die, and a facility that, for a period of time, had no record of it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medilodge of Grand Rapids from 2026-01-29 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 Grand Rapids in Grand Rapids, MI was cited for immediate jeopardy violations during a health inspection on January 29, 2026.
That gap, federal inspectors concluded, put the resident in immediate jeopardy.
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.