Medilodge of Livonia: Bladder Scan Failures After Catheter - MI
The resident, identified in inspection records only as R901, had been admitted to the facility with a broken left femur, diabetes, and hypertension. They required one to two people to help with basic daily activities. A catheter had been placed for urinary retention. On the morning of November 29, 2025, a night nurse removed it.
That same morning, a progress note recorded that the attending physician had been contacted and told about the removal. The physician ordered bladder scans every six hours to monitor for retention. The order was placed. Staff were told to continue monitoring.
What followed was weeks of gaps.
According to the December 2025 medication administration record reviewed by inspectors, two bladder scans went undocumented on December 1st. On December 2nd, there were none. Two more were missing on the 3rd, two on the 4th, two on the 5th. December 6th, 7th, 8th, and 9th showed no documented bladder scans at all, four straight days with nothing recorded. The resident was discharged to the hospital sometime before December 10th.
Nine days. Across that stretch, inspectors counted at least fourteen individual bladder scans that either weren't done or weren't recorded.
There was a second problem buried in the medical record. A physician order dated November 29th, instructing staff to contact the provider if a bladder scan showed more than 500 cubic centimeters of urine retained, had not actually been entered into the system until December 19th, nine days after the resident had already left the facility. The order existed on paper with a November date. In practice, it hadn't been accessible to nursing staff when it mattered.
When inspectors interviewed the Assistant Director of Nursing on May 27th at 12:19 in the afternoon, she acknowledged all of it. She explained that an audit of R901's medical record had been conducted after the resident discharged, and that the audit revealed the physician's bladder scan order had been entered incorrectly into the system. Because of that error, she said, the volume readings from completed scans had not been captured in the record.
She added that nursing staff had been measuring the resident's output during that period.
But she acknowledged it hadn't been documented.
On the missing scan dates, the nine days where the record showed nothing, she acknowledged those too. She did not offer an explanation for them.
The distinction the ADON drew, between measuring and documenting, is not a minor one. A bladder scan order exists so that a physician can track whether a patient is retaining dangerous amounts of urine and intervene before the situation becomes a medical emergency. If the results aren't recorded, the physician can't see them. The threshold written into the order, contact the provider if retention exceeds 500 cc, cannot be acted on if no one writes down what the scan showed. And if the scan isn't done at all, the question of what the physician could have known becomes moot.
R901 was cognitively impaired. They could not have flagged their own symptoms, sought out a nurse, or demanded to know why the monitoring had lapsed. They depended entirely on the staff carrying out what the physician ordered.
Inspectors noted that the facility's medication order policies did not address documentation requirements or ensuring physician orders are carried out according to professional standards. The citation was classified as causing minimal harm or potential for actual harm. Whether the gap in monitoring contributed directly to the hospitalization was not determined in the inspection report.
What the record shows is a resident who needed close watching after a catheter came out, a physician who ordered that watching every six hours, and a facility that couldn't account for where that monitoring went across more than a week. The resident was already in the hospital by the time anyone audited the chart.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medilodge of Livonia from 2026-05-27 including all violations, facility responses, and corrective action plans.
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: August 13, 2026 · Our methodology
Medilodge of Livonia in Livonia, MI was cited for violations during a health inspection on May 27, 2026.
The resident, identified in inspection records only as R901, had been admitted to the facility with a broken left femur, diabetes, and hypertension.
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.