Medilodge of Marshall: Guardian Not Notified of Transfer - MI
The guardian found out another way. They filed a grievance.
The resident, identified in inspection records only as R7, had been living at the facility with diagnoses of paraplegia and neuromuscular dysfunction of the bladder. Cognitive screening conducted in January 2026 showed R7 scored a perfect 15 out of 15, fully intact. R7 had a legal guardian and conservator in place, the kind of formal legal arrangement that exists precisely for moments like this one.
Two days before the transfer, on the evening of February 10, a nurse documented that R7 was lethargic, sleeping all day, and had refused a meal. R7 said they were okay, that they needed to sleep, and declined to go to the hospital. Staff noted it and moved on.
By the morning of February 12, R7 was alert but disoriented and confused. The vital signs told a more urgent story: temperature 103.3, pulse 134, respiratory rate 22, oxygen saturation 88 percent. Staff placed R7 on oxygen, administered a COVID-19 test, and called for a transfer to the emergency room. R7 did not return to the facility.
The grievance form, dated February 12, captured the guardian's response. They were frustrated, the form noted, about not being contacted before R7 was sent to the hospital.
When inspectors interviewed a registered nurse at the facility on May 28, she described the protocol plainly: if a resident had a responsible party other than themselves, staff were supposed to call that person before sending the resident to the ER for evaluation. The unit manager, interviewed the same day, confirmed that R7's legal guardian should have been notified at the time of the transfer. If the guardian couldn't be reached, the next emergency contact should have been called instead. Either way, the attempt and its outcome should have been documented.
No such documentation existed in R7's medical record. What the record showed instead was that a family member, someone not listed as the legal guardian, had been notified of the transfer. Whether staff knew the difference between that person and the guardian, or whether they simply reached for the nearest contact and stopped there, the inspection report does not say.
The citation, classified as causing minimal harm or potential for actual harm, covered one resident out of four reviewed. Inspectors conducted the complaint inspection on May 28, 2026.
The mechanics of what went wrong are not complicated. A resident with a legal guardian, a guardian whose role exists to be the first call in exactly this kind of emergency, was transferred to a hospital in acute distress while that guardian waited. The facility's own unit manager acknowledged, when asked, that the guardian should have been notified. The registered nurse acknowledged the same protocol. The gap between what staff knew the procedure required and what actually happened on February 12 produced a grievance form instead of a phone call.
R7 never came back to Medilodge of Marshall. The guardian's first formal accounting of what happened to their ward that morning arrived not from a nurse, but from a piece of paper they had to file themselves.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medilodge of Marshall from 2026-05-28 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 21, 2026 · Our methodology
Medilodge of Marshall in Marshall, MI was cited for violations during a health inspection on May 28, 2026.
The guardian found out another way.
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.