Medilodge of Marshall: Guardian Not Notified of Transfer - MI
Nobody called the legal guardian.
The resident, identified in inspection records only as R7, had lived at the Marshall facility twice, most recently after a readmission. Their diagnoses included paraplegia and neuromuscular dysfunction of the bladder. A cognitive screening conducted in January 2026 found R7 fully intact, scoring 15 out of 15. A legal guardian and conservator had been established for them, a formal legal arrangement that places decision-making authority with the guardian, not with other family members.
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 told staff they were okay, needed to sleep, and refused to go to the hospital. That note was written at 5:53 in the evening. No record in the inspection report indicates the guardian was contacted then, either.
By the morning of February 12, R7 was placed on supplemental oxygen, tested for COVID-19, and transferred to the emergency room. R7 never returned to the facility.
The guardian learned about the transfer the way people find out things they were supposed to be told first: after the fact, and from someone other than the people responsible for telling them. A grievance form filed that same day, February 12, documented the guardian's frustration at not being contacted before R7 was sent to the hospital.
When inspectors interviewed a registered nurse at the facility on May 28, the nurse said the standard was clear: if a resident was not their own responsible party, staff were supposed to call the responsible party before sending that resident to the emergency room. The unit manager, interviewed separately the same day, confirmed that R7's legal guardian should have been notified at the time of transfer. If the guardian couldn't be reached, the next emergency contact should have been called instead, and any attempt to reach the guardian should have been documented.
The medical record contained no documentation of any attempt to contact the guardian. What it did contain was a notation that a family member, someone not listed as the legal guardian, had been notified of the transfer.
Inspectors cited the facility for failing to notify the resident representative of a change in condition, classifying the violation as affecting a few residents and causing minimal harm or potential for actual harm. The citation stemmed from a complaint investigation completed May 28, 2026.
The gap between what happened and what the facility's own staff described as standard practice is not complicated. A nurse knew the rule. The unit manager knew the rule. The guardian had legal authority over decisions involving R7. When R7, who had refused hospital transport two days earlier, was finally sick enough that staff made the call for them, the one person legally designated to be part of that decision was not reached.
R7 did not come back from the hospital. The record does not say what happened next.
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.
Nobody called the legal guardian.
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.