Medilodge of Marshall: Guardian Not Notified of Transfer - MI
A progress note from February 10, 2026, recorded that the resident, identified in inspection records only as R7, was lethargic, sleeping all day, and had refused a meal. R7 told staff they were okay, just needed to sleep, and declined to go to the hospital. Nobody called the person legally responsible for R7's care that day.
R7 had a court-appointed legal guardian. That guardian was not a formality. Under Michigan law, a legal guardian holds decision-making authority over a ward's medical care. When R7 said they didn't want to go to the hospital on February 10, the person with legal authority to weigh in on that decision was never contacted.
By the morning of February 12, R7 was alert but disoriented and confused. Vital signs were recorded at 10:36 a.m.: temperature 103.3 degrees Fahrenheit, pulse 134 beats per minute, respiratory rate 22 breaths per minute, oxygen saturation 88 percent. Staff placed R7 on oxygen, tested for COVID-19, and transferred them to the emergency room. R7 did not return to the facility.
The guardian found out from a grievance form, not a phone call.
A grievance dated February 12 documented that R7's guardian was frustrated about not being contacted before the transfer. The medical record confirmed a family member was notified of the ER transfer — but that family member was not R7's legal guardian. There was no documentation that anyone attempted to reach the guardian, no record of a call that went unanswered, no note explaining why the wrong person was contacted instead.
When inspectors interviewed a registered nurse identified as RN M on May 28, 2026, the nurse described the protocol clearly: if a resident had a responsible party, staff were supposed to call that person before sending the resident to the emergency room for evaluation. The unit manager, identified as UM P, was equally direct. R7's legal guardian should have been notified when R7 was transferred on February 12. If the guardian couldn't be reached, the next emergency contact should have been called. Either way, there should have been documentation of the attempt.
There was none.
R7 was cognitively intact. A cognitive screening administered in January 2026 gave R7 a perfect score — 15 out of 15 on the Brief Interview for Mental Status. R7 had been admitted to Medilodge of Marshall with paraplegia and neuromuscular dysfunction of the bladder, conditions that required ongoing management. The guardian's role wasn't incidental. It was the legal structure in place to protect someone whose medical situation was complex enough that a court had decided they needed an advocate.
What R7's guardian got instead was a grievance form and the news that someone else had already been called.
The inspection, completed May 28, 2026, was triggered by a complaint. Inspectors cited the facility for failing to notify a resident representative of a change in condition. The level of harm was classified as minimal harm or potential for actual harm — the lowest tier in the federal citation system.
That classification reflects regulatory categories, not the experience of a legal guardian who was cut out of a medical emergency involving the person they were appointed to protect. R7 had been declining for two days. By the time the ambulance came, oxygen saturation had dropped to 88 percent. The guardian learned about it after the fact, through a piece of paper filed in a folder.
R7 never came back to Medilodge of Marshall.
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.
R7 told staff they were okay, just needed to sleep, and declined to go to the hospital.
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.