Medilodge Of Marshall
Medilodge of Marshall in Marshall, MI — inspection on August 21, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the facility reported incident revealed R5's roommate (R4) alleged R5 was having sexual relations with another person .[R5] has a low BIMS [Brief Interview for Mental Status-a cognitive screening tool] and is unable to consent. As such if activity is occurring, it would be without consent.
Review of the medical record revealed R4 was admitted to the facility on [DATE].
The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/23/25 revealed R4 scored 15 out of 15 (cognitively intact) on the BIMS.
Review of the medical record revealed R5 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction.
The MDS with an ARD of 5/9/25 revealed R5 scored 3 out of 15 (severe cognitive impairment on the BIMS. An observation on 8/20/25 at 1:05 PM revealed R4 and R5 were roommates. R4's bed was near the window and R5's bed was near the door. In a telephone interview on 8/20/25 at 3:27 PM, Certified Nursing Assistant (CNA) D reported on 8/16/25 at 2:28 PM, R5 asked to speak with them privately. CNA D reported R5 told them that someone had been coming into their room and having sex with R4 for the past month. CNA D reported they reported the allegation to Licensed Practical Nurse (LPN) E. CNA D reported they worked again on 8/17/25 at 2:30 AM when R4 alleged someone had sex with R5 again the night before at 10:00 PM. CNA D reported they reported the allegation to the charge nurse at that time and also to Registered Nurse (RN) F. CNA D reported when RN G started their shift the morning of 8/17/25, they asked RN G if they had heard any updates about the allegation.
CNA D reported RN G was not aware of the allegation and it was at that time Nursing Home Administrator (NHA) A was notified of the allegation. In a telephone interview on 8/20/25 at 3:12 PM, RN F reported they became aware of the allegation the morning of 8/17/25 and decided to wait one hour until LPN E came into work (at 6:30 AM) to ask if LPN E had already reported the allegation. In a telephone interview on 8/21/25 at 10:20 AM, LPN E reported on 8/16/25 it was reported to them by a CNA that R4 reported hearing weird noises from R5's side of the room. LPN E reported they did not follow up with R4 to gather more information. LPN E reported it was on 8/17/25 around 6:35 AM that they learned the allegation was related to sexual things happening on R5's side of the room.
The facility reported incident revealed the type of alleged incident was abuse and was discovered on 8/17/25 at 9:30 AM.
The allegation was reported to the State Agency on 8/17/25 at 11:11 AM. In an interview on 8/21/25 at 10:39 AM, NHA A reported they were first made aware of the allegation on 8/17/25 between 9:00 AM and 9:30 AM.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
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