Medilodge Of Marshall
Inspection Findings
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake 2595312.Based on observation, interview, and record review, the facility failed to ensure
an abuse allegation was reported timely to the State Agency for one (Resident R5) of five reviewed.Findings include:
Review of the facility reported incident revealed Resident R5's roommate (Resident R4) alleged Resident R5 was having sexual relations with another person .[Resident 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 Resident R4 was admitted to the facility on [DATE REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/23/25 revealed Resident R4 scored 15 out of 15 (cognitively intact) on the BIMS. Review of the medical record revealed Resident R5 was admitted to the facility on [DATE REDACTED] with diagnoses that included cerebral infarction. The MDS with an ARD of 5/9/25 revealed Resident R5 scored 3 out of 15 (severe cognitive impairment on the BIMS. An observation on 8/20/25 at 1:05 PM revealed Resident R4 and Resident R5 were roommates. Resident R4's bed was near the window and Resident 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, Resident R5 asked to speak with them privately. CNA D reported Resident R5 told them that someone had been coming into their room and having sex with Resident 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 Resident R4 alleged someone had sex with Resident 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 Resident R4 reported hearing weird noises from Resident R5's side of the room. LPN E reported they did not follow up with Resident 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 Resident 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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Medilodge of Marshall in Marshall, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Marshall, MI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Medilodge of Marshall or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.