Medilodge Of Marshall
Medilodge of Marshall in Marshall, MI — inspection on May 28, 2026.
Found 8 citations. 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
Based on interview and record review, the facility failed to notify
include:
Review of the medical record reflected R7 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included paraplegia and neuromuscular dysfunction of the bladder.
The Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/9/26, reflected R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).
According to the medical record, R7 had a Legal Guardian/Conservator in place. R7 discharged to the hospital on 2/12/26 and did not return to the facility. A Progress Note for 2/10/26 at 5:53 PM reflected R7 was lethargic, tired, sleeping all day and refused a meal.
According to the note, R7 reported they were ok, needed to sleep and refused to go to the hospital. A Progress Note for 2/12/26 at 10:36 AM reflected R7 was alert but disoriented, confused and had abnormal vital signs, including a temperature of 103.3 (degrees Fahrenheit), a pulse of 134 (beats per minute), a respiratory rate of 22 (breaths per minute) and an oxygen saturation of 88 (percent).
The note reflected R7 was placed on oxygen, tested for COVID-19 and transferred to the emergency room (ER).A grievance form, dated 2/12/26, included documentation that R7's Guardian was frustrated about not being contacted first, when R7 was transferred to the hospital. In an interview on 5/28/26 at 10:42 AM, Registered Nurse (RN) M reported if a resident was not their own responsible party, they were to call the responsible party to ask about sending a resident to the ER for evaluation. In an interview on 5/28/26 at 12:36 PM, Unit Manager (UM) P reported R7's Legal Guardian should have been notified when R7 was transferred to the hospital on 2/12/26. In the event the Legal Guardian was unavailable, the notification should have been made to the next emergency contact. UM P indicated there should have been documentation if they attempted to call the Guardian but could not reach them.
According to R7's medical record, a family member, who was not listed as being R7's Legal Guardian, was notified of their transfer to the ER.
The medical record did not reflect that R7's Legal Guardian was notified of the transfer.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
235495 05/28/2026
Medilodge of Marshall 879 East Michigan Ave Marshall, MI 49068
entitled Conclusion revealed Not verified- the allegation was refuted by evidence collected during the
in his wheelchair in the hallway. R6 did not respond to verbal questions.
235495 05/28/2026
Medilodge of Marshall 879 East Michigan Ave Marshall, MI 49068
required and had not contacted the police as required. NHA could not explain why NHA A had not
235495 05/28/2026
Medilodge of Marshall 879 East Michigan Ave Marshall, MI 49068
on 01/28/2026. NHA A explained that it was his expectation that the facility investigation should
root cause determined, Pain assessment completed, skin assessment completed, Physician see the
plan updated. NHA A confirmed that facility had not contacted the police as required, and had not completed an adequate investigation of the incident that had occurred between R3 and R6 on 01/28/2026. NHA A could not explain why a complete investigation had not been conducted for the resident to resident altercations between R3 and R6.
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Medilodge of Marshall 879 East Michigan Ave Marshall, MI 49068
acknowledged that she would have expected to see an additional intervention.
Regarding R1's fall on
identified a root cause sooner and been more proactive in preventing falls.
235495 05/28/2026
Medilodge of Marshall 879 East Michigan Ave Marshall, MI 49068
management, including leaving a urostomy bag unemptied for too long can increase the risk of urinary
stoma or ureters, especially if urine remains stagnant in the pouch.
Stagnant urine is more likely to
235495 05/28/2026
Medilodge of Marshall 879 East Michigan Ave Marshall, MI 49068
Findings include:On 5/21/26 at 11:46 am a test tray was provided to the survey team.
The stated
mocha fudge cake.
The meal provided was observed to be stuffed pepper casserole, corn and not mocha fudge cake but rather a pistachio cake.
The stuffed pepper casserole lacked an appetizing appearance, as it consisted primarily of rice and a meat sauce, and did not contain visible peppers. the casserole was tasted and determined to lack flavor.
The corn lacked flavor as well.
The meal served did not match the posted menu and overall deemed unappealing in appearance and palatability.
In an interview on 5/21/26 at 2:19 pm, Resident #11 was interviewed regarding the lunch meal. Resident #11 rated the stuffed pepper casserole as nasty with no flavor.
235495 05/28/2026
Medilodge of Marshall 879 East Michigan Ave Marshall, MI 49068
During the interview, R12's lunch tray was delivered. R12 lifted the cover on her plate and an observation of ham on her lunch plate was made. R12 abruptly stopped the Certified Nursing Assistant who delivered her tray and requested an alternative main entree. R12 confirmed that she did not like pork, which included the ham that was delivered on her plate and confirmed that this had been discussed with dietary staff on more than one occasion.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.