Medilodge Of Munising
Medilodge of Munising in Munising, MI — inspection on April 30, 2026.
Found 3 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
said the (brand name elopement prevention device) alarm went off, but there was not an overhead
gone out in her car to search and called RN E and said, I've got her, but she won't get in the car.
Then
had no coat on. R10 stated she was not going back, but she was so cold and the nurses convinced her she needed some hot chocolate so R10 got in the car and was brought back to the facility. RN E It took about 20 minutes to find the resident and then more time to pick her up and convince her to get in the car.On 4/29/26 the investigation was reviewed and found to be missing many details, but it was confirmed R10 left the building on 4/1/2026 around 5:15 AM and was gone over 25 minutes walking with her walker.The investigation did not include many facts such as the weather conditions on the day of the elopement.
Historical weather was investigated by this Surveyor via the internet site: https://www.accuweather.com/en/us/munising-township/49862/april-weather/2638762 for 4/1/2026 and revealed the temperature on the day of the elopement was 22 - 29 degrees F.R10 eloped from the building in freezing temperatures with potential slippery conditions in the dark morning hours and was gone for over 20 minutes without adequate warm clothing. R10 was found on the sidewalk next to the main highway through the center of town.
This situation represents a risk to the resident's health and safety and placed R10 at the risk of cold exposure and danger of being struck by a car.The elopement was not reported to the SA.The facility presented the policy titled Abuse, Neglect and Exploitation last reviewed 1/10/2024.
The policy read in part, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit abuse, neglect, exploitation, and misappropriation of resident property. 4.
Reporting of alleged violations to the Administrator, state agency, and to all other required agencies. within specific timeframes as required by state and federal regulations: . b.
Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
235410 04/30/2026
Medilodge of Munising 300 West City Park Drive Munising, MI 49862
J said R10 came back into the same door, but he did not know what time that was. It was on the
and came back into the building.
The investigation did not include the conditions at the time of the
elopement event occurred when there was snow in the area and a walker and a person on foot may have left evidence of the exact path taken, but this was not considered in the investigation.
There was no measurement of the distance the resident traveled.The investigation did not include many facts such as the weather conditions on the day of the elopement.
Historical weather was investigated by this Surveyor via the internet site: https://www.accuweather.com/en/us/munising-township/49862/april-weather/2638762 for 4/1/2026 and revealed the temperature on the day of the elopement was 22 - 29 degrees F.The risk management report was presented and reviewed. It was written by the DON (who was also the nurse responding to the alarm) and begins This writer heard door alarm going off and responded to alarm at about 0517 ish (5:17 AM).
The report is dated and timed as written 4/1/2026 05:14.
This means the report was inaccurately stated as written before the DON responded to the elopement alarm.The risk management report also included written witness statements of only two CNAs, one nurse, and the DON involved, even though all staff took part in the head count and may have had information relevant to the investigation.
The second nurse who assisted the resident back to the facility was not included as a witness in the investigation.The risk management witness statement of the DON was documented as written on 4/1/2026 but was linked to a progress note in the chart.
When the progress note was reviewed, it was found to be a late entry note written by the DON on 4/15/2026, over two weeks after the elopement.
During an interview conducted on 4/29/26 at 6:32 PM, LPN D stated the elopement event occurred at the end of her shift and the resident who had eloped (R10) was her resident.
She stated she felt she should do the risk management report. LPN D stated, (The DON) asked me if she wanted her (the DON) to do the risk management, even though it was my patient. LPN D said, A while afterwards, quite a while, I checked for a risk management in the chart.
She did not see one. LPN D said, I ask (the DON), she said I am still working on it.
She said I am doing it. It is not there yet. I had to remind her to do it. I am responsible for my resident.
During an interview on 4/30/26 at 10:00 AM, Regional Registered Nurse (RN) H stated she would expect the risk management report and documentation of the event to be completed as part of the investigation as soon as possible and certainly sooner than two weeks later.The facility presented the policy titled, Unsafe Wandering and Elopement Prevention last reviewed 1/1/2022.
This policy read in part, Every effort will be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement.
Nursing personnel must report and investigate all reports of missing residents. 8.
Upon return of the resident to the facility the Director of Nursing Services or Charge Nurse should:.Complete and file an incident report. 10.
Upon return of the resident to the facility the Director of Nursing Services or Charge Nurse should:.Complete and file an incident report and Make appropriate entries into the resident's medical record.
235410 04/30/2026
Medilodge of Munising 300 West City Park Drive Munising, MI 49862
be redirected away from the door as she tried to enter the service hallway toward the outside exit.A
assessment indicative of severely impaired cognition.
The MDS section E-Mood, indicated R11 asked
daily.
Although a wander guard bracelet was on R11's ankle there was not a physician order for this device or an order to check the function of this device.
The care plan for R11 included a focus: TARGET BEHAVIOR 1: Resident often wanders around building throughout the day.
Often gets confused and forgets location of room.
Initiated 11/19/2024.
Revision on 05/06/2025.
The interventions for the behavior care plan which included wandering did not include the wearing of a (brand name elopement prevention device).The elopement risk list which had been presented by Staff F as containing all residents who were wearing a (brand name elopement prevention device) was reviewed. R11 was not on the elopement risk list.Resident #12 (R12)On 4/29/26 at 5:08 PM, CNA G was in the dining room and checked R12's ankle and confirmed R12 was observed wearing a (brand name elopement prevention device).A review of the EMR for R12 revealed and admission date of 4/10/2024.
The most current MDS assessment of 4/28/2026 section C-Cognitive Patterns, indicated R12 had scored 0 of 15 on the BIMS assessment indicative of severely impaired cognition.
The MDS section E-Mood, indicated R12 asked Has the resident wandered? and was scored, Behavior of this type occurred daily.
There was a physician order for Check function and expiration at bedtime Check function and expiration date of (brand name elopement prevention device)/electronic bracelet ordered 12/5/25.
The care plan for R12 included a focus: TARGET BEHAVIOR 1: Elopement risk: increases at night - asking when her family will pick her up, putting on her coat - may attempt to go out service doors or front door.
Initiated 8/3/2023.
Revision on 07/01/2025.
The interventions for the behavior care plan which included wandering did not include the wearing of a (brand name elopement prevention device) although R12 was included on the elopement risk list.Resident #13 (R13)On 4/29/26 at 5:10 PM, R13 was observed wandering in the dining room in her wheelchair.
She was moving in and around the dining room tables and was unable to communicate where she would like to go. CNA G checked R13's ankle and confirmed R13 was wearing a wander guard (brand name elopement prevention device).A review of the EMR for R13 revealed and admission date of 8/26/2025.
The most current MDS assessment of 4/27/2026 section C-Cognitive Patterns, indicated R13 had scored 0 of 15 on the BIMS assessment indicative of severely impaired cognition.
The MDS section E-Mood, indicated R13 asked Has the resident wandered? and was scored, Behavior of this type occurred daily.
There was a physician order for Check function and expiration every night shift.
Check function and expiration date of (brand name elopement prevention device)/electronic bracelet ordered 9/7/25.
The care plan for R13 included a focus: TARGET BEHAVIOR 4: Intrusive Wandering: Resident has a hx (history) of intrusive wandering, in and out of other resident rooms, around the building.
Initiated 8/28/2025.
Revision on 04/07/2026.
The interventions for the behavior care plan which included wandering did not include the wearing of a (brand name elopement prevention device).The elopement risk list which had been presented by Staff F as containing all residents who were wearing a (brand name elopement prevention device) was reviewed. R13 was not on the elopement risk list.The facility presented the policy titled, Unsafe Wandering and Elopement Prevention last reviewed 1/1/2022.
This policy read in part, Every effort will be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement.
Nursing personnel must report and investigate all reports of missing residents.
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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.