Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Okemos during CMS and state inspections, most recent first.
An LPN and other licensed nurses did not maintain CPR/BLS certification that included the required hands-on skills component. During a code for a full-code resident who was found unresponsive and later died in the facility, CPR was started, the AED was used, and EMS responded, while record review showed the nurses’ CPR credentials came from online courses without in-person skills demonstration, contrary to facility policy.
Delayed Response to Resident Call Lights and Care Needs: Multiple residents reported and surveyors observed long delays in call light response, with several lights left on for extended periods and no CNA visible at times. Residents described waiting from minutes to hours for help with toileting, transfers, bedding changes, and returning to bed, and one resident was observed waiting nearly an hour after an appointment with soiled bedding still unchanged. Staff reported limited CNA coverage on the hall, and one CNA said many residents required 2-person assist and mechanical lift transfers, while a family member reported it took 3 hours for an RN to arrive after a CNA said they would get the nurse.
A resident with MS, chronic pain syndrome, and total care needs reported that staff were rough during repositioning and not kind. She stated a CNA refused to change her wet brief, leaving her to clean herself with wet wipes, and that staff repeatedly turned off her call light without providing care, despite her telling them she was soaked underneath.
Failure to respect a resident’s privacy: a resident with MS and Type 1 DM, who had intact cognition, reported that staff routinely entered her room without permission, including during a private attorney conversation and despite a privacy sign on the door. Surveyors observed two staff members enter the resident’s room before she could grant permission, and the DON stated staff should knock, announce themselves, and ask to come in. The NHA reported the facility had no specific personal privacy policy, and the Resident Rights policy did not address personal privacy.
Failure to document why a GDR of Seroquel was not implemented for a resident with vascular dementia, depression, anxiety, insomnia, and a hx of psychotic disorder. The resident had a BIMS score of 13/15, no documented hallucinations or delusions in the prior 30 days, and psychiatry recommended reducing Seroquel from 150 mg to 125 mg nightly, but the resident remained on the higher dose without documented justification.
A resident with epilepsy, morbid obesity, and moderate cognitive impairment fell from a Broda chair when an Activities Aide propelled the chair in a parking lot and the wheel became stuck in a crack in the pavement, causing the chair to tip over onto the resident. The resident sustained a distal femoral fracture and was discharged with a knee brace.
A resident with Crohn's Disease and intact cognition was on contact precautions for vomiting, with a sign outside the room directing staff and providers to clean hands and wear gloves and a gown before entry. A staff member was observed delivering a lunch tray to the room without PPE, and later stated the sign meant PPE was needed only for care. The IP reported anyone entering the room for any reason should have worn a gown, mask, and gloves.
The facility failed to provide proper care for PICC lines for two residents, leading to an increased risk of infection due to overdue dressing changes. Additionally, a resident receiving multiple opioids did not have a PRN Narcan order, contrary to facility policy. These deficiencies were confirmed by the facility's nursing staff and administration.
The facility failed to provide restorative services and enabler bars for three residents, leading to potential declines in their functional levels. One resident did not receive the prescribed range of motion program due to unavailability and lack of documentation. Another resident missed several restorative treatments, with no explanation provided. A third resident required enabler bars for bed mobility, but the referral was missed, and the necessary equipment was not provided.
The facility exceeded the acceptable medication error rate of 5%, reaching 6.67% due to two errors. One resident received Ayr nasal gel without a physician's order, and another resident with diabetes was administered insulin without proper priming or site disinfection. These actions were contrary to the facility's procedures, as confirmed by the DON.
The facility failed to ensure proper medication storage, as observed with a nasal spray and pain-relieving gel left in two residents' rooms without permission for self-administration. The DON confirmed that neither resident had an approved self-administration assessment, indicating a lapse in medication management protocols.
A resident experienced embarrassment and difficulty eating due to the lack of timely dental care, as the facility failed to obtain consent for new dentures. Despite a dentist's recommendation for new dentures due to the poor condition of the existing ones, the consent form was not signed because the social worker missed this step.
Licensed nurses lacked required hands-on CPR certification
Penalty
Summary
The facility failed to ensure that four of 32 licensed nurses maintained current CPR certification for healthcare providers that included a hands-on session, including one LPN involved in the response to a resident emergency. R98 was admitted with diagnoses including intraspinal abscess and granuloma, acute respiratory failure with hypoxia, cardiomyopathy, atrial fibrillation, atherosclerotic heart disease, methicillin susceptible staphylococcus aureus, and chronic kidney disease. The resident’s 5-day MDS showed the resident was cognitively intact, and the resident was full code at the time of death in the facility. On the day of the event, a CNA reported R98 unresponsive and face down between the bed and window. Staff placed the resident on their back, the crash cart was obtained, and a code was called. CPR was initiated at 4:20 AM, 911 was called, the AED was applied at 4:27 AM and again at 4:31 AM with no shock advised, and EMS arrived at 4:32 AM. R98 was pronounced deceased at 5:06 AM. Review of personnel records showed the involved LPN had a CPR/AED/First Aid certificate from an online provider, with no evidence of a hands-on component. Interviews with nursing staff and record review also showed other licensed nurses had CPR certifications from online courses that did not include hands-on demonstration, despite the facility policy requiring BLS/CPR for healthcare providers through a provider that evaluates proper technique through in-person demonstration of skills.
Delayed Response to Resident Call Lights and Care Needs
Penalty
Summary
The facility failed to ensure call lights were answered timely for multiple residents, including residents who were cognitively intact and dependent on staff for care. During observations, several call lights were seen on at the same time on the 300 hall, with no CNA visible on the hall at one point, and residents were waiting for assistance with toileting, transfers, bedding changes, and returning to bed. One resident with trigeminal neuralgia, multiple sclerosis, chronic pain syndrome, polyneuropathy, muscle weakness, and lack of coordination was observed waiting in a wheelchair for almost an hour after returning from an appointment, while her bedding had not been changed and stool was observed smeared on the pad covering her bottom sheet. She stated staff often told her they were too busy and that she had waited up to 1.5 hours for help. Additional observations on the 300 hall showed multiple call lights remaining on for extended periods, including lights that stayed on across repeated checks. A CNA stated there were 2 CNAs on the hall for 23 residents and later reported 11 residents on the hall required 2-person assistance with all care, with 24 residents total on the hall. During one observation, a CNA entered a room, carried out a breakfast tray, and did not provide care while the call light remained on. In another instance, a resident’s call light was turned off without the resident’s brief being changed, and the resident turned the light back on after stating staff had said they would return. Another resident was observed waiting while a CNA stood at the door for another CNA to help with a mechanical lift transfer. Several residents reported long delays in response to call lights and care needs. One resident reported waiting over an hour at times and once waiting 3 hours for staff response. Another resident reported call lights taking from 5 minutes to 1.5 hours to be answered and said CNAs told her they did not have enough staff. A resident with cerebral palsy reported being wet for 4 to 8 hours before being changed a couple times per week, including on third shift, and said more than two CNAs were needed because many residents required 2-person assist and mechanical lift transfers. A resident with dementia had a family member report that a CNA responded to a call light and said they would get the nurse, but it then took 3 hours for the nurse to arrive. The DON stated staffing needs were discussed in stand-up and stand-down meetings and that census and acuity were reviewed, but reported being unaware of any call light concerns from residents.
Failure to Maintain Resident Dignity and Provide Timely Incontinence Care
Penalty
Summary
The facility failed to maintain respect and dignity for one resident who was admitted and readmitted with diagnoses including trigeminal neuralgia, multiple sclerosis, chronic pain syndrome, polyneuropathy, muscle weakness, and lack of coordination. The most recent MDS showed the resident had a BIMS score of 13 out of 15 and was dependent for all care. During an observation and interview, the resident stated that some staff were not very kind and that staff were rough with repositioning her because of her chronic pain and multiple sclerosis. The resident later reported that night staff were the main concern. She stated that a CNA refused to change her brief after she told the CNA she was wet, and that she had to change herself during the night because nobody would change her. She said she pulled her brief off from the side and cleaned herself with wet wipes as best she could, and that staff would look at the front of her brief, say she was not wet, and leave the room even when she told them she was soaked underneath. She also stated her call light was on for over an hour and staff came in and turned it off without providing care, telling her they would be back.
Failure to Respect Resident Privacy
Penalty
Summary
The facility failed to maintain a resident’s personal privacy for one resident who was admitted with multiple sclerosis and Type 1 Diabetes Mellitus and had intact cognition on the MDS Brief Interview for Mental Status (15/15). On 9/2/25, the resident was observed in her room sitting in a power wheelchair, and while the door was closed, two staff members entered at different times after knocking but before the resident could give permission to enter her private room. The resident became upset and stated that staff routinely do not respect her privacy, including entering her room during a private conversation with her attorney and ignoring a privacy sign that had previously been placed on her door. During interview, the DON stated staff should knock, announce who they are, and ask if they can come in before entering a resident room. The NHA stated the facility did not have a policy specifically for personal privacy and provided the Resident Rights policy, which did not mention personal privacy.
Failure to Document Reason for Not Completing GDR of Seroquel
Penalty
Summary
The facility failed to provide justification for not performing a gradual dose reduction (GDR) of Seroquel for one resident. The resident was admitted with diagnoses including vascular dementia without behavioral disturbance, anxiety, insomnia, major depressive disorder, and psychotic disorder with hallucinations. The MDS ARD of 8/2/25 showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact. The resident was observed seated in a Broda chair in the dining room on 9/2/25, and the physician’s orders showed Seroquel 200 mg daily on admission, later decreased on 6/2/25 to 150 mg at bedtime for major depressive disorder with psychotic features. The record included an OBRA assessment stating the resident appeared to be in a depressive episode and had been presenting with psychotic features such as hallucinations, though these could also be related to stroke/neurocognitive changes. A behavior management note stated to continue psychiatric evaluation for GDR of Seroquel, and a psychiatry follow-up note documented no new or worsening behaviors, no auditory/visual hallucinations, and a recommendation to reduce Seroquel from 150 mg nightly to 125 mg nightly. Review of the resident’s behavior documentation for the prior 30 days showed no hallucinations or delusions, yet the resident remained on Seroquel 150 mg at bedtime. The SW and DON both reported that psychiatric recommendations were discussed in behavior management meetings, but neither could provide documentation explaining why the further GDR was not implemented.
Fall From Broda Chair Resulted in Fracture
Penalty
Summary
The facility failed to prevent a fall for one resident who had diagnoses including epilepsy and morbid obesity. The resident’s MDS showed moderate cognitive impairment and dependence on staff for ADLs. On observation, the resident was lying in a bariatric bed with a perimeter mattress and fall mat, and a Broda chair was present in the room. The resident reported that she fell out of her Broda chair and fractured her leg. The witnessed fall report stated that an Activities Aide was propelling the resident in the Broda chair outside in the parking lot when the chair slid sideways, the wheel became stuck in a crack in the blacktop, and the chair tipped over onto the resident. A CNA who witnessed the event reported the aide was pulling the chair with one hand. The aide reported the chair was difficult to push, that it swerved, and that it tipped when the wheel hit a crack in the pavement. Hospital documentation showed the resident sustained an acute nondisplaced distal femoral fracture and was discharged with a right knee brace.
Failure to Use PPE for Resident on Contact Precautions
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff did not use required PPE for a resident on Transmission-Based Precautions. The resident had Crohn's Disease, was cognitively intact with a BIMS score of 15 out of 15, and had contact isolation ordered for vomiting. A sign posted outside the room stated that everyone entering must clean their hands and that providers and staff must put on gloves and a gown before room entry and discard them before room exit. Despite this, a staff member was observed passing a lunch tray to the resident's room without wearing PPE. When asked about the sign, the staff member stated it indicated whether a gown or mask was needed if going in to do care on the resident. The Infection Preventionist later reported the resident had been placed on contact precautions as a precaution for nausea, vomiting, and diarrhea until seen by a provider, and that anyone entering the room for any reason should have worn a gown, mask, and gloves.
Deficiencies in PICC Line Care and Narcan Order
Penalty
Summary
The facility failed to adhere to acceptable standards of clinical practice for the care of peripherally inserted central catheter (PICC) lines for two residents, resulting in an increased likelihood of infection. Resident #348, a male with multiple diagnoses including osteomyelitis and diabetes, had a PICC line dressing that was not changed as per the physician's order of every seven days. Observations revealed that the dressing was dated 8/31/24 and was not changed until 9/10/24, exceeding the seven-day requirement. The Registered Nurse Unit Manager confirmed the oversight and acknowledged that the dressing should have been changed on 9/5/24. Additionally, the dressing was not applied correctly, as the insertion site was not visible through the dressing. Similarly, Resident #350, a female with osteomyelitis and other conditions, had a PICC line dressing that was also not changed according to the seven-day schedule. The dressing was dated 8/31/24 and was not changed until 9/10/24, with serosanguinous drainage noted at the insertion site. The facility's Director of Nursing confirmed that the staff should follow the PICC policy, which includes changing dressings every seven days and assessing the site daily for signs of infection. Additionally, the facility failed to ensure an as-needed Narcan order was in place for Resident #348, who was receiving multiple opioid medications for chronic pain. Despite the resident's active orders for opioids, there was no PRN order for Narcan, which is typically ordered as a safeguard against opioid overdose. The Nursing Home Administrator confirmed the absence of a Narcan order, which was against the facility's policy that requires a physician's order for all medications administered to residents.
Failure to Provide Restorative Services and Equipment
Penalty
Summary
The facility failed to provide restorative services or enabler bars for three residents, leading to potential declines in their functional levels. Resident #18, who was admitted with multiple diagnoses including respiratory failure and spinal cord injury, had a care plan that included a restorative range of motion program. However, the task sheet for the last 30 days did not reflect that the resident received the prescribed restorative care. Interviews revealed that the resident was often unavailable for treatment, and there was no documentation to validate the reasons for not following the program. Resident #75, with diagnoses such as atrial fibrillation and muscle weakness, was also supposed to receive restorative nursing care for range of motion. The task sheets indicated that the resident did not receive the prescribed treatment on several occasions. The Assistant Director of Nursing (ADON) was unable to provide documentation explaining why the treatments were not administered, and the facility did not follow the physical therapy department's recommendations to maintain the resident's highest functional level. Resident #73, who had a left femur fracture and muscle weakness, required a therapy referral for enabler bars to assist with bed mobility. However, no therapy assessment was noted in the resident's electronic medical record, and observations confirmed the absence of enabler bars. The Physical Therapy Assistant acknowledged missing the referral, and the Director of Nursing confirmed that the communication for the assessment was not acted upon, resulting in the resident not receiving the necessary equipment to aid in mobility.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.67% due to two observed medication errors involving two residents. The first error involved a resident with chronic respiratory failure who was administered Ayr nasal gel without a physician's order. The registered nurse applied the gel using a cotton-tipped swab, despite the resident's medical record only containing an order for Ayr Saline Nasal Drops. This discrepancy was confirmed by the Director of Nursing, who acknowledged the absence of an order for the nasal gel. The second error involved a resident with type 2 diabetes mellitus who was prescribed Lantus Solostar insulin. The registered nurse administered the insulin without priming the pen or using an alcohol wipe to disinfect the injection site, contrary to the facility's procedure for insulin administration. The Director of Nursing confirmed that the proper procedure was not followed, which contributed to the medication error rate exceeding the acceptable threshold.
Improper Medication Storage in Resident Rooms
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in two resident rooms, leading to a potential safety issue. In the case of one resident, a bottle of Flonase Nasal Spray was found on the bedside table, despite the resident not having permission to store or self-administer medications. The resident confirmed that the nasal spray was not typically stored in her room. A review of the physician's orders showed an active prescription for Fluticasone Propionate Suspension for the resident. In another instance, two boxes of Voltaren Gel were observed in a different resident's room. The resident stated that he did not self-administer the gel and that the boxes were regularly left in his room. The physician's orders confirmed an active prescription for Voltaren External Gel. The Director of Nursing verified that neither resident had an approved medication self-administration assessment, indicating that the medications should not have been present in their rooms.
Failure to Provide Timely Dental Care
Penalty
Summary
The facility failed to ensure timely dental care for a resident, resulting in embarrassment and difficulty eating due to the lack of dentures. The resident had seen a dentist two months prior, who recommended new dentures due to the poor condition of her existing ones, which were over six years old and very loose. The resident's dental notes indicated moderate soft plaque, hard calculus deposits, and gingivitis. Despite the dentist's recommendation, the consent form for new dentures was not signed by the resident's responsible party, as the social worker responsible for obtaining the consent missed this step. Consequently, the resident did not receive the necessary dental care and continued to experience issues related to the absence of dentures.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Okemos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Willows At Okemos | 0.8 mi | ★★★★★ | 7 | 0 |
| Burcham Hills Retirement Center | 2 mi | ★★★★★ | 4 | 0 |
| Medilodge Of Campus Area | 2.2 mi | ★★★★★ | 11 | 0 |
| Ingham County Medical Care Facility | 2.8 mi | ★★★★★ | 18 | 0 |
| Medilodge Of East Lansing | 3 mi | ★★★★★ | 28 | 0 |
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