Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Lansing during CMS and state inspections, most recent first.
Surveyors found that controlled medications were not properly documented on the Control Substance Record when removed from a medication cart for six residents. Although the medications were administered and recorded in the electronic Medication Administration Record, the required documentation and count on the paper record was not completed at the time of removal, as confirmed by an RN and the DON during interviews.
A facility failed to ensure proper documentation and follow-up regarding advanced directives, a resident's reported fear of certain family members, and allegations that unauthorized visitors administered non-prescribed medication. Staff did not verify legal authority for advanced directives, did not document concerns or actions related to Adult Protective Services involvement, and failed to record the resident's fears or the ban on specific visitors.
The facility failed to adhere to food service safety standards, with observations of debris on kitchen equipment, improper water accumulation, and greasy pans. Staff used a handwashing sink for non-handwashing purposes and began food preparation without washing hands, violating the 2017 FDA Food Code.
The facility failed to maintain therapy equipment adequately, impacting residents' rehabilitation. The parallel bars were too narrow for bariatric residents, and the ScitFit elliptical bike's resistance was malfunctioning. Additionally, the therapy area's stove top oven was not properly secured, posing a safety risk.
The facility failed to update care plans for three residents, leading to deficiencies in their care. A resident with Parkinson's Disease had an outdated care plan, missing necessary equipment and supervision. Another resident with severe cognitive impairment and fractures used a wheelchair instead of a walker, contrary to the care plan. A third resident with a history of substance abuse had no care plan addressing alcohol consumption risks. These issues were identified during a survey, highlighting the need for timely care plan revisions.
A resident with severe cognitive impairment and a history of wandering eloped from the facility due to a lack of a wanderguard alarm on an exit door. The resident exited through the B hall door, triggering an alarm that staff responded to with a delay. The resident was found outside the facility after a search was initiated. Interviews revealed that the door was open when staff responded, and the initial response was delayed as staff checked the nurse's station first.
A resident prescribed Quetiapine Fumarate for mood disorder was not monitored according to provider recommendations. The facility failed to perform orthostatic blood pressure checks, hemoglobin A1C, lipid profile, and EKG as advised. The DON confirmed the absence of these tests and monitoring in the resident's records.
The facility exceeded the acceptable medication error rate of 5%, reaching 8% due to errors involving two residents. One resident received an antibiotic dose too soon due to a scheduling oversight, while another resident's insulin pen was incorrectly primed without a needle. The DON confirmed the errors and the correct procedures.
A significant medication error occurred when an LPN administered the wrong medications to a resident, which had been prepared by an RN for another resident. The error led to adverse symptoms, including tachycardia and lethargy, requiring hospitalization. The incident was attributed to a breach in professional standards, where medications were prepared by one nurse and administered by another, increasing the risk of errors.
Failure to Document Controlled Medication Administration per Professional Practice
Penalty
Summary
The facility failed to ensure that controlled medications were administered and documented according to professional practice for one medication cart, affecting six residents. During an observation of the medication cart, discrepancies were found between the number of controlled medication tablets or capsules recorded on the Control Substance Record and the actual number present in the medication drawer. In each case, a registered nurse stated that the medication had been administered to the resident and documented as given in the electronic Medication Administration Record, but the removal of the medication was not documented on the Control Substance Record at the time of administration. The residents involved had complex medical histories, including conditions such as Parkinson's disease, chronic obstructive pulmonary disease (COPD), chronic pain, diabetes, hypertension, and other chronic illnesses. All residents were assessed as cognitively intact or nearly intact based on their most recent Brief Interview for Mental Status (BIMS) scores. The controlled medications involved included hydrocodone-APAP, pregabalin, tramadol, and oxycodone, which were prescribed for pain management and other chronic conditions. Interviews with the registered nurse and the Director of Nursing confirmed that the professional practice in the facility required controlled medications to be removed from the drawer, documented on the Control Substance Record, and the final count recorded before administration to the resident. After administration, the medication was to be documented as given in the electronic medical record. Both staff members acknowledged that this process was not followed for the residents in question, but could not provide an explanation for the deviation from established practice.
Failure to Document and Follow Up on Advanced Directives, Resident Fears, and Unauthorized Medication Administration
Penalty
Summary
The facility failed to ensure adequate care, follow-up, and documentation regarding advanced directives, resident-reported fear of certain family members, and allegations of unauthorized administration of medication by visitors. A resident with heart disease, diabetes, and dementia, who had moderate cognitive impairment, was admitted with conflicting documentation about code status and power of attorney. The facility's records showed inconsistencies between the advanced directives signed by different family members, with one family member signing as DPOA without legal authority and staff failing to verify or document the correct paperwork. The social worker and other staff were aware of Adult Protective Services (APS) involvement but did not document the concerns or actions taken in the clinical record. Additionally, the resident reported fear of specific family members, leading to a ban on their visitation after allegations that one had brought in and administered non-prescribed medication. Despite staff awareness of these concerns, there was no documentation in the medical record regarding the resident's fear, the ban on visitors, or the investigation into the alleged medication administration. Staff interviews revealed a lack of clarity about the events, poor communication, and failure to document critical information related to the resident's safety and care decisions.
Deficiencies in Food Service Safety and Hygiene Practices
Penalty
Summary
The facility failed to maintain food service safety standards, as observed during a kitchen tour. The top portion of the gasket on the left door of a refrigeration unit had an accumulation of debris, and the juice machine had fuzzy and sticky debris between its spouts. Water accumulation was found under the preparation sink, juice and coffee area, and the three-door refrigeration unit due to improperly installed air gaps. Debris, dirt, and stagnant water were also found behind cold hold units, and greasy pans were improperly stored above the three-compartment sink. Dust and dirt were observed behind the ice machine, along with plastic wrapping and Styrofoam cups. Additionally, a saucepan used for cooking was heavily encrusted with grease, and staff were observed using a handwashing sink for purposes other than handwashing. During meal service, a staff member entered the kitchen, donned gloves, and began food preparation without washing hands. These observations indicate a failure to adhere to the 2017 FDA Food Code requirements for equipment cleanliness, physical facility maintenance, and proper handwashing practices.
Deficiency in Therapy Equipment and Safety Measures
Penalty
Summary
The facility failed to provide and maintain therapy equipment in a manner that meets the needs of all residents. During an interview, the Physical Therapy Manager (PTM) reported that the parallel bars in the therapy area are not wide enough for bariatric residents, forcing them to use only one side for stabilization, which is inadequate for their needs. Additionally, the PTM noted that the ScitFit elliptical bike is malfunctioning, as the resistance does not increase as intended, hindering residents' ability to progress in their recovery. Furthermore, during a tour of the therapy area, it was observed that the kitchenette's stove top oven could be turned on easily, posing a safety risk. The Maintenance Director confirmed that there is a control panel shut off for the stove, which should be locked when not in use, but it was not secured at the time of the observation.
Care Plan Deficiencies for Three Residents
Penalty
Summary
The facility failed to revise care plans for three residents, leading to deficiencies in their care. Resident #34, who was admitted with Parkinson's Disease and unsteadiness, had a care plan that was not updated to reflect his current needs. Observations showed that his four-wheeled walker was not within reach, and his two-wheeled walker was missing, contrary to the care plan. Additionally, he was seen using a motorized wheelchair unsupervised, despite recommendations for manual wheelchair use indoors due to safety concerns. The Director of Nursing acknowledged the need for care plan updates. Resident #62, with severe cognitive impairment and multiple fractures, had a care plan that inaccurately listed a walker for ambulation, despite being non-weight bearing on the right side after a fall. Observations confirmed the use of a wheelchair instead of a walker, and the need for one-on-one supervision due to safety concerns. The care plan was not updated to reflect these changes until it was pointed out during the survey. Resident #57, with a history of memory deficit and schizoaffective disorder, experienced an episode of acute alcohol intoxication. The care plan did not address the risk related to alcohol consumption, which was confirmed by the Director of Nursing. The social worker later added a care plan item addressing the resident's history of substance abuse disorder, but this was only done after the survey identified the deficiency.
Failure to Prevent Elopement and Timely Respond to Door Alarm
Penalty
Summary
The facility failed to prevent an elopement and respond timely to a door alarm for Resident #33, who had severe cognitive impairment and was at risk for elopement due to wandering behavior. Resident #33 was admitted with diagnoses including unspecified dementia, unsteadiness on feet, and disorientation. The resident was observed with a wanderguard bracelet, indicating a known risk for elopement. Despite this, the resident managed to exit the facility through a door that did not have a wanderguard alarm, leading to their temporary absence from the facility. On the night of the incident, Resident #33 exited their room and walked around the nurse's station before triggering the B hall door alarm. The alarm went off, and lights at the nurse's station began flashing, but staff response was delayed. The LPN and CNA at the nurse's station had a brief conversation before checking the door, by which time the resident had already exited the facility. The alarm was turned off, but the flashing light continued, and it took several minutes before staff realized the resident was missing and initiated a search. Interviews with staff revealed that the door was open when they responded to the alarm, and the resident was eventually found outside the facility by the LPN. The former Nursing Home Administrator confirmed that the B hall exit door lacked a wanderguard alarm, which contributed to the resident's ability to leave the facility undetected. The Director of Nursing noted that staff initially checked the nurse's station instead of the door, which delayed the response to the alarm.
Failure to Monitor Antipsychotic Medication
Penalty
Summary
The facility failed to monitor an antipsychotic medication for a resident according to provider recommendations. The resident, who had diagnoses including mood disorder due to a known physiological condition, major depressive disorder, and anxiety disorder, was prescribed Quetiapine Fumarate for mood disorder. The psychiatric services progress note recommended monitoring orthostatic blood pressures every shift when the antipsychotic medication was started or the dose was increased. Additionally, it was recommended to monitor hemoglobin A1C and lipid profile every six months and to obtain an EKG if not recently done. The resident's medical record did not reflect that these recommended tests and monitoring were performed. There was no documentation of orthostatic blood pressures being monitored, nor were there results for hemoglobin A1C, lipid profile, or EKG. The Director of Nursing confirmed that orthostatic blood pressures should have been monitored monthly for residents receiving antipsychotic medications and acknowledged the absence of these tests and monitoring in the resident's records. Despite an email request for these results, they were not provided before the survey exit.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 8%. This was due to two medication errors involving two residents. The first error involved a resident who was prescribed ertapenem sodium solution, an antibiotic, to be administered intravenously every 24 hours. However, the medication was administered approximately 14.5 hours after the previous dose due to a delay in delivery, which was not adjusted in the medication schedule. The Director of Nursing confirmed that the timing of the order should have been changed after the first dose was administered late. The second error involved another resident with a diagnosis of type 2 diabetes, who was prescribed a long-acting insulin pen. The Registered Nurse primed the insulin pen without attaching a needle, which is contrary to the correct procedure. The Director of Nursing confirmed that the correct method of priming involves attaching a needle to the pen before setting the dose selector to two units and pressing the injection button to ensure the needle is open and working. This incorrect priming method was acknowledged by the nurse, who could not recall if this was how she had been trained.
Significant Medication Error Due to Improper Administration Practices
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving the administration of incorrect medications. A resident, who had severe cognitive impairment and multiple medical conditions including a history of stroke and schizoaffective disorder, was mistakenly given another resident's medications. This error occurred when a Licensed Practical Nurse (LPN) administered medications that had been prepared by a Registered Nurse (RN) for two different residents. The LPN inadvertently gave the wrong set of medications to the resident, which included several potent drugs such as Keppra, Lamotrigine, Oxcarbazepine, Seroquel, and Topamax. The error was identified shortly after administration, and the resident began to exhibit adverse symptoms, including tachycardia and lethargy. The resident's condition worsened, leading to a significant drop in pulse rate, necessitating emergency medical intervention and hospitalization. The incident was reported, and the facility's nurse manager and physician assistant were notified immediately. The resident was monitored closely for any changes in condition and was eventually returned to the facility after stabilization in the hospital. Interviews with the nursing staff involved revealed that the error stemmed from a breach in professional standards, where medication prepared by one nurse was administered by another. The Director of Nursing confirmed that this practice was against the facility's expectations and professional standards, as it increased the risk of significant medication errors. The root cause of the incident was identified as the preparation and administration of medications by different nurses, which led to the mix-up and subsequent adverse reaction in the resident.
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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 Lansing
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency At Lansing West | 1.4 mi | — | 2 | 0 |
| Aria Nursing And Rehabilitation | 7.1 mi | — | 3 | 0 |
| Medilodge Of Capital Area | 7.4 mi | — | 5 | 0 |
| The Willows At East Lansing | 7.9 mi | — | 11 | 0 |
| Holt Senior Care And Rehab Center | 8 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.