Inspection Reports for Medilodge of Ludington
1000 E Tinkham Ave, Ludington, MI 49431, United States, MI, 49431
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
79% worse than Michigan average
Michigan average: 5.2 deficiencies/year
Deficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 29, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to properly assess and treat two residents for acute medical changes, resulting in emergency medical interventions.
Complaint Details
The complaint investigation found substantiated failures in assessment and treatment for two residents, resulting in emergency medical attention and surgery for Resident #1 and hospitalization for Resident #2 due to severe constipation and impaction.
Findings
The facility failed to adequately assess and treat two residents, leading to emergency hospital transfers. Resident #1 experienced delayed diagnosis and treatment of a blood clot in the leg, resulting in emergency surgery, while Resident #2 suffered from severe constipation due to lack of appropriate bowel management and timely medical intervention.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals.
Report Facts
Residents affected: 2
Shifts between bowel movements: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in relation to Resident #1's care and SBAR communication |
| RN A | Registered Nurse | Named in relation to Resident #1's care and communication with provider |
| Director of Nursing | Interviewed regarding Resident #2's bowel management concern |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 9, 2025
Visit Reason
The visit was conducted as an abbreviated survey to review the facility's compliance with regulations related to resident abuse following a substantiated verbal abuse complaint involving a staff member and a resident.
Complaint Details
This citation pertains to Intake 1268402. The facility substantiated verbal abuse based on employee admission and corroborating witness accounts. No physical abuse was substantiated following medical assessment, reenactment, and resident report.
Findings
The facility failed to ensure one resident was free from verbal abuse by a staff member who swore at the resident. The facility substantiated verbal abuse and took corrective actions including suspension and termination of the staff member, updating care plans, and conducting audits. The facility demonstrated monitoring and maintained compliance at the time of the survey.
Deficiencies (1)
Failure to protect a resident from verbal abuse by a staff member who swore at the resident.
Report Facts
Residents involved: 1
Staff involved: 1
Dates of key events: May 24, 2025
Dates of key events: Jun 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA J | Certified Nurse Aide | Staff member who verbally abused resident and was terminated |
| RN K | Registered Nurse | Witnessed verbal abuse incident and provided statement |
| CNA L | Certified Nurse Aide | Witnessed verbal abuse incident and provided statement |
| RN N | Registered Nurse | Heard yelling during incident and provided statement |
| DON | Director of Nursing | Provided interviews and information about resident behavior and past non-compliance |
| NHA | Nursing Home Administrator | Provided interviews and information about past non-compliance and incident reporting |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 18, 2025
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to provide appropriate nephrostomy tube care for two residents, resulting in hospitalization and infection.
Complaint Details
The complaint investigation revealed failures in nephrostomy tube care for residents R1 and R2, including improper stopcock positioning leading to blocked drainage, lack of monitoring and documentation of nephrostomy output, inadequate dressing changes, and insufficient staff education and competency, resulting in infections and hospitalizations.
Findings
The facility failed to prevent hospitalization, monitor, assess, intervene, document, and provide appropriate care of nephrostomy tubes for two residents, resulting in infection and hospitalization. Staff were found to be incompetent in managing nephrostomy care, including improper stopcock positioning, lack of monitoring output, incomplete documentation, and inadequate staff education.
Deficiencies (2)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals related to nephrostomy tube care.
Failure to ensure staff competency in nephrostomy care, resulting in repeated incompetent care and hospitalization.
Report Facts
Volume of purulent urine drained: 548
Volume of purulent fluid evacuated: 540
Number of shifts with 0 output documented: 30
Number of shifts with 0 output documented: 22
Highest output recorded: 40
Fluid output after questioning nephrostomy care: 575
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Reported concerns about nephrostomy care and described stopcock positioning and drainage issues for R1 |
| UM H | Unit Manager/Licensed Practical Nurse | Reported on resident behaviors, lack of orders for anchoring tubing, and staff education issues; acknowledged misunderstanding of stopcock positioning |
| DON | Director of Nursing | Reported on staff education, resident behaviors, and care standards; acknowledged lack of order for anchoring tubing and dressing dating |
| RN C | Registered Nurse | Observed nephrostomy bag drainage and stopcock positioning for residents R1 and R2 |
| RN B | Registered Nurse | Reported on nephrostomy tube drainage and stability for R2 |
| RN U | Staff Educator/Registered Nurse | Provided staff education on correct stopcock positioning and nephrostomy care |
| LPN I | Licensed Practical Nurse | Verified stopcock positioning and drainage for R2 |
Inspection Report
Deficiencies: 3
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding residents' rights to dignified existence, proper transfer and discharge procedures, and bed hold policies during hospital transfers.
Findings
The facility failed to provide needed services to ensure the dignified well-being of three residents, including timely assistance with toileting and call light response. Additionally, the facility did not follow proper transfer policies for one resident, including lack of physician orders, missing transfer forms with medication lists, and failure to provide a bed hold policy notification.
Deficiencies (3)
Failed to honor residents' rights to a dignified existence, self-determination, communication, and to exercise rights, resulting in delayed assistance and unmet needs for three residents.
Failed to follow transfer and discharge policy for one resident, including absence of physician orders and missing transfer documentation.
Failed to notify resident or representative in writing about bed hold policy during hospital transfer for one resident.
Report Facts
Residents affected: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding transfer documentation and bed hold policy for resident R61 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 23, 2024
Visit Reason
The inspection was conducted based on complaint intake #MI00147480 and #MI00147635 to investigate allegations related to resident care accommodations, medication storage and labeling, infection prevention and control practices, and laundry services.
Complaint Details
The complaint investigation was substantiated with findings related to inadequate resident care accommodations, medication storage and labeling, infection control practices including enhanced barrier precautions, oxygen storage, and laundry services.
Findings
The facility failed to reasonably accommodate the needs of residents, secure medication carts, properly label and date medications, implement enhanced barrier precautions for infection control, and maintain proper infection control practices for oxygen storage and laundry services. Multiple observations and interviews confirmed these deficiencies.
Deficiencies (3)
Failed to reasonably accommodate the needs of 5 of 5 residents reviewed, including call light placement, hydration, pressure relief, and staff response to resident calls.
Failed to secure 1 of 4 medication carts and failed to follow guidelines for preparing, storing, and dating medications.
Failed to provide and implement an infection prevention and control program, including lack of enhanced barrier precautions for 3 residents, improper oxygen tubing storage and dating, and inadequate laundry infection control practices.
Report Facts
Residents affected: 5
Medication carts unsecured: 1
Residents reviewed for enhanced barrier precautions: 3
Instances of laundry contamination: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse D | Licensed Practical Nurse | Stated medication cart should be locked and medications dated |
| Registered Nurse A | Registered Nurse | Indicated pre-setting medications was unacceptable and led to errors |
| Certified Nurse Aide K | Certified Nurse Aide | Observed removing breakfast tray without repositioning resident |
| Certified Nurse Aide G | Certified Nurse Aide | Reported staff should check call light placement and offer drinks |
| Licensed Practical Nurse R | Licensed Practical Nurse | Indicated residents with PICC should be placed on enhanced barrier precautions |
| Certified Nurse Aide J | Certified Nurse Aide | Was not aware resident was on enhanced barrier precautions |
| Infection Control Preventionist H | Infection Control Preventionist | Reported missing PPE signs and confirmed residents should be on enhanced barrier precautions |
| Environmental Services Manager C | Environmental Services Manager | Reported laundry contamination issues and notified administration |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 25, 2024
Visit Reason
The inspection was conducted due to complaints and allegations regarding neglect, abuse, and failure to follow professional nursing standards at Medilodge of Ludington, including concerns about resident care, medication administration, and catheter care.
Complaint Details
The complaint investigation was triggered by family members reporting serious concerns about resident R8's care, including risk of aspiration, failure to change clothes for several days, missed meals, and improper catheter care. The facility failed to report these allegations to the state agency and did not conduct thorough investigations.
Findings
The facility failed to implement abuse and neglect policies for one resident, resulting in unreported and uninvestigated neglect allegations. Medication administration errors were found for five residents, including failure to follow physician-ordered parameters and documentation errors. The facility also failed to provide appropriate ADL assistance and catheter care for one resident, leading to risks of aspiration, infection, and skin breakdown.
Deficiencies (4)
Failed to implement abuse and neglect policy for 1 resident, resulting in unreported allegations and inadequate investigation.
Failed to follow professional nursing standards for medication administration for 5 residents, resulting in medication errors and administration outside physician-ordered parameters.
Failed to provide appropriate ADL assistance for 1 resident, including failure to change clothes, provide showers, and assist with meals.
Failed to provide appropriate care for a suprapubic catheter for 1 resident, resulting in potential for infection and skin breakdown.
Report Facts
Residents reviewed for abuse and neglect: 13
Residents reviewed for medication administration: 11
Residents with medication errors: 5
Residents reviewed for ADL assistance: 2
Residents reviewed for quality care: 13
Shower frequency: 3
Date of survey completion: Sep 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FM B | Family Member | Reported concerns about resident R8's care including risk of aspiration and neglect |
| DPOA A | Durable Power of Attorney | Reported ongoing unresolved concerns about resident R8's care |
| DON | Director of Nursing | Interviewed regarding complaint investigation and medication administration issues |
| NHA | Nursing Home Administrator | Interviewed regarding complaint forms and reporting of abuse/neglect allegations |
| CNA/RV G | Certified Nurse Aide/Resident Voice | Completed Quality Assistance Forms reporting concerns about resident R8's care |
| SSD H | Social Services Director | Notified of concerns about resident R8's care but did not report allegations to NHA |
| CNA N | Certified Nurse Aide | Observed and reported soiled suprapubic catheter dressing on resident R8 |
Inspection Report
Routine
Deficiencies: 3
Date: Jul 9, 2024
Visit Reason
The inspection was conducted to assess compliance with medication storage, safeguarding resident medical records, and workforce security policies at Medilodge of Ludington.
Findings
The facility failed to secure one medication cart, leaving narcotics and resident medications unsecured, and failed to safeguard the confidentiality of medical records for 12 residents by leaving electronic medication records visible and accessible. Additionally, the facility did not ensure proper logout procedures from workstations.
Deficiencies (3)
Failed to secure 1 of 5 medication carts, resulting in unsecured narcotics and resident medications accessible to unauthorized individuals.
Failed to safeguard confidentiality of medical records for 12 residents, with electronic medication records left open and visible to unauthorized individuals.
Failed to ensure users properly log out of all applications and networks when leaving a workstation.
Report Facts
Residents affected: 12
Residents total: 73
Medication carts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in findings related to unsecured medication cart and open computer screen with resident information |
| RN B | Registered Nurse | Named in findings related to unsecured medication cart and open computer screen with resident information |
| RN C | Registered Nurse | Named in findings related to unsecured medication cart and open computer screen with resident information |
Inspection Report
Deficiencies: 1
Date: Jan 24, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with residents' rights to dignified existence, self-determination, communication, and exercise of rights, focusing on timely staff response to resident requests for assistance.
Findings
The facility failed to ensure that three residents were cared for in a manner that enhanced their quality of life and dignity, as staff did not respond to call lights and requests for assistance in a timely manner, with residents reporting waits of 30 to 45 minutes or longer.
Deficiencies (1)
Failure to ensure timely staff response to resident call lights and requests for assistance, impacting residents' quality of life and dignity.
Report Facts
Residents affected: 3
Wait time for staff response: 30
Wait time for staff response: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA V | Certified Nurse Aide | Responded to Resident #60's call light and informed her that someone from the next shift would assist. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 24, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to provide timely assistance to residents, failure to recognize and implement Durable Power of Attorney (DPOA) in a timely manner, failure to obtain appropriate witness for binding arbitration agreement, and inadequate infection prevention and control program.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to respond timely to residents' call lights, failed to implement DPOA for a cognitively impaired resident, failed to properly obtain informed consent for binding arbitration, and failed to adequately track infections among staff during an outbreak.
Findings
The facility failed to ensure timely response to call lights for three residents, failed to recognize and implement DPOA for one resident with severe cognitive impairment, failed to properly document informed consent and witness binding arbitration agreement for the same resident, and failed to implement adequate infection surveillance including consistent tracking of employee infections during a COVID-19 outbreak.
Deficiencies (4)
Failure to ensure timely assistance to residents when call lights were activated, causing delays of 30-45 minutes.
Failure to recognize and implement Durable Power of Attorney in a timely manner for a resident with severe cognitive impairment.
Failure to obtain appropriate witness to certify resident was competent to make informed consent for binding arbitration agreement and failure to document resident's understanding of the agreement.
Failure to implement adequate infection surveillance including consistent tracking of employee infections during a COVID-19 outbreak.
Report Facts
Residents affected: 3
Residents affected: 1
BIMS score: 13
BIMS score: 15
BIMS score: 5
Time delay: 30
Time delay: 45
Date of survey completion: Jan 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FM S | Family Member / Durable Power of Attorney | Named as DPOA for Resident #56, reported issues with activation and consent |
| Receptionist M | Facility Receptionist | Signed binding arbitration agreement on behalf of Resident #56 without proper witness or activated DPOA |
| Social Services Director O | Social Services Director | Reported unfamiliarity with advanced directive planning and competency evaluations for Resident #56 |
| Registered Nurse L | Infection Preventionist | Oversaw infection control program, reported inadequate tracking of employee illness during COVID-19 outbreak |
| Nursing Home Administrator | Nursing Home Administrator | Responsible for facilitating Alternative Dispute Resolution and admissions process |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 19, 2023
Visit Reason
The inspection was conducted due to a complaint intake MI-000138952 regarding the facility's failure to completely transcribe admission orders and obtain clarification orders from a surgeon for Resident #7, potentially leading to postoperative complications.
Complaint Details
This citation pertains to intake MI-000138952. The complaint investigation found that the facility did not order labs, remove staples, or perform dressing changes as ordered or needed for Resident #7, and failed to contact the orthopedic surgeon for clarification of orders.
Findings
The facility failed to order necessary labs, remove staples, or perform dressing changes for Resident #7 following hip surgery. Documentation did not reflect assessments of the surgical site, and staff did not contact the orthopedic surgeon for clarification of orders. Interviews confirmed missed orders and lack of follow-up on critical postoperative care.
Deficiencies (1)
Failure to completely transcribe admission orders and obtain clarification orders from a surgeon for Resident #7, resulting in potential postoperative complications including wound infection and anemia.
Report Facts
Days staples remained in place: 20
Date of surgery: Jul 20, 2023
Date of admission: Jul 24, 2023
Date of discharge: Aug 6, 2023
Enoxaparin dosage and duration: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner O | Nurse Practitioner | Reported working under the orthopedic surgeon and confirmed staples remained in place 20 days post-surgery. |
| Assistant Director of Nursing A | Assistant Director of Nursing | Reviewed EMR and confirmed lack of documentation for dressing changes, labs, and clarification calls. |
| Unit Manager M | Unit Manager | Acknowledged missed orders for labs and staples removal and confirmed transcription review. |
Inspection Report
Complaint Investigation
Census: 63
Deficiencies: 9
Date: Apr 25, 2023
Visit Reason
The inspection was conducted based on multiple complaint intakes regarding resident care, medication management, environment, and safety concerns at Medilodge of Ludington.
Complaint Details
The visit was complaint-related, triggered by multiple intake numbers including MI00133542, MI00135412, MI00133232, MI00133909, MI00134027, MI00133883, and MI00135796. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, inadequate provision of linens and wipes, failure to provide medications and medical follow-up, inadequate assistance with activities of daily living, improper pressure ulcer care, unsafe use of resident equipment, and failure to properly secure and document narcotic medications.
Deficiencies (9)
Failed to treat residents in a respectful and dignified manner and assure timely response to call lights to avoid incontinent episodes causing embarrassment for Resident #10.
Failed to provide a safe, clean, comfortable, and homelike environment due to lack of linens, wipes, and briefs causing discomfort for 63 residents.
Failed to discharge Resident #1 with medications, resulting in lack of medications for home use and potential medical complications.
Failed to provide adequate assistance with activities of daily living to Residents #5 and #11, resulting in missed meals and showers.
Failed to provide medications as ordered for Resident #5 and failed to identify significant change in condition for Resident #6, resulting in potential medical complications.
Failed to provide appropriate pressure ulcer care and prevent new ulcers for Residents #10, #11, and #12, resulting in skin breakdown and discomfort.
Failed to properly utilize resident equipment for Residents #15 and #11, resulting in potential for serious injury from falls or entanglement.
Failed to assist Resident #1 with making a medical appointment, resulting in lack of medical follow-up and potential complications.
Failed to properly secure, maintain accountability, and document narcotic use for multiple residents, failed to ensure medications were secure, and failed to remove expired/unpackaged medications, resulting in diversion and potential administration of expired medications.
Report Facts
Residents affected: 63
Medication count discrepancy: 8
Medication quantities: 58
Medication quantities: 30
Medication quantities: 30
Medication quantities: 30
Medication quantities: 56
Linen inventory: 110
Linen inventory: 17
Linen inventory: 180
Linen inventory: 51
Resident weights: 202
Resident weights: 200
Resident weights: 215.6
Resident weights: 225.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN L | Registered Nurse | Involved in narcotic count discrepancy and subsequent investigation |
| ADON N | Assistant Director of Nursing | Performed medication pass and discovered narcotic discrepancy |
| DON | Director of Nursing | Interviewed multiple times regarding medication and care deficiencies |
| CNA Y | Certified Nurse's Aide | Reported lack of linens and wipes |
| CNA AA | Certified Nurse's Aide | Reported running out of wipes and sheets |
| CNA BB | Certified Nurse's Aide | Reported frequent shortages of wipes and sheets |
| CNA Q | Certified Nurse's Aide | Admitted not providing shower to Resident #11 as scheduled |
| CNA DD | Certified Nurse's Aide | Observed pushing Resident #15 wheelchair without foot pedals |
| Therapist FF | Therapist | Stated foot pedals are required to prevent injuries when pushing wheelchairs |
| LPN J | Licensed Practical Nurse | Assessed Resident #12's skin breakdown and obtained physician order |
| Housekeeper Z | Housekeeper | Observed Resident #10 waiting over half hour for assistance |
Inspection Report
Routine
Deficiencies: 5
Date: Dec 13, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, treatment, and facility policies, including bed hold notification, baseline care plans, professional standards of care, and post-fall assessments.
Findings
The facility failed to notify a resident about the bed hold policy upon hospital discharge, did not develop baseline care plans within 48 hours for several residents, failed to provide ordered wound care and neurological assessments after falls, and allowed unqualified staff to perform resident transfers resulting in a fall. These deficiencies resulted in potential or actual harm to residents.
Deficiencies (5)
Failed to notify resident or representative in writing about bed hold policy following hospital transfer.
Failed to develop and implement baseline care plans within 48 hours of admission and provide copies to residents or representatives for 4 residents.
Failed to provide wound care treatments as ordered for a resident with a stage 3 pressure ulcer, resulting in missed treatments without explanation.
Failed to follow physician-ordered treatment and assessments, including neurological assessments every shift for 72 hours after falls for 2 residents.
Failed to provide appropriate care to a resident resulting in a fall due to unqualified staff transferring the resident and poor communication, unmet needs, and psychosocial harm.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 1
Missed wound care days: 7
Missed wound care days: 12
Neurological assessments missing: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| K | Regional Director of Operations | Responded regarding bed hold policy and baseline care plans |
| L | Registered Nurse Unit Manager | Interviewed regarding missed wound care treatments |
| J | Social Worker | Interviewed regarding resident communication and care conference |
| I | MDS Registered Nurse | Interviewed regarding MDS completion and resident assessment |
| DON | Director of Nursing | Interviewed regarding resident care concerns and communication |
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