Inspection Reports for
Medilodge of Ludington
1000 E Tinkham Ave, Ludington, MI 49431, United States, MI, 49431
Back to Facility Profile12 CMS Surveys
Inspection Report — Aug 29, 2025
Complaint Investigation
Date: Aug 29, 2025
Visit Reason
Investigation of a complaint received about failure to assess and treat residents for acute changes resulting in emergency medical attention.
Complaint Details
Failure to assess and treat acute changes in Resident #1: established. Failure to manage bowel elimination in Resident #2: established.
Findings
Two residents were not properly assessed or treated for acute medical conditions, resulting in emergency hospitalizations and surgery.
Deficiencies (2)
F 0684 Provide appropriate treatment and care according to orders, resident's preferences and goals: the facility failed to assess and treat Resident #1 for acute right lower limb ischemia, resulting in emergency surgery to save the leg.
F 0684 Provide appropriate treatment and care according to orders, resident's preferences and goals: the facility failed to manage Resident #2's bowel elimination, resulting in extreme constipation and urgent hospital transfer.
Inspection Report — Jul 9, 2025
Complaint Investigation
Date: Jul 9, 2025
Visit Reason
Investigation of a complaint received on 2025-05-24 about staff to resident verbal abuse.
Complaint Details
Staff to resident verbal abuse: established. Physical abuse: not established.
Findings
One allegation of staff to resident verbal abuse was substantiated; no physical abuse was found. The facility demonstrated corrective actions and maintained compliance.
Deficiencies (1)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility substantiated verbal abuse by a staff member who swore at Resident #1 during an incident on 5/24/25.
Inspection Report — Apr 18, 2025
Complaint Investigation
Date: Apr 18, 2025
Visit Reason
Investigation of a complaint received about nephrostomy care and staff competency in managing nephrostomy tubes for two residents.
Complaint Details
Nephrostomy care incompetence: established. Staff competency failure: established.
Findings
The facility failed to provide competent nephrostomy care for two residents, resulting in hospitalization and repeated incompetent care. Staff were not properly educated on nephrostomy care, including correct stopcock positioning and monitoring of output. Documentation and assessments were incomplete or missing.
Deficiencies (2)
F 0684 Provide appropriate treatment and care according to orders, resident's preferences and goals: the facility failed to prevent hospitalization and infection for two residents due to improper nephrostomy tube care, including incorrect stopcock positioning, lack of monitoring output, incomplete dressing changes, and inadequate documentation.
F 0726 Ensure nurses and nurse aides have appropriate competencies: the facility failed to ensure staff were competent to manage nephrostomy care for two residents, with no education provided to key nursing staff and repeated errors in care and documentation.
Inspection Report — Feb 13, 2025
Complaint Investigation
Date: Feb 13, 2025
Visit Reason
Investigation of a complaint received about failure to provide needed services, failure to follow transfer and discharge policies, and failure to notify resident of bed hold policy.
Complaint Details
Failure to provide needed services to ensure dignified well-being: established. Failure to follow transfer and discharge policies: established. Failure to notify resident of bed hold policy: established.
Findings
The facility failed to provide needed services to ensure dignified well-being of residents, failed to follow transfer and discharge policies for one resident, and failed to provide a bed hold policy notification for one resident.
Deficiencies (3)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility failed to provide needed services to ensure the dignified well-being of three residents who experienced delayed assistance and call light response times.
F 0622 Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged: the facility failed to follow their policy for transfers for one resident by not obtaining physician orders and not providing a transfer form with medication list.
F 0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave: the facility failed to provide a bed hold policy to one resident upon transfer to the hospital.
Inspection Report — Oct 24, 2024
Complaint Investigation
Date: Oct 24, 2024
Visit Reason
Investigation of a complaint received on 2024-10-23 about resident care, medication storage, infection prevention, oxygen storage, and laundry services.
Complaint Details
Failure to accommodate resident needs: established. Medication storage violations: established. Infection prevention and control failures including enhanced barrier precautions, oxygen storage, and laundry contamination: established.
Findings
Multiple deficiencies were found related to resident care needs accommodation, medication storage and labeling, infection prevention and control practices including enhanced barrier precautions, oxygen storage, and laundry contamination.
Deficiencies (3)
F 0558 Reasonably accommodate the needs and preferences of each resident: the facility failed to ensure call lights were within reach and residents were not properly positioned to reduce pressure injuries.
F 0761 Ensure drugs and biologicals are labeled and stored properly: medication cart was unlocked and unattended; multiple insulin pens, eye drops, and inhalers lacked dates identifying when opened.
F 0880 Provide and implement an infection prevention and control program: failed to follow enhanced barrier precautions for residents with wounds and indwelling devices, oxygen tubing was improperly stored and undated, and laundry contained contaminated linens.
Inspection Report — Sep 25, 2024
Complaint Investigation
Date: Sep 25, 2024
Visit Reason
Investigation of a complaint received on 2024-09-18 about neglect, medication administration errors, inadequate ADL assistance, and catheter care.
Complaint Details
Failure to prevent abuse and neglect for resident R8: established. Medication administration errors for residents #3, #7, #11, #13, and #2: established. Inadequate assistance with activities of daily living for resident R8: established. Improper suprapubic catheter care for resident R8: established.
Findings
Multiple deficiencies were found related to failure to prevent abuse and neglect, medication administration errors, inadequate assistance with activities of daily living, and improper care of a suprapubic catheter for resident R8 and others.
Deficiencies (4)
F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft: the facility failed to implement their abuse and neglect policy for resident R8, resulting in unreported allegations of neglect, inadequate investigation, and risk of ongoing abuse and neglect.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: medication administration errors occurred for residents #3, #7, #11, #13, and #2, including failure to assess vital signs or blood sugar prior to administration, administering medications outside ordered parameters, and improper documentation.
F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason: resident R8 did not receive adequate assistance with ADLs including hygiene, dressing, nutrition, and hydration; staff failed to change clothes for 4 days, did not provide showers regularly, and missed meals.
F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections: resident R8's suprapubic catheter care was inadequate with soiled dressing left for 5 days, reddened skin, and mucous around the catheter site; the dressing change order was only carried out once.
Inspection Report — Jul 9, 2024
Complaint Investigation
Date: Jul 9, 2024
Visit Reason
Investigation of a complaint received on 2024-07-08 about medication security and resident privacy.
Complaint Details
Medication cart left unlocked allowing access to medications: established. Resident medical records confidentiality breach due to open computer screen: established.
Findings
Two rule violations were established related to medication cart security and safeguarding resident medical records.
Deficiencies (2)
F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs: the facility failed to secure 1 of 5 medication carts, resulting in narcotics and resident medications not being secured and accessible to unauthorized individuals.
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: the facility failed to safeguard the confidentiality of medical records for 12 residents, with electronic Medication Administration Records visible and accessible on an unlocked computer screen.
Inspection Report — Jan 24, 2024
Complaint Investigation
Date: Jan 24, 2024
Visit Reason
Investigation of a complaint received on 2024-01-24 about resident rights, advanced directives, binding arbitration, and infection prevention.
Complaint Details
Durable Power of Attorney not recognized or implemented timely for Resident #56 — established. Binding arbitration consent not properly witnessed or informed — established. Infection surveillance inadequate, employee illnesses not tracked in outbreak — established.
Findings
The facility failed to ensure timely recognition and implementation of a Durable Power of Attorney for a cognitively impaired resident, failed to obtain appropriate witness and informed consent for a binding arbitration agreement, and failed to implement adequate infection surveillance including consistent tracking of employee infections.
Deficiencies (3)
F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive: the facility failed to recognize and implement a Durable Power of Attorney in a timely manner for Resident #56 who demonstrated impaired decision making capacity and defer to the established Attorney-in-fact.
F 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse: the facility failed to obtain appropriate witness to certify Resident #56 was of sound mind and competent to make informed consent for a facility staff member to initial and sign an Alternative Dispute Resolution Agreement on their behalf; failed to document the resident understood the terms and waived their right to a trial by judge or jury.
F 0880 Provide and implement an infection prevention and control program: the facility failed to implement adequate infection surveillance that included consistent tracking of employee infections to monitor for trends and mitigate potential outbreaks; employee illnesses were not included in the COVID-19 outbreak investigation.
Inspection Report — Jan 24, 2024
Complaint Investigation
Date: Jan 24, 2024
Visit Reason
Investigation of a complaint received on 2024-01-23 about delayed staff response to call lights and inadequate assistance to residents.
Complaint Details
Delayed response to call lights and unmet assistance needs for Residents #29, #57, and #60: established.
Findings
The facility failed to ensure timely response to call lights and adequate assistance for three residents, compromising their quality of life and dignity.
Deficiencies (1)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: the facility failed to ensure timely response to call lights and adequate assistance for Residents #29, #57, and #60, resulting in delays up to 45 minutes and unmet needs.
Inspection Report — Oct 19, 2023
Complaint Investigation
Date: Oct 19, 2023
Visit Reason
Investigation of a complaint received on 2023-10-19 about failure to follow physician orders and provide appropriate treatment and care.
Complaint Details
Failure to transcribe admission orders and obtain clarification orders for Resident #7: violation established.
Findings
One deficiency was found related to failure to transcribe admission orders and obtain clarification orders for a resident, resulting in potential postoperative complications.
Deficiencies (1)
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: the facility failed to completely transcribe admission orders and obtain clarification orders from a surgeon for Resident #7, resulting in no labs ordered, no dressing changes, and staples remaining in place for 20 days post-surgery.
Inspection Report — Apr 27, 2023
Complaint Investigation
Date: Apr 27, 2023
Visit Reason
Investigation of multiple complaints received about resident care, medication management, and facility conditions.
Complaint Details
Resident #10 call light delays and dignity issues: established. Lack of linens and wipes: established. Failure to discharge Resident #1 with medications: established. Inadequate ADL assistance for Residents #5 and #11: established. Medication errors for Resident #5 and failure to identify weight gain for Resident #6: established. Pressure ulcer care failures for Residents #10, #11, #12: established. Unsafe equipment use for Residents #15 and #11: established. Failure to assist Resident #1 with medical appointments: established. Narcotic medication diversion and documentation failures: established.
Findings
Multiple deficiencies were found including failure to provide timely and adequate resident care, medication errors and diversion, inadequate pressure ulcer care, failure to assist with medical appointments, and unsafe use of resident equipment.
Deficiencies (9)
Failure to treat Resident #10 with respect and dignity; call lights were not answered timely resulting in resident being soiled and embarrassed.
Failure to provide adequate linens and wipes for 63 residents, causing discomfort and potential for unhygienic conditions.
Failure to discharge Resident #1 with medications, resulting in lack of medications available for home use.
Failure to provide adequate activities of daily living assistance to Residents #5 and #11; R5 was not provided meals and R11 did not receive scheduled showers.
Failure to provide medications as ordered for Resident #5 and failure to identify significant weight gain and notify physician for Resident #6.
Failure to prevent, assess, and provide appropriate pressure ulcer care for Residents #10, #11, and #12 resulting in skin breakdown and discomfort.
Failure to properly utilize resident equipment for Residents #15 and #11; wheelchair foot pedals were missing and electronic stand-up lift was used improperly, risking injury.
Failure to assist Resident #1 with making medical follow-up appointments, resulting in lack of medical follow-up after surgery.
Failure to properly secure, document, and account for narcotic medications for multiple residents (R9, R12, R14, R18, R21, R22, R23); expired and unpackaged medications found in medication carts.
Inspection Report — Dec 13, 2022
Complaint Investigation
Date: Dec 13, 2022
Visit Reason
Investigation of complaints received regarding failure to notify bed hold policy, baseline care plans, professional standards of care, and post-fall assessments.
Complaint Details
Failure to notify bed hold policy: established. Failure to develop baseline care plans: established. Failure to meet professional standards of care including missed wound treatments and neurological assessments: established. Failure to provide appropriate care resulting in resident fall and unmet needs: established.
Findings
The facility was found to have multiple deficiencies including failure to notify a resident of bed hold policy upon hospital discharge, failure to develop and provide baseline care plans within 48 hours for new admissions, failure to provide professional standards of care including missed wound treatments and inadequate post-fall neurological assessments for residents, and failure to provide appropriate care resulting in a resident fall and unmet needs.
Deficiencies (5)
F 0625 Notify the resident or the resident's representative in writing how long the nursing home will hold the resident's bed in cases of transfer to a hospital or therapeutic leave: facility failed to ensure 1 resident (R29) was given written notification of the bed hold policy following hospital discharge.
F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: facility failed to develop and provide baseline care plans within 48 hours for 4 residents (R19, R29, R32, R58).
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: facility failed to follow physician ordered treatment/assessment for 2 residents (R57 and R16), including missed wound care treatments and neurological assessments.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: facility failed to provide quality care to resident R58 resulting in a fall due to unqualified staff transferring and leaving resident unattended on toilet, poor communication, unmet needs, lack of range of motion exercises, and inadequate documentation.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: facility failed to complete neurological assessments every shift for 72 hours following falls for residents R57 and R218, resulting in potential for undetected neurological changes and delayed treatment.
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