Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 Ludington during CMS and state inspections, most recent first.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Two residents with nephrostomy tubes did not receive consistent monitoring, assessment, or documentation of tube care and output, leading to hospitalization and infection. Orders for dressing changes and output monitoring were not reliably followed, and staff demonstrated confusion about proper tube management, including stopcock positioning. There was also a lack of care planning and insufficient documentation of changes in condition or hospital transfers.
Two residents with nephrostomy tubes did not receive competent care due to staff's lack of understanding of proper tube management, including incorrect stopcock positioning and inadequate monitoring of output. This resulted in repeated hospitalizations, improper documentation, and evidence that staff had not received necessary education on nephrostomy care.
The facility failed to provide timely assistance to residents, leading to unmet needs and compromised dignity. A resident receiving end-of-life care reported long waits for help after soiling himself, while another resident dependent on staff for transfers experienced similar delays. Resident council minutes documented ongoing complaints about delayed call light responses. Additionally, a severely cognitively impaired resident was observed without a call light within reach, softly calling for help.
A facility failed to follow its transfer policy for a resident sent to the hospital. The policy required physician orders and a Transfer Form with a medication list, but neither was documented in the EMR. The SBAR form sent with the resident lacked the medication list. The DON confirmed these omissions during an interview.
A facility failed to provide a bed hold policy to a resident during a hospital transfer. The resident was transferred due to a change in condition, but the electronic medical records showed no documentation of the bed hold policy being provided. The Director of Nursing confirmed this oversight, which was against the facility's policy requiring the provision of such notice at the time of transfer or within 24 hours.
The facility failed to accommodate the needs of five residents, including issues with inaccessible call lights, inadequate hydration, and lack of pressure-reducing devices. A quadriplegic resident could not reach the call light or request water, and another resident was left with her leg hanging off the bed. A nurse did not respond to a resident's call for help, and the facility's hydration policy was not followed.
The facility failed to secure a medication cart and did not follow guidelines for preparing, storing, and dating medications. An unlocked cart contained unlabeled pills, and several insulin pens, eye drops, and an inhaler lacked open dates. Interviews with staff confirmed that pre-setting medications is unacceptable and can lead to errors. Facility policies require medications to be stored securely and dated appropriately.
The facility failed to implement enhanced barrier precautions for three residents with indwelling medical devices, as gowns and gloves were not available, and staff were unaware of the precautions. Additionally, improper infection control practices were observed in oxygen storage for a resident, with undated tubing and overdue humidifier bottle replacement. The Environmental Services Manager also reported improper handling of soiled linens, posing infection control risks.
The facility failed to follow professional standards for medication administration, leading to errors for multiple residents. A resident received Midodrine without proper blood pressure assessments, while another had insulin administered without blood sugar checks. Additionally, discrepancies in controlled substance documentation were noted, indicating a lack of adherence to prescribed protocols.
A resident with multiple health issues was neglected, with family reporting concerns about aspiration risks, unchanged clothing, and missed meals. The facility failed to report or investigate these allegations, despite staff awareness and policy requirements.
A resident with multiple medical conditions, including hemiplegia and vascular dementia, did not receive appropriate ADL assistance in an LTC facility. The resident was at risk for aspiration due to thin liquids left at the bedside, and family members reported concerns about the resident not being showered regularly, not having clothes changed for days, and missing a meal. These concerns were not properly addressed or documented by the facility staff.
A resident with a suprapubic catheter did not receive appropriate care, as the facility failed to follow the prescribed routine for changing the catheter dressing. The resident, who was dependent on staff for daily activities, was found with a soiled dressing that had not been changed for five days, leading to potential complications from infection and skin breakdown.
A facility failed to protect the confidentiality of medical records for 12 residents when a computer screen on a medication cart was left open, displaying personal health information. This lapse was observed by surveyors, and interviews with RNs revealed they were aware of the need to secure the screen but sometimes forgot due to being busy. The facility's policy requires logging out of applications when leaving a workstation.
A medication cart was found unlocked and unattended, allowing access to narcotics and resident medications. The responsible RN was administering medications elsewhere, and staff interviews confirmed awareness of the locking requirement. The facility's policy mandates direct observation or locking of medications.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Monitor and Provide Appropriate Nephrostomy Tube Care Resulting in Hospitalization and Infection
Penalty
Summary
The facility failed to provide appropriate care and monitoring for nephrostomy tubes for two residents, resulting in hospitalization and infection. For one resident with a history of hydronephrosis, kidney stones, and recurrent infections, there was a lack of consistent documentation and monitoring of nephrostomy tube output and exit site care. Orders for dressing changes and output monitoring were inconsistently followed, with multiple missed or undocumented dressing changes and no regular recording of nephrostomy output. The resident experienced repeated dislodgement of the nephrostomy tube, redness and drainage at the exit site, and ultimately developed a severe kidney infection with ESBL-producing E. coli, requiring hospitalization and intravenous antibiotics. Hospital records indicated the nephrostomy tube stopcock was in the off position, leading to a large volume of purulent fluid accumulation, which was not documented or addressed in the facility's records. For the second resident, who had diagnoses including urinary tract infection, bacteremia, and hydronephrosis, there was also a lack of a care plan for nephrostomy care and inconsistent documentation of nephrostomy output. Despite orders to empty and record the nephrostomy bag output every shift, there were numerous shifts with zero output documented and one shift with no documentation at all. Observations revealed confusion among staff regarding the correct positioning of the nephrostomy tube stopcock, with some staff unable to confidently determine whether the tube was draining properly. The resident reported minimal output from the nephrostomy tube, and staff interviews confirmed uncertainty about the correct procedures for nephrostomy care. Throughout the review, staff interviews revealed a lack of knowledge and training regarding nephrostomy tube management, including the correct positioning of stopcocks and the importance of securing and monitoring the tubes. There was also evidence of staff documenting care that was not performed, lack of follow-up on missed or refused treatments, and insufficient communication and documentation regarding changes in resident condition or hospital transfers. Facility policy required care consistent with professional standards, including regular assessment, documentation, and prompt reporting of abnormalities, but these standards were not met for the residents reviewed.
Failure to Ensure Staff Competency in Nephrostomy Care
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the necessary competencies to provide appropriate care for residents with nephrostomy tubes, as evidenced by the care of two residents. Both residents had complex medical histories, including hydronephrosis, urinary tract infections, and nephrostomy catheters, and required specialized care and monitoring. Despite these needs, staff demonstrated a lack of understanding regarding the correct management of nephrostomy tubes, including the proper positioning of stopcocks to allow for drainage, and failed to consistently monitor and document output as ordered. For one resident, repeated hospitalizations occurred due to issues with the nephrostomy tube, including the stopcock being left in the off position, resulting in a significant accumulation of purulent fluid and infection. Observations revealed improper dressing and anchoring of the tubing, and staff were unable to confidently assess or describe the correct functioning of the nephrostomy equipment. Documentation was incomplete, with missing transfer forms and inconsistent charting of care, assessments, and outside transfers. The unit manager and other staff members were unclear about the standards of care for nephrostomy tubes and had not received adequate education on the subject. For the second resident, there was a prolonged period where the nephrostomy bag output was documented as zero for multiple shifts, despite the presence of the tube and orders to monitor output. Staff interviews and observations revealed confusion about the correct position of the stopcock and a lack of confidence in assessing the device. Review of training files for relevant nursing staff showed no evidence of education on nephrostomy care, further supporting the finding that staff were not competent to manage the residents' needs as required.
Delayed Response to Call Lights and Inadequate Assistance
Penalty
Summary
The facility failed to provide necessary services to ensure the dignified well-being of three residents, leading to unmet needs. Resident 47, who was moderately cognitively intact and receiving end-of-life care, reported multiple instances of soiling himself and waiting over an hour for assistance. He expressed dissatisfaction with the response times after using the call light and felt that staff were reluctant to assist him due to perceived attitude issues. Resident 47 had complained to supervision about the delays but was told to wait, expressing a desire to return home. Resident 5, who was cognitively intact and dependent on staff for transfers, also reported long wait times after using the call light, often waiting over an hour to be cleaned after incontinence episodes. She had complained to staff about the delays but was told they were busy. Resident council minutes documented complaints of delayed call light response times on the third shift over several months. Resident 71, who was severely cognitively impaired and dependent on staff for toileting, was observed without a call light within reach and was softly calling for help, which could not be heard unless standing close to her.
Failure to Follow Transfer Policy for Hospital Transfer
Penalty
Summary
The facility failed to adhere to its policy for emergency transfers and discharges for a resident who was reviewed for hospital transfers. The policy required obtaining physician orders for emergency transfers, stating the reason for the transfer, and completing a Transfer Form with necessary documentation, including a medication list. However, for the resident in question, there were no physician orders documented in the Electronic Medical Record (EMR) for the transfer to the hospital, nor was there a Transfer Form provided that included a medication list. The SBAR form, which was sent with the resident, contained relevant information about the resident's condition but lacked the medication list. The Director of Nursing confirmed the absence of the Transfer Form and the physician's order in the EMR during an interview.
Failure to Provide Bed Hold Policy During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold policy to a resident who was reviewed for hospitalization. The resident, identified as R61, was originally admitted to the facility on an unspecified date. On February 6, 2025, R61 experienced a change in condition and was transferred to the hospital. A review of R61's electronic medical records revealed that no bed hold policy was provided to her at the time of her transfer. During an interview on February 13, 2025, the Director of Nursing confirmed the absence of documentation indicating that the resident received a bed hold policy upon her transfer to the hospital. The facility's policy on transfer and discharge, last reviewed on October 30, 2023, requires that a notice of the resident's bed hold policy be provided to the resident and their representative at the time of transfer, or no later than 24 hours after the transfer.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of five residents, as observed during a survey. One resident was found with a call light clipped to the privacy curtain, out of sight and reach. Another resident, who is quadriplegic, had a call light touch pad placed on his torso, making it inaccessible. This resident also had an empty cup on the over-bed table, was unable to alert staff for more water, and had dry, cracked lips. Additionally, there were no pressure-reducing devices between his legs or under his feet, despite having contractures. Further observations revealed a resident with her leg hanging off the bed, and a CNA removed her breakfast tray without repositioning her. Another resident was calling for help and attempting to stand, but a nurse nearby did not respond. The call light for another resident was out of reach, and the resident expressed hunger but could not alert staff. The facility's policy on resident hydration, last reviewed in 2022, was not adhered to, as evidenced by the resident's inability to access water.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to secure one of four medication carts and did not adhere to guidelines for preparing, storing, and dating medications. During an observation, a medication cart was found unlocked and unattended by nursing staff. In the top drawer of this cart, there was an unlabeled medication cup containing four unidentified pills. Additionally, several insulin pens, eye drops, and an inhaler were found without dates indicating when they were opened, which is against the facility's policy. These medications were prescribed to various residents, including those in beds 26-1, 9-2, 29-1, 22-2, 21-1, 28-1, 29-2, and 28-2. Interviews with nursing staff revealed that pre-setting medications is not an acceptable practice and can lead to medication errors. The facility's policy requires that all drugs and biologicals be stored in locked compartments and that medications must be under the direct observation of the person administering them or locked in the medication area/cart. The policy also specifies that certain medications, such as multiple-dose injectable vials and eye drops, require an expiration date shorter than the manufacturer's expiration date once opened. The facility's Insulin Reference Guide provides specific guidelines for how long insulin can be kept once opened, which were not followed in this instance.
Infection Control Deficiencies in EBP and Oxygen Storage
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions (EBP) for three residents who required such measures due to the presence of indwelling medical devices and wounds. Observations revealed that gowns and gloves were not readily available for staff performing high-contact care activities for these residents, and there were no signs to alert staff that these residents were on EBP. Interviews with staff, including a Licensed Practical Nurse and a Certified Nurse Aide, confirmed a lack of awareness and implementation of EBP for these residents. The Infection Control Preventionist acknowledged the absence of EBP signs and PPE towers, indicating a lapse in maintaining infection control protocols. Additionally, the facility did not follow proper infection control practices for oxygen storage for one resident. The oxygen tubing lacked a date to indicate when it was last changed, and the humidifier bottle was not replaced within the required timeframe. The tubing was also found coiled in a wastebasket, raising concerns about contamination. Furthermore, the Environmental Services Manager reported instances of urine-soaked briefs and bed linens with solid stool being improperly handled and sent to the laundry, which could pose serious infection control risks. These findings highlight significant deficiencies in the facility's infection prevention and control program.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice for medication administration, resulting in medication errors for several residents. For Resident #3, the facility did not consistently assess blood pressure before administering Midodrine, a medication for hypotension, as required by the physician's orders. On multiple occasions, the medication was administered despite blood pressure readings exceeding the prescribed parameters, or without any blood pressure assessment being conducted prior to administration. Resident #7, who was prescribed insulin for diabetes management, did not have blood sugar levels assessed before the administration of Lyumjev, as required. Despite the lack of assessments, the medication was administered, and on several occasions, doses were withheld without documented blood sugar readings to justify the decision. This lack of adherence to the prescribed protocol for blood sugar monitoring before insulin administration represents a significant deviation from professional standards. Additionally, discrepancies were noted in the administration and documentation of controlled substances for Residents #11, #13, and #2. Resident #11's medication administration record indicated that Zaleplon was given, but the controlled substance record did not reflect this, suggesting a failure in documentation. For Resident #13, a dose of lorazepam was signed out but not administered, and there was no documentation of a second nurse witnessing the waste of the medication. Resident #2's administration record did not reflect the administration of oxycodone, despite the controlled substance record indicating it was given. These documentation errors highlight a failure to follow professional standards in medication administration and record-keeping.
Failure to Implement Abuse and Neglect Policy
Penalty
Summary
The facility failed to implement its abuse and neglect policy and procedure for a resident, resulting in allegations of neglect not being reported to the state survey agency and not being thoroughly investigated. The resident, who was admitted from a private home, had multiple diagnoses including hemiplegia, hemiparesis, vascular dementia, oropharyngeal dysphagia, and required a suprapubic catheter. The resident was dependent on staff for various activities of daily living, including eating and personal hygiene. Family members reported several concerns about the resident's care, including the risk of aspiration due to thin liquids being left at the bedside, the resident not having her clothes changed for four days, and not being served dinner on one occasion. Despite these serious concerns, the facility did not report the allegations to the state agency or conduct a thorough investigation. The Director of Nursing and the Nursing Home Administrator were not immediately aware of the complaints, and the facility's complaint forms lacked details and follow-up actions. Interviews with staff revealed that the concerns were reported to management, but no action was taken to address them. The Social Services Director confirmed that he was aware of the allegations but did not report them or document them in the resident's medical record. The facility's policy on abuse, neglect, and exploitation requires that any potential noncompliance with federal requirements be reported and investigated, but this was not done in this case.
Deficiency in ADL Assistance for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident, leading to deficiencies in the care of activities of daily living (ADLs). The resident, who was admitted from a private home, had multiple diagnoses including hemiplegia, hemiparesis, vascular dementia, oropharyngeal dysphagia, and required a suprapubic catheter. The resident was dependent on staff for various ADLs such as eating, oral hygiene, toileting, dressing, and bed mobility. However, observations and interviews revealed that the resident was at risk for aspiration due to thin liquids being left at the bedside, and there were reports of the resident not having her clothes changed for four days, not being showered regularly, and not being served dinner on one occasion. Family members expressed serious concerns about the resident's care, which were not adequately addressed by the facility. Despite being reported to a staff member, these concerns were not escalated to the Nursing Home Administrator (NHA) or documented in the resident's electronic medical record. The facility's documentation showed that the resident had only been showered three times since admission, and there were no progress notes indicating any refusal of showers or family-reported concerns. This lack of action and documentation contributed to the deficiency in providing necessary ADL assistance to the resident.
Inadequate Suprapubic Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic catheter, leading to potential complications from infection and skin breakdown. The resident, who was admitted from a private home, had a history of hemiplegia, hemiparesis, vascular dementia, oropharyngeal dysphagia, and type 2 diabetes, and required the use of a suprapubic catheter. The care plan for the resident did not include specific interventions for the care of the suprapubic catheter, despite the resident's dependence on staff for various activities of daily living. During an observation, a CNA found the resident with stool around the rectum and a soiled dressing around the suprapubic catheter insertion site, which had not been changed for five days. The dressing was visibly soiled with brown and tan exudate, and the skin around the catheter was reddened with partially dried and sticky tan mucous. The Treatment Administration Record indicated that the order to remove the dressing, cleanse the area, and apply a new drain sponge daily was documented as being carried out only once, highlighting a lapse in the prescribed care routine.
Failure to Safeguard Resident Medical Records
Penalty
Summary
The facility failed to safeguard the confidentiality of medical records for 12 residents, as observed during a survey. On the specified date, a computer screen on the Northeast Wing Medication Cart was left open, displaying multiple residents' electronic Medication Administration Records (e-MAR) with personal and health identifying information. This information was visible to anyone passing by, and there was no staff present to monitor the cart at the time of the observation. This lapse in security resulted in the potential for unauthorized access to residents' medical records and the loss of privacy and confidentiality of their personal health information. Interviews with Registered Nurses (RN) A, B, and C revealed that they were aware of the requirement to lock the medication cart and hide the computer screen to protect residents' privacy and HIPAA information. RN A admitted to forgetting to secure the computer screen due to being busy, while RN B and RN C acknowledged the same responsibility and the possibility of forgetting when occupied with other tasks. The facility's Workforce Security Information System Access Control policy, dated 1/1/22, mandates that users properly log out of all applications and networks when leaving a workstation, which was not adhered to in this instance.
Medication Cart Security Breach
Penalty
Summary
The facility failed to secure one of its medication carts, specifically the Southwest Medication Cart, which resulted in narcotics and controlled substances not being under double lock. During an observation, the cart was found unlocked and unattended in the hallway, with the locking mechanism's red dot visible, indicating it was not secured. This allowed the surveyor to open the drawers containing individual residents' medications and floor stock medications without being observed by facility staff. At the time of the observation, the nurse responsible for the cart, RN C, was in a resident's room administering medications. Interviews with the nursing staff, including RN A, RN B, and RN C, revealed that they were aware of the requirement to lock the medication cart when it is not under direct observation. RN C admitted that sometimes she gets busy and may forget to lock the cart when she walks away to administer medications. The facility's Medication Storage policy, dated 1/30/24, mandates that medications must be under direct observation or locked during a medication pass, and narcotics and controlled substances must be stored under double lock and key.
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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 Ludington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakview Medical Care Facility | 0.4 mi | — | 9 | 0 |
| Oceana County Medical Care Facility | 18.4 mi | — | 1 | 0 |
| Manistee County Medical Care Facility | 22.8 mi | — | 11 | 0 |
| Grand Oaks Nursing Center | 29.1 mi | — | 2 | 0 |
| Optalis Health & Rehabilitation Of Whitehall | 39.2 mi | — | 4 | 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.