Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Ludington during CMS and state inspections, most recent first.
Failure to Stabilize Resident After Fall: A resident with cognitive deficits, repeated falls, and self-transfer behavior fell while moving between a chair and wheelchair and complained of hip pain. Staff used a maxi lift to move the resident from the floor to bed, after which the resident had increased pain and was sent to the hospital; imaging showed a minimally displaced right hip fracture, and the resident later died from medical complications of the fracture.
Inadequate infection surveillance for staff and resident GI illness. The facility did not maintain an effective system to track staff call-offs for GI and other illness, including missing details such as last worked date, unit assignment, and resident contact, and it did not track housekeeping or therapy staff illnesses. Two residents on the same unit had similar GI symptoms and Imodium orders, but their symptoms were not placed on the line list and a possible GI outbreak was not identified or investigated.
Medication administration did not follow physician orders for two residents. One resident with anxiety had lorazepam documented as given at a higher dose than what was dispensed, with no charting explaining the discrepancy. Another resident with paroxysmal atrial fibrillation received digoxin without a recorded pulse on the MAR, even though the order required the medication to be held if HR was below 60 and the DON stated pulse assessment and documentation were standard of care.
The facility failed to provide staff with the competencies and skills needed to manage residents with agitation, confusion, and disruptive behaviors. A resident with alcohol dependence, anxiety, and cognitive communication deficit displayed profanity, physical aggression, and inappropriate toileting, while another resident with dementia and severe agitation wandered into rooms, became combative, and was involved in an incident where he struck one resident and entered other residents’ rooms while naked. The records showed repeated behavioral events, but care plans were not consistently updated and enhanced supervision was not initiated for several of the behaviors.
Resident representative rights not supported or documented: A cognitively intact resident with CHF, DM2, lymphedema, and severe morbid obesity had DPOA paperwork naming his niece as his health care decision maker, and he stated he wanted her involved in both medical and financial decisions. After readmission, he developed a pressure injury and had a fall, but the record had no documentation that the niece was notified, and there was no evidence the facility discussed his wishes, updated the care plan, or addressed the palliative care note about his decision-making ability.
A cognitively intact resident with morbid obesity, CHF, DM2, lymphedema, legal blindness, and a history of falls slid off the bed during a dressing change when he was positioned on his side between an LPN and CNA. The facility identified body habitus, the air mattress, and bed position as the root cause, but only documented monitoring positioning during treatments, did not notify the resident’s family member, and staff reported they were unaware of other mattress modes despite the resident’s limited bed space and difficulty being safely rolled.
Failure to involve the IDT and psych provider in an antipsychotic GDR: A resident with dementia, agitation, and psychotic behaviors remained on quetiapine after a prior failed GDR, but the chart showed a dose reduction was made without a documented psych assessment or clear IDT involvement. The resident was observed yelling, trying to enter other residents’ rooms, and later had continued agitation, restlessness, and disruptive behaviors after the medication change.
A resident with osteoporosis, depression, and anxiety had a missing lower denture that was reportedly thrown away after being left on a meal tray. The care plan called for dental referral as needed, but the facility delayed replacement while trying to determine Medicaid coverage and obtain an invoice from the dental clinic, and the resident reported difficulty eating around others because of how she had to chew her food.
Failure to Provide Timely Hygiene and Incontinence Care: A resident with dementia and prior CVA, dependent on one staff member for all ADLs, was found in bed covered in a large, dried area of diarrhea with a strong fecal odor in the room. A CNA reported not checking on the resident for hours due to being the only CNA on the hall, and when care was provided, staff noted the stool had dried to the skin and the resident’s buttocks were red and non-blanchable.
A resident with CHF, DM2, lymphedema, and severe morbid obesity was dependent for bed mobility and at moderate risk for pressure injury, yet was repeatedly observed in bed without effective repositioning or heel offloading. The record showed inconsistent skin documentation, no comprehensive wound assessment when a buttock pressure injury was identified, no timely notification of the provider or RP, delayed wound treatment orders, and a care plan that did not reflect a turning/repositioning program after the wound was found.
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 Stabilize Resident After Fall
Penalty
Summary
The facility failed to appropriately stabilize a resident after a fall. The resident had diagnoses including cognitive communication deficit, osteoarthritis, spondylosis without myelopathy or radiculopathy, a wedge compression fracture of T5-T6, and multiple bilateral rib fractures. Records showed the resident had repeated falls, self-transfers, confusion, anxiety, fatigue, low O2 saturation, and agitation, and had been educated on call light use and fall safety but continued getting out of bed and into the bathroom without assistance. After one fall, the resident developed a small gash under the right eye and a goose egg on the forehead, and after another unwitnessed fall while moving between a chair and wheelchair, the resident landed on the right side and complained of right hip pain. After the fall, staff assessed the resident, used a maxi lift to move the resident from the floor to the wheelchair and then to bed, and the resident continued to complain of increased hip pain. The resident was sent to the hospital within 30 minutes because of the severity of the pain. Hospital imaging showed a minimally displaced intertrochanteric fracture of the right hip, and the resident was later transferred to a bigger hospital, was not optimized for surgery, and was admitted to end of life care. The death certificate listed death due to medical complications of the right hip fracture.
Inadequate infection surveillance for staff and resident GI illness
Penalty
Summary
The facility failed to implement an effective and current system of surveillance of staff illnesses to identify possible communicable diseases and infections. Review of the February Infection Surveillance Report showed multiple employee call-offs for gastrointestinal illness and other illnesses, including a registered nurse, activities staff member, certified nursing assistants, and an office staff member. The infection control preventionist reported that call-off slips were emailed from HR and reviewed daily, but the employee line list did not include the date last worked, the unit assigned, or documentation of resident contact. She also reported that she did not track call-offs or illnesses for housekeeping staff or therapy staff, and she was not aware there had been multiple staff call-offs related to GI illness. For Resident #35, review of the record showed the resident was admitted to the facility and later had an order for Imodium for diarrhea. A practitioner communication log note dated 2/17/26 documented congested cough and diarrhea, and the practitioner note documented cough, congestion, and diarrhea for 1 day. For Resident #59, review of the record showed the resident was admitted to the facility and had handwritten practitioner communication log notes documenting diarrhea for days and a later request for Imodium. A progress note dated 2/17/26 documented an order received for Imodium related to complaints of diarrhea. The infection control preventionist stated that residents were added to the active line list after daily review of the 24-hour report, which included nursing notes and PRN medication administration. However, she did not identify a potential GI outbreak for residents, stating that it was not ringing a bell when asked. Residents #35 and #59 were on the same unit and both received Imodium orders for similar GI symptoms, but their GI symptoms were not listed on the line list and the potential outbreak was not investigated. The facility policy stated that surveillance is used for identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, volunteers, visitors, and other individuals providing services under contract.
Medication Administration Errors and Missing Pulse Documentation
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders for two residents reviewed for nursing professional standards of practice. One resident with anxiety had orders for lorazepam 0.25 mg in the morning and lorazepam 0.5 mg at bedtime, but the control substance record showed 0.25 mg was dispensed on two occasions while the MAR documented 0.5 mg as administered. The electronic medical record contained no documentation explaining the incorrect doses documented as given. The DON confirmed the medication error and stated occurrence reports were initiated. Another resident with paroxysmal atrial fibrillation had an order for digoxin 125 mcg at bedtime with instructions to hold if heart rate was less than 60. The February and March MARs showed the medication was administered, but no pulse was recorded in the spaces provided. A pulse summary from January through March did not show that the resident's pulse was taken at the time of medication administration daily as ordered. During interview, the DON stated it was standard of care to assess and record the resident's pulse before administering digoxin and said the pulse should have been recorded on the MARs.
Insufficient behavioral health staffing and supervision
Penalty
Summary
The facility failed to provide sufficient staff with the knowledge and skill sets to support and assist residents experiencing agitation and confusion and to implement meaningful behavioral interventions for residents with behavioral health needs. The deficiency involved residents who displayed verbal aggression, physical aggression, inappropriate toileting, wandering into other residents’ rooms, and other disruptive behaviors, while the facility did not consistently update care plans or initiate enhanced supervision in response to those behaviors. One resident was cognitively intact but reported frustration with another resident’s repeated behaviors, including verbal aggression toward staff and residents, profanity, urinating outside designated areas, refusal to bathe, and attempts to intimidate others. The record showed that the other resident had diagnoses including alcohol dependence with withdrawal, anxiety disorder, and cognitive communication deficit, and had documented episodes of inappropriate language toward staff and peers, throwing an object when frustrated, backing his wheelchair toward another resident while using profanity, and urinating in a non-designated area. The facility documented redirection, reassurance, firm limit-setting, distraction, and close monitoring, but did not initiate enhanced supervision or update the care plan for the new behaviors described in the record. Another resident had dementia with severe agitation and behavioral disturbances and was described in complaint information as violent, with reports that he was supposed to have one-on-one assistance, had struck, kicked, and punched residents and staff, and had pulled down his pants and urinated in other residents’ rooms. The record also showed sundowning behaviors, attempts to exit the facility, combativeness with staff, confusion, and repeated entry into other residents’ rooms. An incident investigation documented that he struck one resident in the forearm while holding a spoon and entered the rooms of two other residents while naked, and the investigation summary noted he was placed on one-on-one supervision after the incident. The facility assessment stated it was able to care for residents with mental health and behavior needs, including managing psychiatric symptoms and implementing interventions for anxiety, cognitive impairment, depression, trauma/PTSD, and other psychiatric diagnoses.
Resident representative rights not supported or documented
Penalty
Summary
The facility failed to ensure the resident’s right to designate a representative was supported and accurately recorded in the medical record for one resident. The resident was a cognitively intact male with diagnoses including congestive heart failure, type 2 diabetes, lymphedema, and severe morbid obesity. His record showed a BIMS score of 14 out of 15, and his care plan indicated he planned to stay long-term in the SNF and should be actively involved with family and friends in his plan of care. The resident’s niece was documented as his Responsible Party-Clinical and Emergency Contact on admission, and the resident had signed Durable Power of Attorney paperwork naming her to make health care decisions when he was no longer able to make decisions on his own. A palliative care note stated that the niece was his sole health care advocate and that family had been told a capacity assessment would need to be done by the primary team. During interview, the resident stated he wanted his niece to be his medical and financial decision maker and said he had signed documentation at the hospital for her to become his DPOA even though he was still cognitively intact. After the resident returned from the hospital, he sustained a pressure injury and a fall, but the record contained no documentation that the niece was notified of either event. The resident stated he expected the facility to notify his niece of his fall and skin breakdown because that was what he had signed for, and he confirmed there had been no discussion of her assuming the role of patient advocate after readmission. The social service director reported she was not aware of the advance directive paperwork or the resident’s preference for his niece to be more involved, and the record contained no documentation that the facility discussed those wishes, updated the care plan, or addressed the palliative care note regarding his ability to make his own medical decisions.
Failure to complete a comprehensive fall analysis and implement effective interventions
Penalty
Summary
The facility failed to perform a comprehensive root cause analysis and implement meaningful interventions after a fall involving a cognitively intact resident with congestive heart failure, type 2 diabetes, lymphedema, and severe morbid obesity. The resident was admitted with a history of falls, was non-ambulatory, legally blind, and dependent with transfers. During a dressing change to the left hip, the resident was positioned on his right side with an LPN on one side of the bed and a CNA on the other. The resident stated he was slipping, then slid over the edge of the bed and fell to the floor while staff attempted to support him. He reported back pain rated 8 out of 10 and sustained a skin tear to a toe. The incident documentation identified the root cause as body habitus, the air mattress, and the resident’s position in bed, and the follow-up action was limited to monitoring the resident’s position during treatments to reduce the risk of sliding and falling. The fall care plan was revised to reflect the resident’s risk factors and to monitor positioning during treatments, but no other interventions were implemented. The resident’s family member, documented as his responsible party and emergency contact, was not notified of the fall, despite the facility policy requiring notification of the physician and family after any fall. Review of the resident’s alternating pressure mattress showed it was set to alternate every 10 minutes and was set for 660 pounds, while the resident weighed 335.4 pounds. Staff interviews described minimal space on the bed because of the resident’s size, making it difficult to safely roll and reposition him away from the edge. Staff also reported they were not aware of or using the mattress’s static or max firm modes, which the manufacturer described as options for care and for minimizing movement during treatments. The resident stated he remained scared after the fall and felt nothing had changed, and staff acknowledged that the resident needed a larger bed because there was no room to roll him.
Failure to Involve IDT and Psychiatry in Antipsychotic GDR
Penalty
Summary
The facility failed to include the interdisciplinary team and the psychiatric provider in the process of a gradual dose reduction (GDR) of an antipsychotic medication for one resident with dementia with agitation and psychotic disturbances. The resident was observed yelling in the hallway, attempting to enter another resident’s room, and was described by another resident as constantly yelling and trying to enter other rooms. Her record showed ongoing use of quetiapine for agitation, yelling, and wanting to leave, and the psychiatric follow-up note stated that a GDR was contraindicated and that the medication would be continued because the benefits outweighed the risks. The resident’s physician recommendations documented that quetiapine 25 mg twice daily and 50 mg at bedtime should be maintained because a dosage reduction would likely cause unnecessary distress. However, the record also showed a handwritten communication on 2/10/26 stating that the psychiatry consultation group recommended a GDR of Seroquel to 25 mg twice daily. The electronic medical record contained no documentation that the contracted psychiatry group completed an assessment in February 2026, and the regional director of operations confirmed there was no psychiatric consultation completed in February and could not determine where the recommendation referenced by the physician originated. Despite the lack of documented psychiatric assessment, the resident’s medication was changed from 25 mg in the morning and 50 mg at bedtime to 25 mg twice daily. Facility staff later stated that the resident had failed a prior GDR and that another attempt would be discussed with the interdisciplinary team and the resident’s representative, but the chart did not show that the psychiatric provider and IDT were involved in the February reduction decision. The resident continued to have documented behaviors after the change, including restlessness, agitation, going into other residents’ rooms, and disruptive talking in the dining room.
Delayed Replacement of Missing Denture
Penalty
Summary
The facility failed to obtain dental services to replace a missing lower denture in a timely manner for one resident with diagnoses including osteoporosis without current pathological fracture, depression, and anxiety. The resident’s care plan, initiated on 10/15/2024, identified a dental problem related to being edentulous and included a goal of reduced complications related to dental/oral issues, with an intervention to refer to dental services as needed. The resident reported that the lower denture was lost after being placed on a meal tray and thrown away, and stated that the Nursing Home Administrator was aware but wanted to wait to see what Medicaid would cover. A quality assurance form dated 1/7/2025 documented that the resident dropped the dentures and the lower denture could not be found, with a dental appointment scheduled for 2/20/2025. A later quality assurance form dated 8/20/2025 again documented that the bottom dentures were lost after being left on a tray, and the findings noted that the NHA spoke with the resident about replacement and that the facility contacted the dental office to obtain a quote to determine Medicaid coverage. Email communication with the dental clinic in late 2025 showed the facility was still seeking an invoice for the bottom dentures before replacement could proceed, and the clinic responded that it could not print an invoice for a patient without an outstanding balance.
Failure to Provide Timely Hygiene and Incontinence Care
Penalty
Summary
The facility failed to provide timely care to a resident with dementia and a prior stroke causing left-sided weakness, who was dependent on one staff person for all ADLs. During observation, the resident was found lying in bed with his eyes closed and covered in a large, dried area of diarrhea, and the room smelled strongly of feces. A CNA reported not checking on the resident since arriving on the unit at 7:00 AM and stated she had not yet gotten to him because she was the only CNA on the north-east hall that morning and the acuity level was high. When care was finally provided, the CNA and RN indicated the stool was dried to the resident’s skin and had been there quite a while; the resident’s buttocks were red and non-blanchable with no open areas noted.
Pressure injury prevention, assessment, and treatment failures
Penalty
Summary
The facility failed to implement its pressure injury prevention and management policy for a cognitively intact resident with congestive heart failure, type 2 diabetes, lymphedema, and severe morbid obesity who was dependent for bed mobility and at moderate risk for pressure injury development. The resident’s care plan identified the need for repositioning and heel offloading, but multiple observations showed him lying on his back in bed without repositioning devices in place, and his heel protectors were repeatedly not positioned correctly or not protecting his heels. During interviews, the resident stated that staffing was an issue, that staff did not always get him up, and that he had sores on his buttocks and needed help with repositioning. The resident was identified on readmission as having a left buttock pressure injury, and later documentation also referenced a sacral pressure injury. The record showed no comprehensive wound assessment at the time the pressure injury was identified, including no documented measurements, wound description, odor, peri-wound assessment, tunneling/undermining, or pain assessment. Nursing documentation on multiple days was inconsistent, with some entries stating the skin was intact and others only checking skin tears, abrasions, bruises, or MASD, while pressure ulcer staging was not checked. The record also showed no documentation that the provider or responsible party were notified when the new pressure injuries were identified. Treatment and care planning were also not timely or consistent with the identified wound. The resident’s record showed no new wound treatments initiated when the pressure injury was first identified, and the wound care order was not entered until several days later. The care plan did not reflect a turning and repositioning program after the wound was identified, and the resident’s skin care focus was only later updated to note that he preferred not to be repositioned and preferred to lean to the left side. The resident remained incontinent of urine and stool for most documented entries, and the record continued to show ongoing skin breakdown and treatment use after the wound was first identified.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 21 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 26 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 July 2026) and official state health department websites.