Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Oakview Medical Care Facility during CMS and state inspections, most recent first.
The facility failed to provide a way for visitors, staff, and residents to submit concerns and grievances anonymously. Observation showed no grievance form available outside the nurse's station and no drop box or other location for anonymous submission. The DSS stated grievances were not completed unless a resident asked for one, while the DON said the policy allowed anonymous grievances but there was no specific location for filing them.
Failure to assess a chronic buttock wound on admission for a resident with dementia, DM, and renal dialysis. The Baseline Care Plan noted a long-standing sore on the bottom with pain and use of barrier cream and a bandaid, but the admission assessment and EMR had no wound assessment or related interventions until staff later identified a stage 2 pressure ulcer on the R gluteus. An RN said she was unaware of the wound history, and the wound nurse said it should have been assessed at admission.
A resident with Parkinson’s disease and dementia developed two separate bruises of unknown origin, one a large purple discoloration on the upper arm and another on the lower lumbar area. In both cases, the resident could not recall any incident causing the bruises, and documentation showed that clinical staff, the physician, and family were notified, and monitoring was initiated. However, the Abuse Coordinator was not notified, and the incidents were not reported to the State Agency, despite facility policy identifying physical injuries of unknown source as potential abuse requiring reporting. The DON later stated she did not believe these incidents needed to be reported due to the resident’s restlessness, flailing, and inability to verbalize what had occurred.
A resident with Parkinson’s disease and dementia was found on two occasions to have bruises of unknown origin, including a large bruise on the upper arm and another on the lower lumbar area. In both instances, the resident could not explain how the injuries occurred, and the facility did not obtain staff statements or complete a thorough root-cause investigation as required by its abuse and neglect policy. Documentation showed that the bruises were not consistently entered on the TAR for ongoing monitoring, and there was no evidence of a comprehensive nursing or skin assessment. The DON reported that these incidents were not reported to the State Agency, despite facility policy requiring identification, reporting, and investigation of physical injuries of unknown source.
A resident with Parkinson’s disease, dementia, and known fall risk experienced multiple falls associated with anxiety, terminal restlessness, impaired balance, and attempts to self-transfer despite alarms sounding. After the first witnessed fall, documentation identified root causes but did not include meaningful post-fall interventions, and q15-minute safety checks noted on a fall checklist were not added to the care plan. Before a later unwitnessed fall from a recliner, the resident was supposed to be on q15-minute checks, and staff again identified that the resident should not be left alone in a room chair, but this intervention was not timely reflected in the care plan. The DON acknowledged concerns about delayed implementation of care plan interventions and failure to follow the existing care plan.
The facility failed to maintain kitchen equipment and physical facilities, affecting 69 residents. Observations revealed low grout in the dishwashing area, missing handwashing signage, and issues with ice machine filters. The Maintenance Director was unsure of maintenance schedules, violating FDA Food Code standards.
The facility failed to follow professional standards for medication administration, resulting in four residents receiving medications outside of physician-ordered parameters and without necessary vital sign assessments. A resident with hypertension and atrial fibrillation was given Metoprolol without pulse checks, while another with hypertension received Lisinopril despite low pulse readings. A third resident's Lisinopril was administered based on outdated vital signs, and a fourth with orthostatic hypotension was given Midodrine despite high blood pressure readings. The DON confirmed these errors.
A resident's care plan was not updated to reflect current treatment needs, including a urinary catheter and an active coccyx wound. Despite the wound reopening and a catheter being placed, the care plan inaccurately documented the wound as healed and lacked a catheter care plan. Staff interviews confirmed the oversight, contrary to facility policy requiring updated, person-centered care plans.
The facility failed to follow standards for medication storage and labeling. An unlocked treatment cart contained prescription medications, including an undated Humalog insulin pen. The narcotic box on a medication cart was intentionally left unlocked with a straw, and a medication cup with pudding was left unattended. A nurse confirmed these practices were unacceptable, violating the facility's policy requiring locked storage for all drugs and double-lock for controlled substances.
Lack of Anonymous Grievance Submission Process
Penalty
Summary
The facility failed to provide a process for visitors, staff, and residents to submit concerns and grievances anonymously. During observation on 4/7/26 at 2:00 PM, there was no concern or grievance form available outside of requesting one at the nurse's station, and no box or location was found for anonymous grievance submission. In interviews, the Director of Social Services stated that grievances are not completed for residents unless a resident asks for one and that grievance forms were not available outside the nurse's station. The Director of Nursing Services stated that grievances can be filled out by anyone and that the facility policy allows grievances to be submitted anonymously, but there was no specific location at that time for residents to file grievances anonymously. Review of the facility's Resident & Family Grievances policy revised 9/2/25 showed that grievances or complaints may be submitted verbally in person, by telephone, in writing, or anonymously.
Failure to Assess Chronic Buttock Wound on Admission
Penalty
Summary
The facility failed to assess a skin concern identified on admission for one resident with dementia, diabetes, and dependence on renal dialysis. The resident’s Baseline Care Plan documented a “spot on bottom, long time, (no change), hurts,” with barrier cream and the wife placing a bandaid, but there was no assessment of this chronic wound and no interventions specific to it. The resident’s admission assessment also did not include the chronic buttock wound noted in the Baseline Care Plan. The resident’s current care plan later identified a stage 2 pressure ulcer on the right gluteus and noted the resident was at risk for pressure injuries, but there were no mentions or interventions for the chronic wound on the gluteus before that wound was identified. The EMR contained no documentation of the buttock wound until staff identified it on 3/22/2026. An RN stated she was not aware of the resident’s history of chronic buttock pressure ulcer until it was recently identified, and the wound nurse stated the chronic buttock wound should have been assessed at admission and appropriate interventions ordered, but could not determine whether the wound was open or healed at admission.
Failure to Report Injuries of Unknown Origin as Potential Abuse
Penalty
Summary
The facility failed to follow its abuse, neglect, and exploitation policy by not reporting injuries of unknown origin for one resident to the Abuse Coordinator and State Agency. The resident had Parkinson’s disease, Parkinsonism, and dementia and was unable to recall incidents that could have caused the bruising. On one occasion, an incident report dated 10/16/25 documented a large purple discoloration on the resident’s upper right arm measuring 15 cm by 6 cm, with the resident unable to recall any incident that may have caused the bruising. The nursing progress note for the same date confirmed the size and location of the bruise and noted that a message was left in the provider binder for practitioner review and that family would be notified by day shift, but there was no documentation that the Abuse Coordinator was notified. On another occasion, an incident report dated 11/26/25 documented a 4 cm by 4 cm purple/blue bruise with yellow fading around the edges on the resident’s lower lumbar region, discovered when a CNA was assisting the resident to the bathroom. The cause of the bruise was unknown, and the resident was unable to provide a description. The incident report showed that the physician, family member, and MDS nurse were notified, and a nursing progress note confirmed the findings and that the charge nurse was notified and monitoring was initiated, with a note placed to the provider. However, there was again no indication that the Abuse Coordinator was notified or that the incident was reported to the State Agency. In an interview, the DON acknowledged that these incidents were not reported to the State Agency and stated she did not think reporting was necessary due to the resident’s restlessness, flailing, and inability to verbalize what had happened, despite facility policy requiring reporting of physical injuries of unknown source as potential abuse.
Failure to Investigate and Monitor Injuries of Unknown Origin
Penalty
Summary
The facility failed to follow its policies and procedures to thoroughly investigate injuries of unknown origin for one resident. The resident had Parkinson’s disease, Parkinsonism, and dementia and was admitted on an unspecified date. On 10/16/25 at 2:00 AM, nursing staff documented a large purple discoloration on the resident’s right upper arm measuring 15 cm by 6 cm. The resident could not recall any incident that could have caused the bruising. The incident report and corresponding nursing progress note showed that no staff statements were obtained and no thorough investigation of the root cause of the injury was completed. Although the physician was notified and a message was left for the practitioner, there was no documentation on the Treatment Administration Record (TAR) that the bruise was monitored until it resolved, despite facility expectations that bruises be monitored daily for a week and then weekly until resolved. On 11/26/25 at 6:25 PM, another bruise of unknown origin was identified on the same resident. A CNA observed a 4 cm by 4 cm purple/blue bruise with yellow fading around the edges on the resident’s lower lumbar region while assisting the resident to the bathroom. The resident was unable to describe how the bruise occurred, and the incident report again lacked staff statements and evidence of a thorough investigation into the root cause. The nursing progress note documented the bruise and indicated that monitoring was set up and a note was placed to the provider, but there was no documentation of a comprehensive nursing or skin assessment. During interview, the DON acknowledged that these incidents were not reported to the State Agency and stated she did not think reporting was necessary based on the resident’s restlessness and flailing and inability to verbalize what happened. These actions were inconsistent with the facility’s Abuse, Neglect & Exploitation policy, which requires identification, reporting, and investigation of physical injuries of unknown source, including use of investigation worksheets, witness interviews, and collection of information for State Agency reporting.
Failure to Implement Timely Post-Fall Interventions and Care Plan Updates
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention policies and to implement timely, meaningful care plan interventions after falls for a resident with significant fall risk factors. The resident had Parkinson’s disease, Parkinsonism, and dementia, and was care planned as being at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, and Parkinson’s. On one occasion, a housekeeper approached the resident’s room and observed the resident standing and pivoting to his walker when his foot became stuck in the walker wheel, causing a loss of balance and a fall. The resident sustained a skin tear to the back of the right hand. Staff statements indicated that a CNA had just left the room after providing care, the resident had been in his chair, and an alarm was sounding at the time of the fall. Following this fall, facility documentation identified root causes including anxiety, terminal restlessness, Parkinson’s, loss of balance, and impaired balance with unawareness of safety needs. However, the Nurse-Risk Management Note stated only that all safety interventions were in place and did not document meaningful post-fall interventions. A Fall Packet/Investigation Checklist indicated that q15-minute safety checks were to be added to the plan of care, but the care plan did not reflect the addition of these 15-minute safety checks. The facility’s Fall Prevention Program policy required ongoing identification of residents at risk for falls, assessment of current interventions for effectiveness, and implementation of new interventions after each fall based on root cause analysis, including interim safety measures within the first 24 hours if needed. On a subsequent date, the resident experienced another fall, this time unwitnessed, after a CNA heard the chair alarm and found the resident on the floor in front of the recliner chair. Documentation suggested the resident likely slipped on a blanket or slippers while attempting to self-transfer. The root cause analysis for this fall again cited terminal restlessness and that it was unsafe for the resident to be in the room in a chair without supervision, concluding the resident should not be in a chair in the room alone. The resident was supposed to be on q15-minute checks per the prior fall investigation, and the Fall Packet/Investigation Checklist for this second fall noted that q15-minute safety checks were already on the plan of care, yet no new interventions were initiated or added. The fall care plan did not timely reflect the intervention that the resident should not be left alone in the room recliner, and the DON acknowledged concerns about the timeliness of implementing care plan interventions and not following the care plan to prevent a fall.
Deficiencies in Kitchen Maintenance and Equipment
Penalty
Summary
The facility failed to maintain its kitchen and related equipment in accordance with professional standards, potentially affecting 69 residents who receive food and water from the facility. During a tour of the kitchen, it was observed that the dishwashing area had a large section of flooring with low grout, leading to a buildup of food residues, debris, standing water, and grime between the floor tiles. Additionally, the kitchenette in the living center lacked a handwashing reminder sign at the hand sink, and the ice machine's water filter was not labeled or dated. In the shared hallway kitchenette, an ice machine was found without a water filter installed. Interviews and record reviews revealed further deficiencies in maintenance practices. The Maintenance Director was unsure of when the last maintenance, specifically the filter change, had occurred for the ice machine in the living center. He also did not know why the other ice machine lacked a filter but indicated he would investigate further. These findings are in violation of several sections of the 2017 FDA Model Food Code, which require physical facilities to be kept clean and in good repair, handwashing signage to be visible, and water system devices to be regularly inspected and serviced.
Failure to Follow Medication Administration Protocols
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice for medication administration for four residents, resulting in the administration of medications outside of physician-ordered parameters and without necessary vital sign assessments. Resident #29, a female with hypertension and atrial fibrillation, was administered Metoprolol despite the absence of pulse assessments on multiple occasions and even when her pulse was below the prescribed threshold. Resident #40, a male with hypertension, received Lisinopril on several days when his pulse was below the physician-ordered parameter. Resident #22, a female with hypertension, had her blood pressure and pulse assessed only once over a three-day period, yet Lisinopril was administered daily based on outdated vital sign data. Resident #49, a female with orthostatic hypotension, was given Midodrine despite her blood pressure exceeding the physician-ordered limit on multiple occasions. The Director of Nursing confirmed these medication errors and acknowledged that vital signs should have been assessed prior to medication administration, with ordered parameters followed.
Failure to Update Resident Care Plan for Current Treatment
Penalty
Summary
The facility failed to update the care plan for a resident, identified as R13, to reflect current treatment needs. R13 was admitted with diagnoses including cerebral infarction and dementia. The resident had a urinary catheter inserted on January 10, 2025, due to a non-healing coccyx wound. However, the care plan, active as of February 12, 2025, incorrectly documented the coccyx wound as healed and did not include a care plan for the urinary catheter. Interviews with the Wound RN and MDS Coordinator confirmed the discrepancies in the care plan. The Wound RN reported that the coccyx wound had reopened on July 26, 2024, and the urinary catheter was placed to aid in its healing. Despite this, the care plan was not updated to reflect these changes. The Director of Nursing acknowledged that care plans are expected to be updated to reflect current treatments. The facility's policy on comprehensive care plans emphasizes the need for person-centered care plans that include measurable objectives and timeframes to meet residents' needs, which was not adhered to in this case.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to standards of practice for medication storage and labeling, as observed during a survey. An unlocked and unattended treatment cart was found containing prescription medications, including insulin pens. A partially used Humalog insulin pen prescribed to a resident was not dated to indicate when it had been opened. Additionally, the narcotic box on the green hall medication cart was found unlocked, with a drinking straw intentionally placed through the back hinge to prevent it from latching and locking. A Registered Nurse acknowledged that this was not an acceptable practice. Furthermore, a small plastic medication cup containing chocolate pudding and a spoon was left unattended and uncovered on the medication cart, with uncertainty about whether it contained any prescribed medications. The facility's policy requires all drugs and biologicals to be stored in locked compartments, with controlled substances 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) |
|---|---|---|---|---|
| Medilodge Of Ludington | 0.4 mi | ★★★★★ | 13 | 0 |
| Oceana County Medical Care Facility | 18.1 mi | ★★★★★ | 1 | 0 |
| Manistee County Medical Care Facility | 23.1 mi | ★★★★★ | 11 | 0 |
| Grand Oaks Nursing Center | 29.1 mi | ★★★★★ | 2 | 0 |
| Optalis Health & Rehabilitation Of Whitehall | 38.9 mi | ★★★★★ | 26 | 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 July 2026) and official state health department websites.