Medilodge of Ludington

In the surveyor’s words

From the most serious findings on record at Medilodge of Ludington, in the surveyor’s own words.

• Immediate jeopardy, patternF684Feb 18, 2021

  This citation pertains to intake # MI 737 Based on interview and record review, the facility failed to ensure diabetic residents received care in accordance with professional standards: 1.) Failed to notify the provider of blood glucose results greater than 400 and/or less than 70. 2). Failed to routinely assess resident blood glucose levels. 3.) Failed to obtain laboratory tests ordered by the physician. 4.) Failed to obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] #104) reviewed for quality of care, resulting in an immediate jeopardy when, beginning on [DATE], the facility staff failed to ensure diabetic care interventions were in place including physician notification of a change of condition and abnormal blood glucose results. […]

• Actual harm, isolatedF684Mar 11, 2026

  This citation pertains to intake 2646749 Based on interview and record review the facility failed to appropriately stabilize 1 resident after a fall (R93), out of 2 residents reviewed for falls, resulting in increased pain, transfer to the hospital, and death. Findings:Resident #93 (R93)Review of an admission Record reflected R93 admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, osteoarthritis, spondylosis without myelopathy or radiculopathy (age-related degeneration of the spine involving disc wear and bone spurs without spinal cord compression), wedge compression fracture of T5-T6 (thoracic vertebra), and multiple fracture of ribs, bilateral. […]

• Actual harm, isolatedF684Aug 29, 2025

  Based on interview and record review the facility failed to assess and treat two residents (Resident #1 and Resident #2) for acute changes, out of four residents reviewed, resulting in the need for emergency medical attention for both residents. Findings:Resident #1 (R1)Review of an admission Record revealed R1 was a [AGE] year-old-female, originally admitted to the facility on [DATE], with pertinent diagnoses of presence of a cardiac pacemaker, a prosthetic heart valve, and implanted cardiac defibrillator, morbid obesity, high blood pressure, chronic kidney disease stage 3, atrial fibrillation, chronic obstructive pulmonary disease, and congestive heart failure. […]

• Actual harm, isolatedF684Apr 18, 2025

  This citation pertains to intakes M100151387 and M100151421. Based on observation, interview and record review, the facility failed to prevent hospitalization , monitor, assess, intervene, document, and provide appropriate care of nephrostomy tubes for 2 (R1 and R2) of two residents reviewed for nephrostomy care, resulting in hospitalization and infection. Findings include: Resident #1 (R1) Review of a Face Sheet revealed R1 originally admitted to the facility on [DATE] and readmitted to the facility after a hospitalization on [DATE]. […]

• Actual harm, isolatedF684Jan 3, 2023

  This citation pertains to intake MI00133465. Based on interview and record review, the facility failed to appropriately assess, monitor, document, implement treatment/ resources, and notify the physician promptly for changes in condition for 2 (Resident #1 and Resident #4), resulting in both residents being hospitalized and one resident receiving pain medications potentially masking underlying condition. Findings include: Review of a policy titled Notification of Changes last reviewed [DATE] revealed The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. […]