Medilodge of Ludington

Inspectors wroteThis citation pertains to Intake 3042861 Based on interview and record review, the facility failed to ensure residents who required two people to assist with transfers, were transferred by two people at all times for 4 residents (R5, R6, R7, and R9) out of 10 residents reviewed for accidents and hazards.

Inspectors wroteThis citation pertains to intake 3042861 Based on observation, interview, and record review, the facility failed to ensure staff were deployed in sufficient numbers to meet the needs of 6 residents (R3, R10, R5, R6, R7 and R9) out of 10 residents reviewed for staffing.

Inspectors wroteThis 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.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective and current system of surveillance of staff illnesses to identify possible communicable diseases and infections to prevent the spread of an illness/outbreak for 2 of 18 residents (Residents #35 and #59) and all residents residing in the facility, reviewed for infection prevention and control.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered in accordance with physician orders for 2 of 8 residents (Resident #6 and #8) reviewed for nursing professional standards of practice.

Inspectors wroteThis citation pertains to intakes #: 2652909 and 2646749Based on interview and record review, the facility failed to provide sufficient staff with the knowledge and skills sets to support and assist residents experiencing agitation and confusion and implement meaningful behavioral interventions for 5 of 18 residents (Residents #67, #19, #91, #57, and #85), reviewed for behavioral health needs.

Inspectors wroteThis citation pertains to intake # 2646749Based on observation, interview and record review, the facility failed to provide timely care to one (Resident #33) of three residents reviewed for dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to designate a representative was supported and accurately recorded in the medical record for 1 of 8 residents (Resident #27) reviewed for resident rights.

Inspectors wroteThis citation pertains to intake #: 2646749Based on interview and record review, the facility failed to 1.) implement the facility policy for pressure injury prevention and management 2.) ensure pressure injury assessments were comprehensive and accurate, and 3.) ensure treatments were ordered and completed for 1 of 2 residents (Resident #27) reviewed for pressure injury prevention and management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform a comprehensive root cause analysis and implement meaningful interventions/preventative measures following a fall for 1 of 9 residents (Resident #27) reviewed for accidents and hazards.

Inspectors wroteBased on interview and record review the facility failed to include the Interdisciplinary Team (IDT) and psychiatric provider in the process of the gradual dose reduction of an antipsychotic medication for 1 of 5 residents (Resident #83) reviewed for psychotropic medication use.

Inspectors wroteBased on interview and record review, the facility failed to obtain dental services to replace a missing lower denture in a timely manner for 1 resident (R10) out of 1 resident reviewed for dental services. Resident #10 (R10)Review of an admission Record reflected R10 admitted to the facility on [DATE] with diagnoses that included osteoporosis without current pathological fracture, depression and anxiety. Review of a Care Plan Report initiated on 10/15/2024 R10 has a dental problem related to being edentulous, with a goal of reduced complications related to dental/oral issues. Interventions included in the Care Plan included Refer to dental services as needed. During an interview on 3/09/2026 at 10:12 AM, R10 states that she lost the lower denture when she accidentally put them on a meal tray and they got thrown away. [...]

Inspectors wroteBased 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.

Inspectors wroteThis citation pertains to Intake 1268402Based on observations, interview, and record review, the facility failed to ensure 1 resident (Resident#1) of 3 was free from verbal abuse when a staff member swore about the resident's behavior.

Inspectors wroteThis 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.

Inspectors wroteThis citation pertains to intakes M100151387 and M100151421. Based on observation, interview and record review, the facility failed to ensure staff were competent to manage care for two (R1 and R2) of two residents reviewed for nephrostomy care, resulting in hospitalization and repeated incompetent care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide needed services to ensure the dignified well-being of three residents (R47, R5, and R71) and the potential for all dependent residents to have unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy for transfers for one (R61) of one resident reviewed for hospital transfers. Findings Include: Review of a policy titled Transfer and Discharge (including AMA (Against Medical Advice)) last reviewed/revised 10/30/23 revealed: Emergency Transfers/Discharges- . a. obtain physicians' orders for emergency transfer or discharge, stating the reason the transfer or discharge is necessary on an emergency basis. d. Complete and send with the resident (or provide as soon as practicable) a Transfer Form which documents: Review of a Face Sheet for R61 revealed she originally admitted to the facility on [DATE]. Review of the SBAR (Situation-Background-Assessment-Recommendation) dated 2/6/25 for R61 revealed she had a change of condition and was sent to the hospital. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold policy to one (R61) of one resident reviewed for hospitalization.

Inspectors wroteThis citation pertains to intake #MI00147480 Based on observation, interview, and record review, the facility filed to provide care to accommodate the needs of 5 of 5 residents reviewed.

Inspectors wroteThis citation pertains to intake # MI00-147480 Based on observation, interview, and record review, the facility failed to secure 1 of 4 medication carts and failed to follow guidelines for preparing, storing, and dating medications.

Inspectors wroteThis citation pertains to intake #MI00147635 Based on observation, interview, and record review, the facility failed to follow standards of practice for enhanced barrier precautions for 3 of 3 resident's reviewed and failed to follow infection control practices for oxygen storage for 1 of 3 resident's, and for laundry services.

Inspectors wroteThis citation pertains to intake #'s: MI00146057 and MI00145975 Based on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 5 of 11 residents (Resident #3, #7, #11, #13, and #2), reviewed for the provision of nursing services, resulting in medication errors and medications being administered outside of the physician ordered parameters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their abuse and neglect policy and procedure for 1 resident (R8) of 4 residents reviewed for abuse and neglect from a total sample of 13 residents, resulting in allegations of neglect not being reported to the state survey agency, allegations of neglect not being thoroughly investigated, the potential for abuse and neglect to go undetected, and the potential for residents not being protected from ongoing abuse and neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services and carry out Activities of Daily Living (ADL) assistance for 1 resident (R8) of 2 residents reviewed for ADLs from a total sample for 13 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment for the care of a suprapubic catheter was carried out for 1 resident (R8) out of 13 residents reviewed for quality care, resulting in the potential for complications from infection and/or skin breakdown.

Inspectors wroteThis Citation pertains to Intake Number MI00145415. Based on observation, interview, and record review, the facility failed to safeguard the confidentiality of medical records for 12 of 73 residents (R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, and R17), resulting in the potential for unauthorized access to residents' medical records and the potential for the loss of resident privacy and the confidentiality of their personal health information.

Inspectors wroteThis Citation pertains to Intake Number MI00145415. Based on observation, interview, and record review, the facility failed to secure 1 of 5 medication carts (Southwest Medication Cart), resulting in narcotics/controlled substances not being under double lock, resident medications not being secured, the potential for unauthorized individuals gaining access to the medication cart, and the potential for medication theft.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 residents (Residents #29, #57, and #60 ) were cared for in a manner that enhanced their quality of life, promoted resident dignity, and assured equal access to quality care and services regardless of the level of staff support required when requests for assistance were not met in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to implement adequate Infection Surveillance that included consistent tracking of employee, volunteer, and contract employee infections, as appropriate, to monitor for trends, mitigate the potential for Outbreaks of infectious disease and aide in conducting outbreak investigations.

Inspectors wroteBased on interview and record review, the facility failed to recognize and implement a Durable Power of Attorney, in a timely manner for 1 resident (Resident #56) from a total sample of 18 residents reviewed for Advanced Directives, who demonstrated impaired decision making capacity and defer to the established Attorney-in-fact who could act in the best interest of the resident based on their wishes.

Inspectors wroteBased on interview and record review, the facility failed to obtain appropriate witness to certify 1 of 4 residents reviewed for Binding Arbitration (Resident #56) from a total sample of 18 residents was of sound mind and competent to make informed consent for a facility staff member to initial and sign an Alternative Dispute Resolution Agreement (binding arbitration) on their behalf; failed to document the resident understood the terms of the binding arbitration agreement and waive their right to a trial by judge or jury to have some or all dispute claims heard in a court proceeding.

Inspectors wroteThis citation pertains to intake MI-000138952 Based on interview and record review, the facility failed to completely transcribe admission orders and obtain clarification orders from a surgeon for one resident (Resident #7), resulting in the potential for postoperative complications including wound infection and anemia.