Medilodge of Ludington: Blocked Artery, Bowel Neglect - MI
That is what a federal inspection report found at Medilodge of Ludington following a complaint investigation completed August 29, 2025. Two residents were harmed. Both required emergency hospital transfers. One needed immediate vascular surgery. The other vomited fecal matter after going 18 shifts without a bowel movement while staff gave her none of the medications ordered for exactly that situation.
The first resident, identified in inspection records only as Resident 1, had a physician order a STAT ultrasound of the right leg. The ultrasound had not been completed. When a licensed practical nurse was asked to document an RN assessment of what was happening, she wrote down UTI.
What was actually happening: acute right lower limb ischemia, a condition in which blood stops reaching the leg. Emergency room notes from July 6, 2025, documented right leg pain, pallor, coolness, and pulses that could not be detected by hand or by Doppler. Doctors ordered a CT scan to check for a blocked artery. What they found was a complete occlusion of the right iliac artery, the main vessel supplying blood to the lower leg, located in the groin. The blockage was total.
Physicians contacted a level 1 trauma hospital in Grand Rapids. The transfer needed to happen immediately. Aeromedical transport was grounded because of bad weather. Staff initiated a priority 1 ground transfer for emergency vascular surgery.
The inspection report does not describe what the facility had documented about the leg's condition in the days before the emergency room visit, other than that a STAT ultrasound had been ordered and not performed, and that the nurse's written assessment named a different problem entirely.
The second case unfolded over the following weeks. Resident 2, a woman with multiple sclerosis and a documented history of constipation, had a medium-sized bowel movement on the afternoon of August 15. Her next bowel movement, documented as small, came in the early morning of August 18. After that, nothing, across 18 consecutive shifts, until she was sent to the hospital on August 24.
Her medication record showed three standing orders for exactly this scenario. If she went three days without a bowel movement, staff were to give her 30 milliliters of Milk of Magnesia. If that produced no result after nine shifts, a Dulcolax suppository. If that failed after ten shifts, a Fleet mineral oil enema. If none of it worked, call the doctor.
None of it was given. The doctor was not called.
On August 24, at 1:00 in the afternoon, staff filled out a transfer form. Resident 2 had abdominal distension and rigidity. She was vomiting brown liquid. A hospital progress note dated August 27 described what they found: extreme constipation with a large stool burden and distal impaction.
The Director of Nursing, interviewed by inspectors on the morning of August 29, said the facility had become aware of the bowel management concern the day before, August 28. Four days after the resident had been hospitalized. Nine days after the last bowel movement before the emergency. More than two weeks after the 18-shift gap had begun.
The director said they were looking into the matter.
Inspectors cited both failures under the same federal standard, findings that carry a designation of actual harm to a limited number of residents. That language, in federal inspection terminology, means the harm already happened. It is not a warning about what might occur. It is a finding about what did.
Resident 2 was still in the hospital when inspectors arrived at Medilodge on August 29. The inspection report does not say when, or whether, she returned.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medilodge of Ludington from 2025-08-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Medilodge of Ludington in Ludington, MI was cited for neglect violations during a health inspection on August 29, 2025.
That is what a federal inspection report found at Medilodge of Ludington following a complaint investigation completed August 29, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.