The resident, identified as R1 in the August 29 federal inspection report, was rushed to the emergency room on July 6 with what doctors discovered was "acute right lower limb ischemia" — a complete blockage of blood flow to her leg.
Emergency room physicians found her right leg was pale and cool to the touch. They could not detect any pulses in her lower leg, even with specialized equipment. A CT scan revealed "complete occlusion of the right iliac artery," the main blood supply to the lower leg located in the groin area.
"Unfortunately, Aero Med is not flying at this time because of bad weather," emergency room notes stated. "We will initiate a priority 1 transfer for immediate vascular surgery."
R1 had told staff she felt the nurse "ignored her concerns and did not assess the problem." The inspection found her assessment accurate.
LPN C had filled out a communication form on July 6 noting the resident was "requesting to go to emergency room, feels she may have a blood clot behind her knee." But the nurse failed to document any assessment of the right leg's circulation, skin color, temperature, or pulse status.
A physician had already ordered a STAT ultrasound of R1's right leg on July 5 that had not been completed. Instead of focusing on the leg concerns, LPN C wrote that she believed the resident had a urinary tract infection.
The facility's problems extended beyond missed blood clots. Another resident went 18 shifts without a bowel movement while staff ignored their own medication protocols.
Resident 2, a woman with multiple sclerosis and chronic constipation, had her last documented bowel movement on the afternoon of August 15. She did not have another until the early morning of August 18, described as small in size.
That was her final bowel movement before being rushed to the hospital on August 24.
The facility had clear protocols for constipation management. After three days without a bowel movement, staff should give 30 milliliters of Milk of Magnesia. If that failed after nine shifts, they should administer a Dulcolax suppository. After 10 shifts with no results, staff should give a Fleet's mineral oil enema and call the doctor.
None of these medications were given. The doctor was never notified.
R2 was transferred to the hospital on August 24 at 1:00 PM with "abdominal distention and rigidity with brown emesis and nausea." Hospital records from August 27 showed she had "extreme constipation with large stool burden and distal impaction."
The Director of Nursing told inspectors on August 29 that the facility only became aware of the bowel management problem the day before — August 28 — and were "looking into the matter."
This was three days after R2 had been hospitalized for a condition that developed over nearly two weeks of documented neglect.
The inspection classified both incidents as causing "actual harm" to residents. Federal inspectors found the facility failed to ensure residents received proper treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
For R1, the delay in recognizing a vascular emergency could have resulted in limb loss or death. Complete arterial occlusion requires immediate intervention to restore blood flow and save the affected limb.
For R2, the failure to follow basic bowel management protocols led to severe impaction requiring hospitalization. Her multiple sclerosis already put her at higher risk for constipation complications.
Both cases revealed a pattern of nursing staff either dismissing resident concerns or failing to follow established medical protocols. R1's repeated warnings about a potential blood clot were documented but essentially ignored. R2's constipation was tracked daily but never treated according to the facility's own procedures.
The inspection found these failures affected few residents but caused actual physical harm to those involved. R1 required emergency vascular surgery in Grand Rapids during dangerous weather conditions. R2 suffered painful impaction that could have been prevented with basic nursing care.
Medilodge of Ludington's license shows ongoing struggles with resident assessment and treatment protocols that put vulnerable patients at serious risk.
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.