Medilodge of Montrose: Restorative Therapy Failures - MI
"I work today and tomorrow," CNA M told inspectors on May 27. "Tomorrow I don't know where I will be. I could wake up tomorrow and it will say CNA if short staffed."
She estimated she worked as a floor aide one to two days a week. On a three-day workweek, she said she could be pulled two of those three days. Restorative therapy for the full building, she acknowledged, did not get done when that happened. "Maybe for the ones in the hall she was working in," she told inspectors, "but there were residents on the other side also, and you can't always get to the Restorative Plan if busy."
She mentioned a resident who was supposed to ride a stationary bike in therapy and needed someone present for it to happen safely. "If have time," she said, "then can do the ROM."
The inspection was triggered by a complaint and focused in part on Resident 105, a patient with an ordered plan that called for range-of-motion exercises five to seven times a week and splint application cycling two hours on and two hours off, also five to seven days a week. When inspectors asked the MDS Nurse why the plan wasn't being completed, she said she was unsure. When asked whether Resident 105 was refusing the splint or not tolerating it, the nurse reviewed the progress notes and found nothing to explain the gap. No documented refusals. No documented complaints. The therapy simply wasn't happening.
The Therapy Director was direct about what that meant for the resident. Range-of-motion exercises, she explained, exist "to maintain ROM and positioning and to keep ROM to all extremities." Asked what happens if the plan isn't followed, she did not hedge. "He could have a loss of range of motion, lose degrees of motion."
Loss of range of motion in a nursing home resident is not a temporary setback. Joints that stiffen from disuse don't reliably recover. The therapy ordered for Resident 105 existed precisely to prevent that kind of permanent decline.
When inspectors sat down with the Administrator and Corporate Nurse K that afternoon, the facility's own records told a stark story. Over the prior 30 days, the ordered ROM exercises had been completed just seven days total. The splint application, ordered for five to seven days a week, had also been completed only seven days, with application times ranging from 15 to 90 minutes rather than the prescribed two-hour intervals.
In a month with roughly 30 days, a plan ordered five to seven times per week should have been completed somewhere between 21 and 30 times. It was completed seven.
The facility's own policy states that it "takes measures to minimize the loss of residents' functional abilities" and "provides maintenance and restorative programs to assist residents in achieving and maintaining the highest practicable outcome." The gap between that language and what the records showed was not subtle.
The structural problem was plain. One aide. One building. Chronic short-staffing pulling her away from her designated role. She was candid about the math: when she's assigned to floor care, the residents on the other side of the building don't get their restorative plans. There was no backup documented in the inspection report. No coverage system. No one else completing the exercises when she wasn't available.
CNA M said she had no idea where she'd be assigned the next morning. Resident 105, meanwhile, had a therapy plan that went uncompleted for most of a month, and a therapist who said clearly what happens to joints when that occurs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medilodge of Montrose Inc from 2026-05-27 including all violations, facility responses, and corrective action plans.
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: August 12, 2026 · Our methodology
Medilodge of Montrose Inc in Montrose, MI was cited for violations during a health inspection on May 27, 2026.
"I work today and tomorrow," CNA M told inspectors on May 27.
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.