Medilodge of Montrose: Catheter Left Without Order - MI
That is what federal inspectors found when they visited the facility on August 14, 2025, following a complaint.
Resident #106 was admitted on January 9, 2025, transferred from a hospital setting. The admission assessment noted an indwelling catheter draining clear yellow urine. The resident carried a serious list of diagnoses: atrial fibrillation, heart failure, renal insufficiency, wound infection, respiratory failure, cellulitis of the lower limb, and lymphedema. This was not a healthy person with a minor, easily-overlooked medical device. This was a medically fragile patient whose catheter management could directly affect kidneys already under strain.
A review of the physician order recap for January 2025 turned up no order for the catheter. None. Not an order to keep it in, not an order for how often to change it, not an order for a securement device to hold it in place. The medication administration record and the treatment administration record for both January and February showed no nursing monitoring of the catheter at any point during the resident's stay.
The nursing progress notes, running from January 9 through the resident's discharge on February 20, never mentioned catheter care once.
A care plan for catheter care had been started on January 9, the day of admission. Someone knew the catheter was there. The care plan existed. The orders did not.
The Director of Nursing, interviewed by inspectors at 11:28 a.m. on the day of the visit, reviewed the same records and reached the same conclusion. There was no physician order for the Foley catheter. There was no order to discontinue it. Nurses had done no documented monitoring. The DON acknowledged directly that a physician's order should have existed and that any decision to remove the catheter would have required one.
That acknowledgment matters because it frames what the six-week gap actually meant. Without an order to discontinue, the catheter stayed in. Without monitoring orders, nurses had no formal directive to check for signs of infection, obstruction, or a compromised closed system. Without a securement device order, there was no documented plan to keep the catheter properly anchored. The resident was discharged on February 20, and only the following day, February 21, did transferred physician orders appear, specifying how to change the catheter if clinically indicated.
The order arrived one day after the resident left.
Indwelling urinary catheters carry well-documented risks. They are among the leading causes of healthcare-associated infections. For a resident already dealing with renal insufficiency, an undetected catheter-associated infection would not be a minor complication. Inspectors cited the violation as carrying potential for bladder injury and prolonged illness.
What makes this case harder to explain away is the paperwork trail. The admission assessment documented the catheter on day one. A care plan was opened on day one. The facility's own physician oversight policy, dated September 2024, states that a physician must provide orders for residents' immediate care and needs. The quality care policy, dated January 2022, requires treatment in accordance with professional standards of practice and the resident's care plan.
The care plan said catheter care. The orders said nothing.
Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting a few residents. The citation covered one resident. Whether Resident #106 developed any complications during those six weeks, the inspection report does not say. The resident was discharged before inspectors arrived, and the records they reviewed told a story that ended not with a resolution but with a date: February 21, when the order finally came through for a patient who was already gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medilodge of Montrose Inc from 2025-08-14 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 22, 2026 · Our methodology
Medilodge of Montrose Inc in Montrose, MI was cited for violations during a health inspection on August 14, 2025.
That is what federal inspectors found when they visited the facility on August 14, 2025, following a complaint.
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.