Medilodge Of Montrose Inc
Medilodge of Montrose Inc in Montrose, MI — inspection on August 14, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
the medication required for a hypoglycemic episode was not available to them and they were unable
protocol entitled, Diabetic Protocol, the protocol stated, .Diabetic Protocol;
management of hypoglycemia is important to ensure that the resident does not have further decline in their condition.
Residents that have a diagnosis of diabetes or on medications that could lower the blood sugar should have orders for glucose monitoring and treatment of hypoglycemia, unless otherwise ordered by the practitioner.if the blood glucose reading is 70mg/dl or below, the nurse should utilize the hypoglycemic protocol as per the practitioner's orders.Blood glucose (BG) less than 70 mg/dl and resident is unable or unwilling to take nutrition orally: give glucagon 1 mg subcutaneously or 3 mg intranasal or 1mg intramuscularly.
Turn resident on their side to prevent aspiration.
235600 08/14/2025
Medilodge of Montrose Inc 9317 West Vienna Road Montrose, MI 48457
catheter care, and appropriate care to prevent urinary tract infections.
Citation pertains to intake Number 2585749.Based on interview and record review, the facility failed
resident (Resident #106), resulting in the potential for bladder injury, prolonged illness, and an indwelling catheter being left in place with no physician's order.Findings include:Resident #106:
Record review of Resident #106's Minimum Data Set (MDS) dated [DATE] revealed that the resident had an indwelling urinary catheter.
Medical diagnosis included: Atrial fibrillation, heart failure, renal insufficiency, wound infection, respiratory failure, cellulitis of lower limb, and lymphedema.
Record review of Resident #106's 'Nursing admission Evaluation' assessment dated [DATE] revealed an indwelling catheter with clear yellow urine.
Record review of Resident #106's physician order recap report for the month of January 2025 revealed that there was no physician's order for a urinary Cather ordered.
Record review of Resident #106's nursing progress notes from January 9,2025 through February 20th, 2025, noted upon discharge there was no mention urinary catheter care.
Record review of Resident #106's January 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed there was no monitoring of urinary catheter, no order for when to change the urinary catheter, no order for a urinary catheter secured deviceAn interview and records review on 8/14/2025 at 11:28AM with the Director of Nursing (DON) regarding Resident #106's stay at the facility revealed the resident was admitted back on January 9, 2025, from the hospital setting.
Record review of admission assessment had an indwelling catheter.
Record review physician orders, no order for Foley catheter by physician, or for the urinary catheter to be discontinued.
Record review of the MAR TAR for January & February revealed there was no monitoring by nurses of the urinary catheter,
Record review of care plans noted a catheter care plan started 1/9/2025.
The DON stated that there should have been a physician order for the Foley catheter and monitoring on the treatment record by the nurses and to discontinue the urinary catheter would have to be done by a physician's order.
Record review of the facility 'Physician Visits and Physician Delegation' policy dated 9/26/2024 revealed it is the policy of the facility to ensure the physician takes an active role in supervising the care of residents. (g.) A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for residents' immediate care and needs.
Record review of the facility 'Provisions of Quality Care' policy dated 1/1/2022 revealed that based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified people in accordance with professional standards of practice . (4.) Qualified people will provide the care and treatment in accordance with professional standards of practice, the resident's care plan, and the resident's choices.
Record review of Resident #106's transferred facility physician orders revealed that on 2/21/2025 to change indwelling Foley catheter (PRN) as needed clinically indicated with signs/symptoms of obstruction (leakage, increased sediment, etc.) infection, or if closed system was compromised.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.