Medilodge Of Montrose Inc

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

started the line in his lower arm. There was no IV (intravenous) dextrose on the crash cart and they were only able to administer fluids to the resident. Review was completed of the email from the facility pharmacy representative, the emailed stated, .The facility was stocked with 5 Gvoke in the MedBank since 4/11. There was 5 on hand the entire month of July, with no transactions.We will be unable to advise on how many were

in the crash cart, as that is stocked by the facility. The facility was unable to provide documentation that proved glucagon or IV dextrose was accessible on the crash cart during Resident #108's hypoglycemia episode. While the facility asserts diabetic supplies were available in the medication room it was not easily accessible during a resident emergency who was a known diabetic. Three nurses conformed the medication required for a hypoglycemic episode was not available to them and they were unable to appropriately treat Resident #108 during this critical incident.Review was completed of facility protocol entitled, Diabetic Protocol, the protocol stated, .Diabetic Protocol; Hypoglycemia.Hypoglycemia is a condition that is typically related to diabetes treatment. Effective 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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Medilodge of Montrose Inc

9317 West Vienna Road Montrose, MI 48457

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to intake Number 2585749.Based on interview and record review, the facility failed to obtain a physician's order for urinary catheter per professional standards of practice for one 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 REDACTED] 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 REDACTED] 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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