Medilodge of Montrose Inc

In the surveyor’s words

From the most serious findings on record at Medilodge of Montrose Inc, in the surveyor’s own words.

• Immediate jeopardy, patternF880Jul 29, 2024

  This Citation Pertains to Intake Number MI00145690. Based on observation, interview and record review, the facility is placed in Immediate Jeopardy for its failure to 1) Initiate remediation measures, per standards of practice, and as requested by the Local Health Department, after one resident (Resident #205) tested positive for Legionella (a bacteria that spreads through water systems and devices) in a urine antigen test on [DATE]; 2) Complete and submit a Legionella Environmental Assessment Form (LEAF) in a timely manner to the Health Department; 3) Provide representative environmental water samples to the Health Department (at least 20 samples) to retest for Legionella in the facility, as the facility's water had tested positive for Legionella on several occasions in the past and most… […]

• Actual harm, isolatedF600Mar 5, 2026

  This citation pertains to Intake Numbers 2736807, 2736887, 2736910 and 2742953 Based on observation, interview and record review, the facility failed to ensure that one resident (Resident #2) was free from neglect when staff did not complete a skin assessment after identifying a new area of skin concern, did not ensure appropriate treatment was in place, and did not accurately monitor and document the resident's skin condition, of one resident reviewed for neglect of care, resulting in Resident #2 being admitted to the hospital for 5 days with a diagnosis of cellulitis (bacterial skin infection) and having to receive IV antibiotics.Findings include:Resident #2 (R2):A review of R2's medical record revealed an admission into the facility on [DATE] with diagnoses that included memory… […]

• Actual harm, isolatedF684Aug 14, 2025

  This citation pertains to Intake Number 2580183.Based on interview and record review the facility failed to have diabetic supplies available to facility staff when Resident #108 had a hypoglycemic episode, resulting in a blood sugar of 52 and being placed on ventilator upon arrival to the Emergency Room. Findings Include: Resident #108:On [DATE] at approximately 11:00 AM, a review was conducted of Resident #108'S medical record and it revealed he admitted to the facility on [DATE] with diagnoses that included, Peripheral Vascular Disease, Heart Disease, Atrial Fibrillation, Diabetes Mellitus, Chronic Kidney Disease and Hypertension. Resident #108 was his own person and able to make his needs known to staff. […]

• Actual harm, isolatedF686Jul 9, 2025

  This citation pertains to intake 1205083 and 1205084.Based on interview and record review, the facility failed to Prevent 2 facility acquired stage II pressure ulcers/PU, for 1 resident (Resident #15) of 3 resident's reviewed for PU's, resulting in 2 facility acquired stage II pressure ulcers, pain, increased risk for infection, antibiotic usage and hospitalization.Findings Include:Review of the Face Sheet, Resident #15's facility care plans dated 3/24/25 through 4/1/25, Physician, Nurse Practitioner and nursing notes dated 3/24/25 through 3/27/25, revealed Resident #15 was [AGE] years old, unable to make own healthcare decisions, admitted to the facility on [DATE], after a severe car accident, had a tracheostomy, feeding tube (G-tube), urinary catheter, dependent on staff for all… […]

• Actual harm, isolatedF689Jul 3, 2024

  This Citation pertains to Intake Number MI00142716. Based on interview and record review the facility failed to provide adequate supervision and assistance for one resident (Resident #113) of 3 residents reviewed for falls resulting in Resident #113 falling and sustaining a serious laceration requiring hospitalization . Findings include: Resident #113 (R113): Review of R113's face sheet dated 7/2/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: Chronic respiratory failure with hypoxia, congestive heart failure, muscle weakness, difficulty in walking, liver disease, dependent on supplemental oxygen, and dependent on other enabling machines. […]