Medilodge of East Lansing: Respiratory Care Lapses - MI
The resident, identified as R1 in inspection records, requires a cough assist machine three times daily to clear their airways and maintain breathing. Federal inspectors found the facility failed to provide this critical respiratory care according to physician orders.
R1 lives with spastic quadriplegic cerebral palsy and chronic respiratory failure with hypoxia. They cannot speak and rarely understands or is understood by others. A surgical opening in their throat holds a tracheostomy tube for breathing.
During a complaint investigation in August, inspectors observed the cough assist machine sitting on a table in R1's room. The resident sat in a wheelchair with the tracheostomy secured by ties around their neck.
Respiratory Therapist D told inspectors R1 received cough assist treatments three to four times daily and there was an order to document each session. But records told a different story.
In July 2025, R1's Respiratory Administration Record showed they missed 20 opportunities to receive the prescribed treatment. Staff cited reasons including "lack of tolerance," "refusal," or the resident "being asleep" for the scheduled 7:00 AM, 4:00 PM and 8:00 PM sessions.
The missed treatments occurred despite R1's recent hospitalization for pneumonia, septic shock and gram-positive bacteria. Hospital discharge records from their readmission specifically noted R1 was "tracheostomy dependent" and must continue cough assist therapy three times daily.
A physician progress note from August 12 reinforced the hospital's recommendation for R1 to continue the cough assist three times daily upon return to the nursing home.
The facility documented R1's first cough assist treatment after returning from the hospital at 10:00 PM on August 12. But gaps continued immediately.
August records showed R1 missed their scheduled 7:00 AM treatment on August 20, the 3:00 PM session on August 24, and three separate 10:00 PM treatments on August 16, 17 and 24. Staff again documented reasons as "refusal," "being asleep" or "being out of the facility."
When inspectors called Respiratory Therapist E on August 27, they learned something more troubling. The therapist reported R1 "did not tolerate the cough assist" and could not recall the last time they attempted to administer the treatment.
For residents with tracheostomies and chronic respiratory failure, cough assist machines provide mechanical help clearing secretions from the airways. The devices simulate natural coughing by inflating the lungs and then rapidly switching to suction, helping patients who cannot cough effectively on their own.
R1's medical history shows the critical nature of consistent respiratory care. Their diagnoses include not only the tracheostomy dependence and chronic respiratory failure, but also the recent bout with pneumonia and septic shock that required hospitalization.
The inspection found the facility's respiratory care failures affected few residents, but the harm was classified as minimal with potential for actual harm.
The August complaint investigation revealed a pattern of missed treatments spanning multiple months, with staff documenting various reasons for non-administration while a respiratory therapist admitted they couldn't remember their last attempt to provide the prescribed care.
R1's case illustrates the challenge of providing complex medical care to residents who cannot advocate for themselves. Unable to speak or communicate effectively, R1 depends entirely on nursing home staff to follow physician orders for life-sustaining respiratory treatments.
The facility's records show a disconnect between documented care plans and actual delivery of services. While orders clearly specified three daily cough assist sessions, implementation fell short repeatedly across both July and August.
Federal inspectors documented their findings as part of a complaint investigation completed on August 27, 2025. The citation falls under federal requirements for facilities to provide safe and appropriate respiratory care when needed.
R1 remains at Medilodge of East Lansing, dependent on staff to follow through with the breathing treatments that help prevent the pneumonia and respiratory complications that previously required emergency hospitalization.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medilodge of East Lansing from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Medilodge of East Lansing in East Lansing, MI was cited for violations during a health inspection on August 27, 2025.
The resident, identified as R1 in inspection records, requires a cough assist machine three times daily to clear their airways and maintain breathing.
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.