Medilodge of Livingston: Ventilator Care Failures - MI
The inspection at Medilodge of Livingston found that respiratory staff were not taking vital signs at the time they administered breathing treatments to residents on mechanical ventilators. Instead, they were pulling readings from nursing notes that had been recorded eight to 14 hours earlier and using those numbers to assess whether a treatment had any effect.
When inspectors pressed the facility's Respiratory Therapy Director on how a therapist could possibly know whether a breathing treatment was effective using vital signs from that far back, the director's answer was direct: they should be taken at the time of the breathing treatment. The director acknowledged the gap between what staff were doing and what the assessment required.
The director also acknowledged that when residents on mechanical ventilators are admitted, vital signs should be taken as part of the initial assessment. Inspectors reviewed breathing treatment evaluations from August 10 and August 11, 2025, and found the same pattern in both.
The explanation offered for why progress notes were also being filled out incorrectly was staffing. The director told inspectors that staff were short-handed and had probably recorded previous ventilator settings in the notes rather than the actual current settings to save time. That meant the written record of what a ventilator-dependent resident's settings were did not necessarily reflect what the machine was actually doing.
Mechanical ventilators breathe for people who cannot breathe adequately on their own. Residents dependent on them are among the most medically fragile in any nursing facility. A breathing treatment, typically a medication delivered directly into the lungs, is meant to open airways, reduce inflammation, or clear secretions. Whether it worked is not a question a clinician can answer by looking at numbers from the prior shift.
Vital signs, including respiratory rate, oxygen saturation, pulse, and blood pressure, are the primary tools a respiratory therapist uses to gauge a patient's condition before a treatment and to measure the response afterward. Without a before-and-after comparison taken close in time, the evaluation is guesswork.
The inspection classified the violations under F0695, which covers the care of residents who require respiratory services. The level of harm was listed as minimal harm or potential for actual harm, and inspectors noted that few residents were affected.
That classification reflects the regulatory floor, not a clinical reassurance. Ventilator-dependent residents have no margin for undetected deterioration. A breathing treatment that fails to work, or one that causes an adverse reaction, can move a fragile patient toward crisis quickly. The whole point of taking vital signs before and after is to catch that movement while there is still time to respond.
The Respiratory Therapy Director did not dispute any of the inspectors' findings during the review. On the question of the old vital signs, the director confirmed the problem. On the question of the falsified progress notes, the director explained it as a time-saving shortcut born from being short-staffed.
What the inspection report does not contain is any indication of what the facility did, or planned to do, once the pattern was identified. It does not say whether the residents whose treatment evaluations were reviewed on August 10 and 11 experienced any adverse effects. It does not say how long the practice had been in place before inspectors arrived.
What it does say is that on at least two consecutive days, respiratory therapists completed formal evaluations of breathing treatments for ventilator-dependent residents without collecting the data those evaluations were supposed to be based on, and that the person overseeing the respiratory therapy program knew, once asked, exactly why that was a problem.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medilodge of Livingston from 2025-08-27 including all violations, facility responses, and corrective action plans.
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: October 2, 2026 · Our methodology
Medilodge of Livingston in Howell, MI was cited for violations during a health inspection on August 27, 2025.
The director acknowledged the gap between what staff were doing and what the assessment required.
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.