Medilodge of Farmington: Tracheostomy Care Failures - MI
The breakdown at Medilodge of Farmington left resident R904 without documented tracheostomy care on multiple dates between June and August, according to federal inspectors who visited September 3rd following a complaint.
R904 cannot speak, does not track with their eyes, and remains in a vegetative state. The resident's responsible party had contacted authorities with concerns about the tracheostomy care their loved one was receiving.
When inspectors reviewed treatment records, they found a pattern of missing documentation spanning three months. In June alone, day shift staff failed to document tracheostomy assessment and care on June 9th, then missed five consecutive days from June 22nd through 26th, and again on June 29th. Night shift missed treatments on June 4th and 6th.
July brought more gaps. Day shift missed July 22nd and 23rd. Night shift missed July 10th.
August continued the pattern with day shift missing August 7th and night shift missing August 21st.
The facility's own policy requires tracheostomy care twice within every 24-hour period. The policy states that "respiratory therapy or trained and competent personnel will provide and document tracheostomy care to all residents with a tracheostomy twice within 24 hours."
But something had changed in how the facility handled these critical treatments.
The Director of Nursing told inspectors that tracheostomy care had been transferred from respiratory therapy staff to nursing staff. She suggested this transition might explain why treatments were missed, saying nursing staff "may have thought respiratory therapy provided the care."
The confusion left R904 without proper assessment of the stoma site under the tracheostomy collar and without the cleaning and maintenance that tracheostomies require to prevent complications.
Tracheostomies create an opening in the neck that allows breathing when the upper airway is blocked or compromised. The surgical opening requires regular cleaning and assessment to prevent infection, blockage, or tissue breakdown around the site.
For someone in R904's condition, unable to communicate discomfort or alert staff to problems, the regular assessments become even more critical. A blocked or infected tracheostomy can quickly become life-threatening.
The missed treatments occurred over a span of nearly three months, suggesting the handoff from respiratory therapy to nursing created a systematic gap in care rather than isolated oversights.
When inspectors observed R904 on September 3rd at 11:25 AM, the resident was lying in bed with the tracheostomy visible. The inspection came one day after the responsible party had raised concerns about the care their family member was receiving.
The facility's medication administration records and treatment administration records showed the gaps clearly when inspectors reviewed them at 11:55 AM that same day.
Federal inspectors classified this as a failure to "provide safe and appropriate respiratory care for a resident when needed." They determined the violation created minimal harm or potential for actual harm, but noted it resulted in "the potential for tracheostomy complications."
The case illustrates how administrative changes within nursing homes can create dangerous gaps in specialized care. When responsibility for complex medical treatments shifts between departments, residents who cannot advocate for themselves become vulnerable to oversights that could prove serious or fatal.
R904's responsible party had to step in to ensure their loved one received proper care, highlighting how family vigilance often serves as the last line of defense against institutional failures.
The inspection found that few residents were affected by this particular violation, but for R904, the impact was weeks of missed treatments during a period when consistent respiratory care was medically necessary.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medilodge of Farmington from 2025-09-04 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: August 4, 2026 · Our methodology
Medilodge of Farmington in Farmington, MI was cited for violations during a health inspection on September 4, 2025.
R904 cannot speak, does not track with their eyes, and remains in a vegetative state.
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.