Life Care Center of Michigan City: Wrong Oxygen Rate - IN
The finding came from a complaint inspection at Life Care Center of Michigan City, conducted October 27 and 28, 2025. Inspectors identified one violation, rated at the lowest level of harm, involving a single resident identified in records as Resident E.
The resident's physician had ordered oxygen at 2 liters per minute, continuously. That order had been in place since April 3, 2024, more than 18 months before the inspection. Her diagnoses included COPD, hypertension, and chronic cough.
On the afternoon of October 27, at 1:13 p.m., an inspector observed the resident lying in her bed with a nasal cannula in place. The oxygen concentrator beside her was running at 4 liters per minute. Nobody adjusted it.
The next morning, at 9:15 a.m., the inspector returned. The resident was seated in her room. The nasal cannula was still on. The concentrator was still set to 4 liters per minute.
The resident herself said she was supposed to be on 2.
That observation, the resident's own account of what her prescription was supposed to be, is what prompted the interview with the nurse assigned to her care. At 1:20 p.m. on October 28, LPN 1 told the inspector that the resident was on 2 liters per minute. Then the nurse looked at the concentrator. It was set to 4. She adjusted it to the correct rate.
The error had persisted across two separate inspections on two separate days. It was corrected only after a nurse was asked about it directly and checked the machine herself.
Whether staff had checked the concentrator's setting at any point during those 20-plus hours is not addressed in the inspection report. What the report does address is that the resident was assessed as cognitively intact. She knew her prescription. She knew the machine beside her was not set correctly. She told an inspector.
COPD is a condition in which the lungs' ability to move air is permanently compromised. Many patients with COPD depend on supplemental oxygen to maintain adequate blood oxygen levels, and their prescriptions are calibrated carefully. Too little oxygen leaves tissue undersupplied. Too much can, in certain COPD patients, suppress the respiratory drive the body uses to regulate breathing, because some patients' systems have adapted to elevated carbon dioxide levels and rely on low oxygen as a trigger to breathe. A physician's order specifying a precise flow rate is not a general guideline.
The inspection report rates the violation as causing minimal harm or potential for actual harm. It does not describe any clinical consequences the resident experienced from receiving double her ordered oxygen flow over that period.
What the report does describe is a gap between what staff understood to be happening and what was actually happening. The nurse said the resident was on 2 liters. The machine said 4. Both statements were made in the same conversation, seconds apart, and only one of them required looking at the equipment to verify.
Life Care Center of Michigan City is a skilled nursing facility. The inspection was triggered by a complaint, logged under intake number 2645073. The October 28 report covers three pages and identifies this oxygen error as the single citation.
The resident with COPD, cognitively intact and aware of her own care plan, had been breathing from a concentrator set to the wrong rate. She knew it. She said so. The machine was adjusted, and the inspector left.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Michigan City from 2025-10-28 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: September 6, 2026 · Our methodology
LIFE CARE CENTER OF MICHIGAN CITY in MICHIGAN CITY, IN was cited for violations during a health inspection on October 28, 2025.
The finding came from a complaint inspection at Life Care Center of Michigan City, conducted October 27 and 28, 2025.
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.