Medilodge of Farmington: Feeding Tube Overdose - MI
The resident, identified in inspection records only as R905, had been admitted on July 30, 2025, with diagnoses including dysphagia and gastrostomy status. Their hospice physician had written a clear order: Glucerna 1.2 formula, 40 milliliters per hour, for 16 hours. The total volume that should have been delivered was 720 milliliters.
Nobody transcribed that order correctly.
When staff entered the feeding instructions into the facility's system, the rate was recorded as 45 milliliters per hour, not 40, and no stop volume was set to cap how much formula the pump would deliver. The pump kept running. By the time a nurse caught it the following morning, the resident had received 1,191 milliliters, 471 milliliters more than the physician ever ordered.
The nurse, identified in the inspection report as Nurse A, described walking in after shift report and immediately seeing something was wrong. They stopped the pump, called the on-call nurse practitioner, and reported what they found. The nurse practitioner ordered the feeding held and called for a STAT abdominal X-ray. The Director of Nursing was notified. The resident's abdomen, the progress note from that morning reads, "was hard and distended." The nurse pulled 1,000 cubic centimeters of residual fluid.
Nurse A told inspectors that the facility's enteral pumps would simply keep running unless staff manually programmed a stop time. No stop time had been set for R905.
The transcription error, a rate of 45 milliliters per hour instead of 40, may look small on paper. Over 16 hours, it compounds. But the larger failure was the absence of any volume ceiling in the pump settings, a safeguard that would have stopped the delivery at 720 milliliters regardless of rate. Without it, the pump had no instruction to stop at all.
Federal inspectors reviewed the case on September 2 and 3, 2025, following a complaint submitted to the state agency. When they spoke with the Director of Nursing on September 3, the director confirmed they already knew about the error and said the facility had conducted an in-service with nursing staff on administering enteral orders correctly. The in-service had happened after the fact.
The inspection covered two residents with feeding tubes. The transcription and administration error was found in one of them.
The facility's own feeding tube policy, reviewed by inspectors on September 4, states that enteral nutrition must be administered consistent with and following the practitioner's orders. R905's orders called for 720 milliliters. The resident received 1,191.
Medilodge of Farmington sits on Grand River Avenue in Farmington, a suburb west of Detroit. The inspection was completed September 4, 2025, and federal regulators classified the violation as causing minimal harm or potential for actual harm.
R905 was discharged from the facility on August 3, 2025, three days after the overfeeding. The inspection report does not say what the abdominal X-ray showed, or what the resident's condition was when they left.
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.
Download the official CMS inspection PDF from Medicare.gov
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 22, 2026 · Our methodology
Medilodge of Farmington in Farmington, MI was cited for violations during a health inspection on September 4, 2025.
The resident, identified in inspection records only as R905, had been admitted on July 30, 2025, with diagnoses including dysphagia and gastrostomy status.
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.