The discrepancy involved one nurse, identified in inspection records only as Nurse #1, and one resident, identified as Resident #5.
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No interviews with other residents.
Nobody told him to do it that way.
That classification means inspectors did not find a single isolated lapse.
He described it spurting water.
The deficiency was one of 13 cited during the inspection.
The incident unfolded across two days in mid-July at the facility on North California Street.
The violation was classified at scope and severity level E, meaning inspectors saw the problem not as an isolated incident but as a recurring pattern.
That finding was one of 17 deficiencies federal health inspectors cited at Medilodge of Southfield during a complaint inspection completed August 15, 2025.
But they found the potential for more than minimal harm was real.
Inspectors classified it as an isolated deficiency with no documented actual harm, but with potential for more than minimal harm to residents.
The respiratory care citation, recorded under regulatory tag F0695, was classified as an isolated deficiency with no documented actual harm.