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The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Huron Woods Nursing Center during CMS and state inspections, most recent first.
A resident with severe dementia and physical limitations fell from a mechanical lift during transfer, resulting in a head laceration and intraventricular hemorrhage. The incident occurred when two CNAs were transferring the resident using an Invacare 450 lift and mesh sling, which allowed the resident to slip out due to instability. The facility lacked a written policy for lift use, did not provide accessible manufacturer guidance or ongoing staff training, and failed to individualize the care plan for safe transfers. The fall was not reported to the State Agency, and the investigation did not clearly identify the root cause.
A resident with multiple complex medical conditions and high dependence for daily activities experienced repeated falls from her wheelchair, resulting in injuries and hospitalization. Despite documented fall risk interventions, there were no measures for increased supervision or monitoring, and staff response to a fall was significantly delayed, contributing to the deficiency.
The facility failed to maintain safe food temperatures during breakfast service, with scrambled eggs served below the required 135 degrees Fahrenheit. The Dietary Manager confirmed that food temperatures were only checked once when removed from the oven, leading to inconsistent temperature maintenance. Additionally, an inspection revealed an unsanitary ice machine with an unknown black substance, indicating a lack of clear cleaning procedures.
The facility failed to respond to residents' needs in a timely and dignified manner, as reported by residents during a council meeting. Complaints included extended wait times after call lights were canceled and staff prioritizing other tasks. Residents felt neglected and dissatisfied with management's response, which advised reactivating call lights if staff did not return promptly. The Recreation Director could not provide recent council meeting minutes, as they were with the administrator.
A resident with dementia in an LTC facility was repeatedly found in soiled clothing and bedding, with a strong odor of urine and bowel movement. Despite the resident's known resistance to care, staff failed to provide consistent and adequate assistance with ADLs, resulting in undignified conditions. The care plan required oversight with dressing and bathing, but these interventions were not effectively implemented.
A resident at risk for pressure ulcers did not receive timely assessments or proper interventions, leading to improper heel positioning and a lack of skin assessments. Despite a care plan, the resident's heels were not floated, and there was a nine-day gap in skin assessments, complicating the determination of the ulcer's origin.
The facility failed to implement a comprehensive Restorative Nursing Program (RNP) for two residents, resulting in increased pain and decreased range of motion (ROM) for one resident and contracture development for another. Despite therapy recommendations, the RNP was not effectively communicated or implemented, leading to difficulties in activities of daily living (ADLs) and increased pain. Interviews with staff revealed a lack of communication and follow-through on therapy recommendations and RNP tasks.
A facility failed to provide adequate hydration for a resident, who was observed with dry, chapped lips and expressed thirst. The resident, dependent on staff for mobility and eating, did not have a beverage available in their room on multiple occasions. Despite the care plan specifying nectar-thick liquids and adaptive equipment, these interventions were not consistently implemented. Staff interviews confirmed the expectation for residents to have fresh water and assistance as needed, but no hydration policy was provided.
A resident with hypothyroidism was improperly administered Levothyroxine in the evening instead of the prescribed morning time, leading to symptoms of hypothyroidism. The medication was given alongside other medications and snacks, potentially affecting its absorption. The DON acknowledged the issue and discussed it with the responsible nurse.
The facility's infection control program was found deficient due to incomplete surveillance and tracking of infections. The Infection Control LPN confirmed that only residents receiving antimicrobial treatment were tracked, omitting those with untreated infections. This led to inadequate infection control tracking, increasing the risk of microorganism spread among residents. The facility's policy required comprehensive monitoring, but current practices did not align with these requirements.
Failure to Ensure Safe Mechanical Lift Transfer and Fall Prevention
Penalty
Summary
The facility failed to implement and operationalize policies and procedures to ensure safe transfer of a dependent resident using a mechanical lift, and did not ensure that planned interventions for fall prevention were in place. During a transfer using a mechanical lift, a resident with severe cognitive impairment, dementia, and significant physical limitations fell from the lift, resulting in a laceration to the forehead and an intraventricular hemorrhage. The incident occurred while two CNAs were transferring the resident from a Broda chair to bed using an Invacare 450 mechanical lift with a mesh sling. The resident slipped out of the side gap of the sling, hit their head on the metal bar of the lift, and landed on the floor. Staff interviews and demonstrations revealed that the lift and sling combination allowed for significant tipping and instability, and that the resident, who lacked core strength, was unable to support themselves during the transfer. The facility did not have a written policy or procedure for mechanical lift and sling use, relying instead on the manufacturer's guide, which was not accessible to staff. Staff training was limited to a competency check-off at hire, and there was no evidence of ongoing or refresher training. The care plan for the resident included a general intervention to follow the guide for sling type and loop attachment, but did not provide specific, individualized instructions or precautions. The investigation into the incident lacked statements from all involved staff, and the root cause of the fall was not clearly identified. The facility's documentation and staff interviews indicated confusion and inconsistency regarding how the fall occurred and what factors contributed to the resident slipping out of the sling. Following the fall, the resident experienced a significant decline in condition, including loss of ability to interact, make eye contact, or participate in activities as before. The injury was initially treated with steri-strips, but continued to bleed, requiring a pressure dressing by hospice staff. Diagnostic imaging confirmed an intracranial hemorrhage. The facility did not report the fall with severe injury to the State Agency as required. The lack of clear policies, inadequate staff training, and failure to ensure safe equipment and individualized care planning directly contributed to the resident's fall and subsequent injury.
Failure to Prevent Repeated Falls and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified when a resident experienced repeated falls from her wheelchair, resulting in injuries and hospitalization. The resident, who was cognitively intact with a BIMS score of 14, had multiple complex medical diagnoses including hemiparesis, diabetes, seizure disorder, and ischemic cardiomyopathy. She was dependent or required maximum assistance for most activities of daily living, including toileting, dressing, and personal hygiene. Despite these needs, the resident experienced three separate falls in her room over a two-month period, with the most recent incident resulting in facial injuries and a hospital transfer. Review of the resident's care plans revealed interventions such as encouraging non-skid footwear, keeping personal items within reach, using a floor mat next to the bed, and providing adaptive equipment like a wheelchair and mechanical lift. However, there were no documented interventions specifically addressing increased supervision or monitoring for this resident, despite her repeated falls. The care plans included general fall risk management strategies and environmental modifications, but did not include enhanced supervision or monitoring after the initial and subsequent falls. Interviews with the resident and her former roommate indicated that after the most recent fall, there was a significant delay in staff response, with both reporting that it took between 30 to 45 minutes for staff to arrive after the call light was activated and the roommate began yelling for help. The facility's fall management policy requires assessment, intervention, and monitoring to minimize fall risk, but the lack of timely staff response and absence of increased supervision measures contributed to the repeated falls and injuries sustained by the resident.
Deficiencies in Food Temperature Management and Ice Machine Sanitation
Penalty
Summary
The facility failed to maintain a clean and sanitary ice machine and did not ensure safe food service and holding temperatures during a breakfast meal. During an observation, it was noted that the scrambled eggs were served at temperatures below the required 135 degrees Fahrenheit. The dietary staff initially recorded the scrambled eggs at 132 degrees Fahrenheit, which was below the safe serving temperature. The Dietary Manager was informed and took corrective action by reheating the eggs to 190 degrees Fahrenheit before returning them to the steam table. However, subsequent temperature checks by another dietary staff member showed the scrambled eggs at 142.7 degrees and later at 131.0 degrees, indicating inconsistent temperature maintenance. The facility's food temperature logs revealed that scrambled eggs were recorded at 160 degrees Fahrenheit before leaving the kitchen, but there was no consistent monitoring of temperatures during service. The Dietary Manager stated that food temperatures are checked only once when removed from the oven and not during service. This practice led to discrepancies in maintaining safe food temperatures, as evidenced by the varying temperatures recorded during the breakfast service. Additionally, an inspection of the ice machine in the facility's kitchen revealed the presence of an unknown black substance on the interior ledge, which came into contact with the ice. The Dietary Manager and staff confirmed the presence of the substance and indicated that maintenance staff were responsible for cleaning the ice machine. However, there was no clear documentation or policy regarding the cleaning schedule or responsibilities, leading to unsanitary conditions in the ice machine.
Failure to Respond to Call Lights Timely and Dignified Manner
Penalty
Summary
The facility failed to respond to residents' needs in a timely and dignified manner, as evidenced by complaints from an anonymous group of residents during a Resident Council meeting. Residents reported that staff would turn off call lights without providing immediate assistance, leading to extended wait times. One resident mentioned waiting 20 minutes after the call light was canceled, only to wait an additional 25 minutes before assistance was provided. Another resident expressed frustration at having to repeatedly engage the call light if staff did not return within 10 minutes. There were also reports of staff prioritizing other call lights and expressing reluctance to assist residents requiring more complex care, such as those needing a Hoyer lift and two staff members for assistance. The Resident Council group expressed dissatisfaction with management's response to their complaints, stating that they were advised to reactivate their call lights if staff did not return promptly. The residents felt that management's assurances of 'working on it' were insufficient, leading to feelings of neglect and insignificance. The Recreation Director was unable to provide the last six months of resident council meeting minutes, as they had been given to the administrator for uploading, and were not available before the survey concluded. This deficiency highlights a failure to honor residents' rights to a dignified existence and timely communication, as outlined in the HCAM Resident Rights booklet.
Failure to Provide Dignified ADL Care
Penalty
Summary
The facility failed to provide dignified Activities of Daily Living (ADL) care for a resident, resulting in the resident being found in soiled clothing and bedding, and a bathroom in an unsanitary condition. On multiple occasions, the resident was observed with a strong odor of urine and bowel movement emanating from their room and person. The resident was seen wearing the same soiled clothes over two days, with visible brown residue on their clothing, indicating a lack of timely assistance with personal hygiene. The resident, who has a diagnosis of dementia and severely impaired cognition, was noted to be resistant to changing clothes and accepting assistance with ADLs. Despite this, the facility staff, including CNAs and the Director of Nursing (DON), acknowledged the resident's condition but failed to ensure consistent and adequate care. The resident's care plan indicated the need for oversight with dressing in clean clothes daily and assistance with bathing, yet these interventions were not effectively implemented. Interviews with staff revealed that the resident's resistance to care was known, and strategies such as using a hairdryer to encourage showering were suggested. However, the resident continued to be found in soiled conditions, and the facility did not adequately address the resident's needs, as evidenced by the repeated observations of soiled clothing and bedding, and the persistent odor in the resident's room.
Failure in Pressure Ulcer Prevention and Assessment
Penalty
Summary
The facility failed to ensure timely assessment and implementation of interventions for pressure ulcer prevention for a resident. The resident, who was moderately cognitively impaired and dependent on staff for bed mobility and transferring, was at risk for pressure ulcer development. Despite having a care plan that included interventions such as bridging heels in bed and applying barrier cream, observations revealed that the resident's heels were not properly floated, and their foot was pressing against the footboard of the bed. The resident had a history of fragile skin and was admitted with a suspected deep tissue injury on the coccyx, which was noted to have developed during a hospital stay. However, there was a lack of consistent skin assessments, as evidenced by a nine-day gap in documentation prior to the resident's hospitalization. This gap raised concerns about the facility's ability to determine the origin of the pressure ulcer accurately. Further observations and interviews with nursing staff confirmed that the resident's heels were not appropriately positioned to prevent pressure ulcers. The wound care nurse acknowledged the improper positioning and the absence of a skin assessment during the critical period. The facility's policy required regular skin assessments to identify changes in skin condition, but this was not adhered to, contributing to the deficiency.
Failure to Implement Restorative Nursing Program Leads to Resident Decline
Penalty
Summary
The facility failed to implement a comprehensive Restorative Nursing Program (RNP) for two residents, leading to a lack of communication and implementation of planned RNP per therapy recommendations. Resident #15 experienced increased pain and decreased range of motion (ROM) in their right arm, which was not addressed by the facility's RNP. Despite being discharged from therapy with recommendations for continued exercises and ambulation, these were not effectively communicated or implemented, resulting in Resident #15's difficulty with activities of daily living (ADLs) and increased pain. Resident #30 developed a contracture and experienced a decline in ROM, which was not adequately addressed by the facility's RNP. The resident was dependent on staff for all ADLs and had impaired bilateral upper and lower extremity ROM. Despite having a care plan that included passive ROM exercises and the use of palm guards, these interventions were not consistently implemented. Staff documented completion of ROM tasks even when they were not fully performed due to the resident's pain, and therapy staff were not informed of the resident's decline in ROM or increased pain. Interviews with facility staff, including CNAs, therapists, and the Director of Nursing (DON), revealed a lack of communication and follow-through on therapy recommendations and RNP tasks. The facility's policy on restorative nursing was not effectively operationalized, leading to the residents' functional decline and increased pain. The DON acknowledged the concerns but did not provide explanations for the deficiencies in implementing the RNP.
Failure to Provide Adequate Hydration
Penalty
Summary
The facility failed to ensure the availability and provision of fluids to maintain appropriate hydration for a resident, resulting in the resident experiencing thirst and having visibly dry and chapped lips. Observations on two consecutive days revealed that the resident did not have a beverage available in their room, and their oral cavity appeared dry. The resident, who was moderately cognitively impaired and dependent on staff for mobility and eating, expressed thirst and consumed multiple cups of water when offered by staff. The resident's care plan indicated the use of adaptive equipment and specified a diet with nectar-thick liquids, but there was no evidence of consistent implementation of these interventions. Interviews with staff, including the Director of Nursing, confirmed that residents should have fresh water available and be assisted to drink if needed. However, the facility did not provide a policy or procedure related to hydration by the conclusion of the survey, indicating a lack of adherence to hydration protocols.
Improper Administration of Thyroid Medication
Penalty
Summary
The facility failed to ensure the appropriate administration of a thyroid hormone medication for a resident diagnosed with hypothyroidism, dementia, and mood disturbance. The resident was admitted on March 15, 2024, and had a physician's order for Levothyroxine Sodium, initially at 25 MCG, which was increased to 50 MCG on October 16, 2024, to be administered at 6:00 AM. However, the medication was being administered in the evening along with other medications, contrary to the prescribed time. This improper administration led to abnormal lab values and the resident experiencing symptoms of hypothyroidism, such as tiredness and constipation. Observations and interviews revealed that the resident often felt tired and constipated, preferring to stay in bed. The Director of Nursing (DON) was informed of the issue and acknowledged that the resident was receiving their thyroid medication at 8:00 PM, along with other medications like Rexult, Mirtazapine, Acetaminophen, Tamsulosin, and Atorvastatin Calcium. The DON admitted to discussing the time change with the nurse responsible. The medication administration audit report confirmed that the resident received their Levothyroxine with other medications and snacks, which could interfere with its absorption, as per the American Thyroid Association's guidelines for thyroid hormone administration.
Inadequate Infection Control Surveillance in LTC Facility
Penalty
Summary
The facility failed to implement a comprehensive infection control program, as evidenced by their inadequate infection surveillance and tracking system. The facility's Infection Control Resident Surveillance line listing documentation only included residents who received antimicrobial treatment, omitting those with signs or symptoms of infection who did not receive such treatment. This lack of comprehensive tracking was confirmed by the Infection Control LPN, who acknowledged that infections not treated with antimicrobials were not included in the surveillance documentation. This oversight resulted in a lack of accurate and comprehensive infection control tracking, increasing the likelihood of the spread of microorganisms and illness among the facility's 47 residents. During the review of the October 2024 Infection Control Resident Surveillance line listing, it was found that the documentation was incomplete and inconsistent. For instance, one resident was listed with multiple antimicrobial treatments for a single infection, and the onset dates were unclear. The LPN admitted that the line listing tracked the dates of antimicrobial treatment rather than the onset of infection symptoms. Additionally, the facility's monthly summary form did not provide any additional data related to the onset of infections or address antimicrobial treatments, nor did it include surveillance for potential infections that did not receive antimicrobial treatment. The facility's policy on infection prevention and control, updated in March 2024, stated that infections are monitored when a treatment plan is ordered by a healthcare practitioner. However, the policy did not ensure the inclusion of infections not requiring antimicrobial treatment in the surveillance data. The Infection Prevention Manager was responsible for the surveillance, aggregation, and analysis of data, but the current practices did not align with the policy's requirements for comprehensive monitoring and evaluation of infections and communicable diseases for all residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kawkawlin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carriage House Nursing And Rehabilitation | 6.7 mi | — | 1 | 0 |
| Bay Shores Senior Care And Rehab Center | 7 mi | — | 13 | 0 |
| Hampton Nursing And Rehabilitation | 9.4 mi | — | 0 | 0 |
| Bay County Medical Care Facility | 10.1 mi | — | 2 | 0 |
| Caretel Inns Of Tri-cities | 10.4 mi | — | 2 | 0 |
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