Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Huron County Medical Care Facility during CMS and state inspections, most recent first.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards, as identified during the survey.
A resident admitted with acute respiratory failure, heart failure, COPD, and an infection requiring IV antibiotics did not have a baseline care plan developed within 48 hours to address their IV catheter and infection needs. Staff confirmed the omission, and review of the care plan showed it lacked required interventions for these conditions.
A resident with a urinary catheter was observed on two occasions with the catheter tubing and bag in contact with the floor while in a wheelchair. The resident, who had impaired cognition and required extensive assistance, had the catheter tubing exposed and dragging on the floor in both the dining room and hallway, contrary to infection control guidelines.
The facility did not ensure that physician's orders for oxygen administration included specific flow rates for two residents with respiratory conditions. Both residents received oxygen therapy based on orders that only directed staff to maintain oxygen saturation above 90%, without specifying the liters per minute. The DON confirmed that none of the oxygen orders included flow rates, and facility policy requiring this information was not followed.
A resident with dementia and behavioral disturbances was not treated with dignity when a CNA argued with her, removed her bingo chips, and forcefully pushed her in a wheelchair out of the activity room after a group activity. The staff did not follow the resident's care plan, which required individualized support and reassurance, resulting in the resident's distress and confusion.
The facility failed to maintain sanitary conditions in the kitchen, leading to potential cross-contamination and foodborne illness risks. Observations included soiled floors, improper storage of food items, and incomplete cleaning documentation. Additionally, sanitizing solutions were found ineffective, and temperature control for food items was inadequate, with milk stored at unsafe temperatures.
The facility failed to implement effective infection control measures, as staff did not adhere to hand hygiene and PPE protocols in isolation rooms. There was inadequate tracking of resident and employee illnesses, and a resident's urinary catheter bag was improperly placed on the floor. Staff inconsistently followed Enhanced Barrier Precautions, compromising resident safety.
The facility failed to maintain resident dignity by not responding to call lights promptly, leading to residents soiling themselves. Additionally, the closure of the Bingo store and the unprepared outdoor patio further contributed to residents' dissatisfaction and feelings of neglect.
The facility failed to address multiple concerns raised by residents, including unresponsive call lights, unsatisfactory food service, an unusable outdoor patio, and the removal of the Bingo store. Despite repeated mentions in Resident Council meetings, the facility did not take effective action to resolve these issues, leading to resident frustration and dissatisfaction.
A facility failed to develop a baseline care plan for falls within 48 hours for a resident with epilepsy, depression, and profound intellectual disabilities, who was assessed as high risk for falls. The care plan was delayed, and the resident sustained falls after admission. The facility's policy requires such plans to be developed within 48 hours, including interventions for fall risks.
A resident with Alzheimer's Dementia and severe cognitive loss was admitted to a facility without a comprehensive, resident-centered care plan. Despite being assigned a 1:1 staff member for supervision due to wandering behavior, the care plans lacked specific interventions for the resident's likes and dislikes. The care plans were developed weeks after admission and did not include person-centered interventions, contrary to the facility's policy.
A resident with epilepsy, depression, and profound intellectual disabilities experienced two falls in the facility. After the second fall, the care plan was not updated until five days later, contrary to the facility's policy. The Restorative Nurse acknowledged the delay, which resulted in a deficiency.
A resident with severe cognitive impairment developed a facility-acquired pressure injury on the heel, suspected to be caused by wheelchair foot pedals. Despite interventions, the facility failed to ensure timely nutritional evaluation, with the dietitian assessing the resident nearly a month after the injury. The facility's policy required prompt referral to the dietitian, which was not followed.
The facility failed to ensure proper respiratory care and equipment management for residents. A resident with COPD was found with an empty oxygen tank, and another resident's CPAP machine was improperly maintained with undated distilled water and a water chamber not emptied daily. Additionally, distilled water for a CPAP machine was improperly stored on the floor. Staff acknowledged the need for better monitoring and documentation.
A resident with severe cognitive loss was treated with Bactrim for a suspected UTI without appropriate lab tests to confirm the infection or determine antibiotic effectiveness. The facility's antibiotic stewardship policy was not followed, as necessary urinalysis and culture and sensitivity tests were not conducted, and the resident's care plan was outdated.
A resident did not receive the 2023/2024 influenza vaccine despite having consented, due to the facility's policy of not administering flu vaccines after March 31st. The resident was initially unwell but later received a COVID-19 booster, indicating they were healthy enough for vaccinations. The DON could not provide CDC documentation supporting the facility's policy.
Failure to Follow Professional Standards for Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report. No information is given regarding the medical history or condition of any residents at the time of the deficiency.
Failure to Develop Baseline Care Plan for IV Therapy and Infection
Penalty
Summary
The facility failed to develop a baseline care plan that addressed the immediate needs of a resident within 48 hours of admission, as required by facility policy. The resident was admitted with acute respiratory failure with hypoxia, heart failure, and chronic obstructive pulmonary disease, and was observed receiving oxygen therapy. The resident also had a midline IV catheter for antibiotic administration due to an infection. During interviews, the resident reported issues with the IV catheter, including needing to leave the facility for a replacement, and confirmed ongoing antibiotic treatment. Upon review, it was found that the baseline care plan did not include interventions or care planning for the IV catheter or the infection. The Unit Manager and MDS Nurse both confirmed that the care plan lacked documentation and planning for these critical needs, despite the facility's policy requiring a baseline care plan to be developed within 48 hours of admission and to include all necessary instructions for person-centered care, including special needs such as IV therapy. The deficiency was identified through observation, interview, and record review.
Catheter Bag and Tubing Found Resting on Floor
Penalty
Summary
A deficiency was identified when a resident with a urinary catheter was observed on two separate occasions with the catheter tubing and bag in contact with the floor. On the first occasion, the resident was in the dining room in a wheelchair, with the catheter bag hooked under the wheelchair and approximately eight inches of tubing resting on the floor. The catheter bag cover was also observed touching the floor. On the second occasion, the resident was again in their wheelchair, and the catheter tubing was seen exposed and dragging on the floor as the resident was assisted through the hallway and positioned in the dining room. The resident involved had a history of cancer, anemia, and obstructive uropathy, with severely impaired cognition and required extensive assistance with all activities of daily living. The improper securing of the catheter bag and tubing, resulting in contact with the floor, was directly observed by staff and reported to facility management. The report references CDC and other guidelines that state catheter bags should not be placed on the floor due to the risk of contamination.
Failure to Specify Oxygen Flow Rates in Physician Orders for Residents Receiving Respiratory Care
Penalty
Summary
The facility failed to ensure that physician's orders for oxygen administration included specific flow rates for two residents who required respiratory care. For one resident with diagnoses including pulmonary fibrosis, COPD, acute respiratory failure, and interstitial pulmonary disease, observation revealed oxygen being administered at 6 liters per minute, but the physician's order only directed staff to maintain oxygen saturation at or above 90% without specifying a flow rate. The Director of Nursing confirmed that none of the oxygen orders for residents included flow rates, and staff would not know the correct rate without checking previous charting. A second resident, admitted with acute respiratory failure with hypoxia, heart failure, and COPD, was observed receiving oxygen via nasal cannula, with the flow rate fluctuating between 2 and 4 liters per minute as documented in the treatment record. However, the physician's order for this resident also lacked a specified flow rate, only instructing to maintain oxygen saturation at or above 90%. The DON acknowledged that the oxygen order should have included the liters per minute for administration. Facility policy requires physician orders for oxygen to include flow rate, route, and duration, but this was not followed for either resident.
Failure to Treat Resident with Dignity During Activity
Penalty
Summary
A deficiency occurred when staff failed to follow the care plan and treat a resident with dignity during and after a group activity. The resident, who had diagnoses including dementia, stroke, and behavioral disturbances, was observed to have severely impaired cognition and required assistance with activities of daily living. The care plan specified that staff should provide activities the resident enjoys, avoid interrupting her during activities, and offer reassurance, as she becomes confused and frustrated if contradicted. During a bingo activity, the resident became upset, insisting that her bingo chips, purse, and coat had been taken. Staff statements and video surveillance confirmed that a CNA argued with the resident, removed bingo chips from her hands, and forcefully pushed her in her wheelchair out of the activity room. The CNA was observed raising her voice, physically moving the resident's hands from the table, and quickly pushing her out of the room, despite offers of assistance from other staff. The incident resulted in the resident displaying distress, calling out, and slamming her hand on the table. Multiple staff interviews corroborated that the CNA's actions were loud, forceful, and did not align with the resident's care plan, which emphasized dignity and individualized support. The resident was later found in another area, still expressing confusion and distress about her belongings. Documentation in the medical record noted previous behavioral issues during activities, but the care plan required staff to manage these behaviors with patience and reassurance, which was not observed during this incident.
Sanitation and Temperature Control Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which increased the potential for cross-contamination of food and foodborne illness. During an inspection, the surveyor observed several issues, including a soiled floor with visible debris in the walk-in freezer and cooler, broken eggshells, and a container of heavy whipping cream on the floor. The Dietary Manager acknowledged the issues but attributed them to the stock person's schedule and recent mopping. Additionally, there was a heavy accumulation of ice buildup on the refrigerant lines in the walk-in cooler, which the Dietary Manager was unaware of. Further observations revealed unsanitary conditions in the second floor's kitchenette, where a container of liquid butter was stored improperly, leading to a heavy coating of butter on the cabinet. The Dietary Manager was unaware of this issue and noted that the butter should have been in a squeeze bottle. The cleaning checklist for the kitchen was only partially filled out, indicating incomplete documentation of daily cleaning tasks. The Dietary Manager described it as a work in progress. The facility also failed to maintain proper sanitization and temperature control. A sanitizing bucket in the third floor's kitchenette was found to have a concentration of zero, and the temperature of the chemical solution was below the required level. The Dietary Manager admitted the solution might have been from the morning and needed to be remade. Additionally, a half-gallon of milk was found at an unsafe temperature, and the Dietary Manager acknowledged it should be discarded. The Regional Dietary Supervisor suggested ordering personal containers of milk to maintain proper temperature control.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper hand hygiene and personal protective equipment (PPE) protocols. On several occasions, staff members entered a room designated for contact and droplet isolation without performing hand hygiene or donning the required PPE, such as gowns and masks. This was despite clear signage indicating the need for such precautions. Additionally, there was no trash receptacle available for the disposal of PPE, leading staff to use a bathroom trash can instead. The facility also lacked a comprehensive system for tracking resident and employee illnesses. During a review of the infection control line listing, it was found that there was no mapping of infections, and the documentation for employee illnesses was inadequate. The Infection Control Nurse and Director of Nursing admitted that they relied on call-in slips to monitor employee illnesses but did not have a formal tracking system in place. This lack of documentation and follow-up could hinder the facility's ability to identify and respond to potential outbreaks. Specific deficiencies were noted in the care of Resident #20, who had a urinary catheter bag improperly placed on the floor, increasing the risk of contamination. The resident, who had multiple health conditions including acute respiratory failure and pneumonia, was under Enhanced Barrier Precautions. However, staff did not consistently wear PPE when changing bed linens, contrary to the instructions posted on the resident's door. This inconsistency in following infection control protocols further highlights the facility's failure to maintain a safe environment for its residents.
Deficiencies in Resident Dignity and Facility Maintenance
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner, as evidenced by several issues reported by a group of residents. Residents on the 2nd and 3rd floors expressed that during the night shift, their call lights were not answered in a timely manner. Staff members would sometimes turn off the call lights without addressing the residents' needs, leading to situations where residents were left to soil themselves due to lack of assistance. This delay in response time was noted to sometimes extend up to an hour, despite the call light system being designed to alert a supervisor if unanswered for too long. Additionally, residents reported dissatisfaction with the closure of the Bingo store, which had been a source of enjoyment and provided them with items they needed. The store was removed to repurpose the space, with promises of reopening it elsewhere in the facility, but no solution had been provided for several months. Furthermore, the outdoor patio was not maintained, with tables and chairs not set up and a lack of necessary equipment to care for the resident's garden. This neglect prevented residents from using the patio for activities and visits, contributing to their feelings of disrespect and discouragement.
Facility Fails to Address Resident Concerns
Penalty
Summary
The facility failed to address multiple concerns raised by the Resident Council and a specific resident, leading to frustration and dissatisfaction among the residents. The issues included call lights not being answered promptly, food preferences not being accommodated, cold food being served, the inability to use the outdoor patio, and the removal of the Bingo store. Despite repeated mentions of these issues in Resident Council meetings, the facility did not take effective action to resolve them. Residents reported that call lights were often turned off without assistance being provided, leading to situations where residents soiled themselves due to lack of timely help. The Dietary Manager was aware of the complaints about cold food and the quality of evening meals but had not implemented any interventions to address these concerns. Additionally, the facility's failure to accommodate specific dietary needs, such as gluten-free options, further contributed to resident dissatisfaction. The outdoor patio remained unprepared for use, with tables and chairs not set up and the garden hose lacking a nozzle, preventing residents from enjoying the space or entertaining visitors. The Bingo store, which was a source of enjoyment and necessity for residents, was closed for remodeling and had not been reopened, despite promises to do so. The facility's inaction on these matters, despite being aware of them, highlights a significant deficiency in addressing resident grievances and maintaining their quality of life.
Failure to Develop Timely Baseline Care Plan for Fall Risk
Penalty
Summary
The facility failed to develop a baseline care plan for falls for a resident within the required 48-hour timeframe following admission. The resident, who is [AGE] years old, was admitted with diagnoses including epilepsy, depression, and profound intellectual disabilities. Despite being assessed as a high risk for falls with a score of 22 on 05/14/24, the baseline care plan addressing falls was not implemented until 05/17/24. This delay in creating a care plan was confirmed by the Minimum Data Set Nurse, who acknowledged that the baseline care plan should have been completed within 48 hours of admission and should have addressed fall risks. The resident sustained falls on 05/22/24 and 07/04/24, indicating that the lack of a timely baseline care plan may have contributed to these incidents. The facility's policy on baseline care plans, reviewed in February 2024, mandates that such plans be developed within 48 hours of admission and include interventions for health and safety concerns, such as fall risks. The failure to adhere to this policy resulted in an incomplete baseline care plan for the resident, potentially compromising their safety and care.
Failure to Develop Resident-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a resident-centered comprehensive care plan for a resident with Alzheimer's Dementia and other medical conditions, including urinary retention, glaucoma, anxiety, depression, and severe cognitive loss. The resident, who was admitted to the facility with a BIMS score of 3/15, was observed wandering non-stop in the hallways and attempting to enter other residents' rooms. Despite being assigned a 1:1 staff member for supervision, the resident's care plan lacked specific interventions to address his likes and dislikes, and the care plans were not developed until several weeks after his admission. Interviews with facility staff revealed that the resident had been wandering since admission and had been transferred to a psychiatric hospital for medication stabilization before returning to the facility. The care plans, including those for mood, mobility, safety, bladder management, pain, visual function, and behavior, were all dated after the resident's return from the hospital, and none included person-centered interventions. The facility's policy on comprehensive care plans emphasizes the importance of developing a person-centered care plan with measurable objectives and time frames, but this was not adhered to in the case of this resident.
Delayed Care Plan Update After Resident Falls
Penalty
Summary
The facility failed to update the care plan in a timely manner for a resident who experienced falls, resulting in a deficiency. The resident, who has epilepsy, depression, and profound intellectual disabilities, was admitted to the facility and had a history of falls. On two occasions, the resident sustained falls, one on 05/22/24 and another on 07/04/24. After the first fall, a new intervention was implemented by placing a perimeter mattress on the bed. Following the second fall, the bed was placed in the lowest position as a new intervention. However, the care plan was not updated until five days after the second fall, which was not in accordance with the facility's policy. The facility's Fall Prevention Program policy requires that the interdisciplinary team review falls and evaluate the need for further interventions promptly. Despite this, the care plan for the resident was not revised until 07/09/24, five days after the fall on 07/04/24. The Restorative Nurse responsible for updating the care plan acknowledged that the update should have occurred sooner and was unsure how the delay happened. This delay in updating the care plan after the fall incident led to the deficiency noted by the surveyors.
Failure to Prevent Pressure Injury and Ensure Timely Nutritional Evaluation
Penalty
Summary
The facility failed to prevent the development of a facility-acquired pressure injury and ensure timely nutritional evaluation for a resident with a suspected deep tissue injury (SDTI) on the left heel. The resident, who had severe cognitive impairment and was dependent on a wheelchair, developed a fluid-filled blister with a purple center on the heel, which was later identified as a deep tissue injury. The wound care nurse confirmed that the injury was facility-acquired and suspected it was caused by the foot pedals on the resident's wheelchair. Despite interventions such as padding the foot pedals and using pressure-relieving boots, the facility did not ensure timely nutritional evaluation following the injury. The resident's medical record showed a delay in nutritional evaluation, with the next assessment occurring nearly a month after the injury was identified. The dietitian was not notified promptly about the pressure injury, and there was no record of contact regarding the wound. Although the resident had a good appetite and was consuming protein Jello, the dietitian only evaluated the resident's nutritional needs a month after the injury's development. The facility's policy required nursing staff to refer residents with pressure injuries to the dietitian for nutritional review, but this was not done in a timely manner. Interviews with the wound care nurse and dietitian revealed that the interdisciplinary team, which included the dietitian, reviewed resident wounds weekly. However, the dietitian did not have a record of being contacted about the resident's injury and stated that typically, she would see residents immediately after being informed of such injuries. The facility's protocol required a nutrition risk assessment and dietitian notification within 72 hours of identifying a new pressure injury, which was not adhered to in this case.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide adequate respiratory care for Resident #58, who was observed with an empty oxygen tank while using a nasal cannula. The resident, diagnosed with chronic obstructive pulmonary disease, heart disease, and anxiety disorder, was found propelling herself in her wheelchair with the oxygen tank indicator on red, suggesting it was out of oxygen. Despite wearing the nasal cannula, the resident did not feel any oxygen flow, and there was no sound from the cannula. A CNA confirmed the tank was empty and replaced it, while a nurse monitored the resident's oxygen saturation, which was between 92% and 94%. The CNA admitted to not checking the resident's oxygen tank at the start of the shift, and the Unit Manager acknowledged the need for more frequent checks when tanks are low. In another instance, the facility did not properly manage the CPAP machine and distilled water for Resident #70, who had diagnoses including dementia, insomnia, and sleep apnea. The CPAP machine was found with a partially filled water chamber and an undated, partially used gallon of distilled water on the bedside table. The Director of Nursing and Unit Manager confirmed that distilled water should be dated upon opening, and the water chamber should be emptied and dried daily, although there were no documented orders for this procedure. The CPAP machine was later removed as the resident had been refusing its use, and it was discontinued prior to the observation. Additionally, the facility failed to ensure proper storage of distilled water for a CPAP machine in another resident's room. The water was stored on the floor, contrary to the facility's expectations, and the Unit Manager noted that the resident had moved it there. The Director of Nursing indicated that the facility's policy did not require dating the distilled water, and the CPAP/BiPAP policy was requested but not provided by the facility.
Failure to Follow Standards for Antibiotic Use and Laboratory Testing
Penalty
Summary
The facility failed to adhere to standards of practice for laboratory testing and antibiotic use for a resident with a history of urinary tract infections. The resident, who had severe cognitive loss and required assistance with all care, was treated with the antibiotic Bactrim for a suspected urinary tract infection without appropriate laboratory tests to confirm the infection or determine the effectiveness of the antibiotic. The Infection Prevention and Control Nurse was unable to provide laboratory reports for urinalysis and culture and sensitivity tests, which are necessary to identify the infection and the most effective treatment. The physician's orders indicated that Bactrim was prescribed for ten days, but the documentation lacked evidence of a culture result or sufficient rationale for the antibiotic treatment. The urinalysis results showed potential contamination, and no culture and sensitivity reports were available to confirm an infectious organism or antibiotic sensitivity. The facility's policy on antibiotic stewardship was not followed, as laboratory testing was not conducted in accordance with current standards of practice. Additionally, the resident's bladder management care plan had not been updated to reflect the recent antibiotic treatment.
Failure to Administer Influenza Vaccine
Penalty
Summary
The facility failed to administer the 2023/2024 influenza vaccine to a resident, despite the resident having given consent for the vaccination on May 13, 2024. A review of the resident's immunization records on July 10, 2024, revealed no documentation of the influenza vaccine being administered. The resident had been admitted with a gastrointestinal infection and was on antibiotics intermittently, which the Director of Nursing (DON) cited as the reason for not administering the vaccine initially. However, the resident later received a COVID-19 booster on May 31, 2024, indicating they were healthy enough for vaccinations at that time. The DON stated that the facility's medical director does not allow flu vaccinations after March 31st, despite the Centers for Disease Control and Prevention (CDC) guidelines indicating that flu vaccines do not expire until June 30th and can still be administered in the spring. When asked to provide CDC documentation supporting the medical director's policy, the DON was unable to find any such guidance. This discrepancy between the facility's policy and CDC guidelines contributed to the failure to vaccinate the resident against influenza.
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What surveyors actually found near you
We read the 36 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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 Bad Axe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Courtney Manor | 2.6 mi | ★★★★★ | 10 | 0 |
| Medilodge Of Cass City | 15.4 mi | ★★★★★ | 12 | 0 |
| Lakeview Extended Care And Rehabilitation | 19.2 mi | ★★★★★ | 6 | 0 |
| Autumnwood Of Deckerville | 24.3 mi | ★★★★★ | 8 | 0 |
| Tuscola County Medical Care Facility | 27.2 mi | ★★★★★ | 11 | 0 |
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