Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Woods Nursing Center during CMS and state inspections, most recent first.
Failure to Complete Ordered Chest X-Ray: A resident with CVA-related hemiplegia, dysphagia, and chronic cough had a chest x-ray ordered after the daughter raised concern for aspiration and abnormal lung sounds, but the x-ray was never completed. Nursing notes documented diminished breath sounds, vomiting, a productive cough, low-normal O2 saturation, and IV fluids for decreased intake. Interviews showed the DON, RN, and LPN described communication and order-entry issues with the diagnostic company, and the order was not carried through to completion.
A facility failed to maintain food service best practices when surveyors observed the ice machine drain line sitting directly in the drain and found pureed foods on the tray line hot held below the required temperature. During lunch observation, puree green beans were 123 F and puree chicken was 127 F, while staff stated hot holding should be 135 F and the facility follows the FDA Food Code.
Advance directive code status was not clearly documented or accessible in the chart for two residents. Both residents had physician determinations showing decision-making capacity, but their face sheets and advance directive links did not clearly identify CPR or DNR status or PTO. The DON stated staff relied on a red binder at the nurse’s station for the up-to-date code status, even though it was not part of the medical record, and one resident’s binder entry differed from the chart while the other had no CPR/DNR distinction.
Failure to Provide Medicare Non-Coverage Notices: The facility did not have ABN/NOMNC documentation for three residents reviewed, including residents who were Medicare Part A recipients and discharged home. During record review, the Admissions Director confirmed that only an older notice from a prior stay was found for one resident and that no 2025 NOMNC/ABN was in the records for the other residents.
Failure to provide routine diabetic foot care for a resident with DM2 and diabetic polyneuropathy. The resident was cognitively intact, had an active podiatry order per consent, and reported repeated requests to see the podiatrist. Staff could not confirm whether she was on the schedule, and her toenails were observed to be long and unkempt. The DON confirmed the resident had not received routine podiatry follow-up after a prior visit and that documentation for renewed consent after readmission was not available.
A resident with COPD, heart failure, and other chronic conditions was observed using an oxygen concentrator set at 3 L/min, but the nurse initially found no oxygen order in the chart and was unsure what the setting should be. The resident’s care plan included checking O2 saturation and initiating oxygen as ordered, and a later physician order specified oxygen at 2 L/min via NC with titration to keep saturation above 90%.
Failure to complete annual CNA performance reviews: The facility did not ensure annual performance/competency evaluations were completed for two CNAs, and the missing reviews also meant yearly education training was not documented. HR stated the DON and/or Clinical Care Coordinator were responsible for completing the evaluations and returning them to HR, but the employee files for a CNA/Med Tech and another CNA had no current annual evaluation on record, and HR confirmed no 2025 evaluations were available.
Failure to maintain annual CNA training and competency documentation. The facility used a computerized training system and stated that CNA education included lessons on Alzheimer’s disease and communication strategies, but one CNA’s file did not contain a 2025 annual performance/competency evaluation. HR confirmed no 2025 evaluation was available and no other training documents were presented for that employee.
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 Complete Ordered Chest X-Ray
Penalty
Summary
The facility failed to implement physician orders for a resident with hemiplegia and hemiparesis following cerebral infarction, dysphagia, chronic cough, and need for assistance with personal care, resulting in a chest x-ray not being performed. After the resident’s daughter requested a chest x-ray because she was concerned about swallowing and the resident’s lungs sounding bad, nursing staff assessed the resident and documented diminished but clear breath sounds. The nurse informed the DON, and the resident was to be seen by the NP. The NP evaluated the resident and ordered a chest x-ray to assess for possible aspiration or an acute pulmonary process and reinforced the pureed diet with nectar thick liquids due to aspiration risk. Physician orders show two chest x-ray orders were entered, but the diagnostic company later reported it did not have an order on file, and the facility’s portal showed no results, indicating the x-ray was never completed. Nursing documentation also noted the resident had vomiting, a productive cough, diminished breath sounds, a temperature of 97.1, oxygen saturation of 92% on room air, and received IV normal saline due to decreased fluid intake. Subsequent notes show speech therapy evaluated the resident at the daughter’s request and believed the resident should not have anything by mouth. The physician notified the family and asked them to decide on further care or hospital transfer, and the daughter later requested hospital evaluation and treatment. During interviews, the DON stated there was a communication gap with the diagnostic company and that the nurse did not enter the order into the All-Stat portal, while the RN stated the chest x-ray order was placed but the company never provided an approximate time. The LPN stated she believed there was no clinical indication and that she may have contacted the on-call person or left a note for the doctor.
Food Service Area and Hot Holding Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area. During the initial kitchen tour, the drain line to the ice machine was observed sitting directly in the drain. During lunch observation, a tray with purees individually stored in bowls on the tray line was observed, and puree green beans were temped at 123 F while puree chicken was temped at 127 F using a Thermapen. When interviewed, [NAME] G stated that hot holding should be 135 F, and Corporate Dietician F stated the facility follows the FDA Food Code.
Advance Directive Code Status Not Clearly Documented
Penalty
Summary
The facility failed to ensure that residents’ advance directive code status was documented and accessible in the medical record for two residents reviewed. For one resident, the MDS showed moderate cognitive impairment, while the physician determined the resident was capable of making medical treatment decisions. The resident’s face sheet and advance directives link did not show a clear CPR or DNR status, and the physician determination of decision-making capability was present without a clearly documented code status. Orders referenced the Preferred Treatment Option (PTO) for advance directives, and the care plan included an intervention to review advance directives and know the resident’s wishes for treatment. For the second resident, the MDS showed cognitive intactness, and the physician determined the resident was capable of making medical treatment decisions. The face sheet and advance directives link again did not show an identifiable CPR or DNR status or PTO. Orders referenced the PTO for advance directives, and the care plan included an intervention to review advance directives and know the resident’s wishes for treatment. In both records, the code status was not clearly documented in the charted advance directive section. During interview, the interim SW stated that nurses and SW shared responsibility for ensuring code status was in place and that either could complete care plans. The DON stated that updated code statuses were kept in a red binder at the nurse’s station and that the scheduler uploaded signed documents to the medical chart after physician signature. The DON acknowledged that the red binder was not part of the medical record and that the chart did not reflect the resident’s code status until the physician signed it. Observation of the red binder showed one resident had a different PTO in the binder than in the chart, with a handwritten DNR noted as pending signature, and the other resident’s PTO had no CPR or DNR distinction. The DON stated the facility had changed practice to clarify CPR or DNR on PTO forms, but the charted records still did not clearly identify the residents’ code status.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide adequate notice of non-coverage and failed to maintain documentation for Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) for three residents reviewed. Record review of the facility’s 11/2022 Advanced Beneficiary Notice policy showed that the facility is to prepare and deliver an ABN and NOMNC when the utilization review entity expects Medicare probably will not pay for or will not continue to pay for extended care items or services, and that a completed NOMNC is to be provided no later than two days prior to termination of services. During interview and record review with the Admissions Director, the surveyor reviewed five resident records for ABN/NOMNC documentation. Resident #56, who was discharged home on 9/19/2025, did not have 2025 ABN/NOMNC documentation in the medical record; the Admissions Director checked the electronic record and stated the only notice found was dated 2024 from a previous stay. Resident #58, a Medicare Part A recipient, also had no 2025 ABN/NOMNC documentation in the record for the stay/discharge reviewed. Resident #59, who was discharged home on 9/24/2025 and was a Medicare Part A recipient, likewise had no 2025 ABN/NOMNC documentation in the medical record. The Admissions Director stated the facility did not have an admission director at that time and that there was no 2025 NOMNC/ABN for these residents’ stays/discharges.
Failure to Provide Routine Diabetic Podiatry Care
Penalty
Summary
The facility failed to ensure diabetic foot care was provided for one resident who was cognitively intact and admitted with diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, difficulty walking, need for assistance with personal care, history of falling, gait and mobility abnormalities, and lack of coordination. The resident had an active order for podiatry services per consent and a charted consent for services through the facility’s contracted company. A podiatry note in the record showed an initial and routine foot care exam had been completed, and the contracted company’s report listed the resident as having received nail debridement and an initial visit for toenail fungus and generalized atherosclerosis. During interview, the resident stated she had asked several times to be seen by the podiatrist and believed staff told her she needed to be on the calendar to be seen. She reported her nails were getting very long and expressed concern because she was diabetic and needed regular foot care. When she removed her socks, her feet were observed to have a long, thickened toenail on the little toe of the left foot and long, unkempt toenails on all five toes of the right foot. She also stated that she had seen the podiatrist several months earlier, but staff could not tell her when the podiatrist would return or whether she was on the schedule. The DON reviewed the record and the contracted company’s census information and confirmed that the resident had been enrolled in podiatry services and had been seen previously, but had not received routine podiatry care since that visit. The DON stated the lack of follow-up was an oversight and acknowledged that, after the resident returned from a hospital stay and changed from skilled nursing to LTC status, the facility could not produce documentation showing a new consent or declination for services upon readmission.
Missing Oxygen Order and Care Plan Follow-Through
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for a resident with heart failure, a history of stroke with left-sided weakness, hypertension, hypothyroidism, COPD, diabetes, depression, and anxiety. The resident’s MDS showed mild cognitive decline with a BIMS score of 12/15 and that she needed assistance with all care. During a facility tour, the resident was observed lying in bed awake with an oxygen concentrator running at 3 liters per minute, and when asked if that was the normal setting, she said she did not know. When the nurse was asked about the resident’s oxygen, she looked at the concentrator and said she was not sure what the oxygen should be set at and would check the order. After reviewing the chart, she stated there was no oxygen order in the computer and said the resident was supposed to have oxygen but she was unsure why there was no order. A physician order for oxygen was later documented for respiratory distress, with oxygen to start at 2 L per minute via nasal cannula, recheck oxygen saturation as needed, and titrate oxygen to maintain saturation above 90%. The resident’s care plan already included interventions to check oxygen saturation and initiate oxygen as ordered.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for two of five CNA files reviewed, which also resulted in the lack of yearly education training. The facility’s Staffing Template policy stated that it was the facility’s policy to conduct, document, and annually review a facility-wide assessment that included staff, staffing plan, staff training/education, competencies, and education and training. The facility assessment also stated that annual CNA/Nurse skills training is performed by the Corporate Clinical Educator and that the educator assists, oversees training, and assesses annually and as needed. During interview and record review, Human Resource Staff B stated that annual employee performance evaluations and competencies are tracked through human resources and are to be completed by the DON and/or Clinical Care Coordinator E, then returned to human resources for tracking and upload into the employee file. Review of CNA G’s file showed a hire date of 10/12/2021 and a last documented annual performance/competency review dated 11/8/2024, with no 2025 evaluation found. Review of CNA/Medication Tech F’s file showed a hire date of 2/22/2002 and a last documented annual performance/competency review dated 8/13/2024, with no 2025 evaluation found. Staff B confirmed that no 2025 annual performance/competency evaluations were present for either employee and stated that reminders had been sent out, but no other documents were presented to the surveyor.
Failure to Maintain Annual CNA Training and Competency Documentation
Penalty
Summary
The facility failed to implement an effective in-service nurse aide training program that ensured continued compliance with the required 12 hours of annual education for nurse aides. Record review of the facility assessment dated 10/13/2025 showed the facility used computerized training with specialized lessons addressing Alzheimer's disease and communication strategies for residents with behavioral health needs, and stated that individualized training would assist with behavioral training and meaningful interventions. The facility staffing template policy dated 6/2019 stated that the facility would conduct, document, and annually review a facility-wide assessment, including staff training, education, and competencies. During the annual survey, the Human Resource staff member stated that the facility used a computerized staff training system to issue required training for CNAs to obtain the annual 12 hours of continuing education. However, review of CNA G's employee file showed a hire date of 10/12/2021 and the last documented annual performance/competency evaluation dated 11/8/2024, with recommendations to increase personalization and communication. No annual 2025 performance/competency evaluation was found in the file, and the Human Resource staff member confirmed there was no 2025 annual performance/competency evaluation for CNA G. No other education training documents were presented to the surveyor for this employee.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 135 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Huron Woods Nursing Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.