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 Marwood Manor Nursing Home during CMS and state inspections, most recent first.
A resident with end stage kidney disease, stroke, and diabetes received Plavix, Furosemide, and Lokelma together on dialysis days, contrary to manufacturer guidance that Plavix and other oral medications should be separated from Lokelma by at least two hours. An LPN administered these medications together multiple times weekly, and the consultant pharmacist's monthly reviews did not identify the issue, resulting in a failure to ensure accurate medication regimen review and administration.
A resident with cognitive impairment was injured when transported in a wheelchair without foot pedals, resulting in a right fibula fracture. The CNA, familiar with the resident's behavior, attempted to calm them by taking them to see ducks, but the resident refused foot pedals and placed their foot on the ground during transport. The facility's policy requires foot pedals for wheelchair transport, which was not adhered to in this case.
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific needs. One resident with Alzheimer's lacked a hospice care plan, while two others with behavioral issues had no plans to manage their agitation. Another resident's use of a pommel cushion was not care planned, and a resident with COPD had inconsistencies in oxygen and CPAP use not reflected in their care plan. The facility's policy requires comprehensive care plans, which were not followed.
The facility failed to properly date and label medications in four of seven medication carts, and three of 14 carts were found unlocked and unattended. Medications such as latanoprost and dorzolamide eye droppers, and a Trelegy inhaler lacked proper dating and resident identifiers. Staff acknowledged these issues, and the DON confirmed the expectation for secure storage of medications.
The facility failed to secure residents' personal information on medication cart computers, leaving them unattended and visible on multiple occasions. Despite the policy requiring computers to be locked or logged off, staff did not consistently adhere to this protocol, as confirmed by interviews with LPNs and the DON.
A resident with COPD and dementia was observed using oxygen via nasal cannula during the day without a physician order. Facility staff, including a nurse and the DON, confirmed the absence of an order, despite believing one existed. The facility's policy requires a physician order for oxygen therapy, which was not followed, resulting in a deficiency.
A resident with intact cognition and multiple diagnoses, including weakness and osteoarthritis, did not receive restorative services as per their care plan. Despite an active order and a detailed care plan, the last service was recorded over a month prior, and the maintenance plan was not implemented. The Restorative Coordinator admitted to not knowing the current services provided and confirmed the care plan was outdated and lacked progress notes.
Failure to Ensure Accurate Medication Regimen Review and Administration
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs by not conducting accurate Medication Regimen Reviews (MRR), not administering medications correctly, and not providing adequate medication monitoring. Specifically, a Licensed Practical Nurse (LPN) was observed administering Plavix, Furosemide, and Lokelma together to a resident on a dialysis day, without regard to manufacturer guidance that Plavix and other oral medications should be given at least two hours before or after Lokelma. The manufacturer's prescribing information for Lokelma indicates that co-administration can reduce the effectiveness of Plavix and increase systemic exposure to certain drugs like Furosemide, and that Lokelma contains sodium, which may cause edema. The resident involved had diagnoses of End Stage Kidney Disease, Stroke, and Diabetes, and had been receiving Plavix and Lokelma since November 2024. Medication Administration Records showed that Plavix and Lokelma were administered together three to four times weekly over several months. The consultant pharmacist's monthly reviews from January through July 2025 did not identify any concerns, and the facility's policies required medications to be administered according to professional standards and manufacturer specifications. Despite these requirements, the medication administration and review processes failed to identify or address the inappropriate timing of these medications.
Failure to Ensure Safe Wheelchair Transport Results in Resident Injury
Penalty
Summary
The facility failed to ensure the safe transport of a resident, identified as R42, in a wheelchair, which resulted in a fracture of the right fibula. The incident occurred when R42, who has severely impaired cognition, was being transported without foot pedals on the wheelchair. Despite the resident's cognitive impairment, they refused the use of foot pedals, and the CNA proceeded to push the wheelchair without them. During the transport, R42 placed their foot on the ground, leading to the injury. R42's medical records indicate that they were admitted with a diagnosis of a fracture of the upper and lower end of the right fibula. On the day of the incident, R42 was observed with a gray orthopedic boot on their right leg. The resident's care plan noted their poor awareness of personal space and their preference for activities that do not involve demanding cognitive tasks. The CNA, familiar with R42's behavior, attempted to calm the resident by taking them to see ducks, a known calming activity for R42. The facility's policy on transporting residents in wheelchairs requires the use of foot pedals unless the resident chooses to self-propel. However, R42's cognitive impairment raises questions about their ability to make such decisions. The Director of Nursing acknowledged that the CNA could have re-approached the situation differently, suggesting that the resident could have been asked to self-propel instead. The incident highlights a lapse in adhering to the facility's policy and ensuring the resident's safety during transport.
Removal Plan
- The care plan for the resident was reviewed and updated to include approaches for staff to use in response to any reluctance to use the foot pedals.
- A building wide audit was completed to identify all other residents without foot pedals. Foot pedals were issued and will be used for all residents when being transported in a wheelchair outside their room.
- Care plans for residents were reviewed and revised to reflect use of foot pedals and wheelchair locomotion.
- The policy Transporting Residents in Wheelchairs was reviewed and identifies that any resident being transported in a wheelchair outside their room will require the use of foot supports/pedals.
- Education done with all staff regarding the policy, transportation expectations and response to refusals.
- Ongoing monitoring of compliance will be completed through audits to assure compliance.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plan interventions for five residents, leading to deficiencies in addressing their specific needs. Resident R78, who was admitted with chronic kidney disease and Alzheimer's disease, was observed becoming agitated in the dining room. Despite being on hospice care, there was no active care plan for managing R78's hospice needs. Similarly, Resident R130, with chronic respiratory failure, depression, and anxiety disorder, exhibited increased behaviors and agitation, yet lacked a care plan to manage these issues. Resident R145, diagnosed with hypertension, gastrostomy malfunction, major depressive disorder, and anxiety disorder, was observed refusing food and exhibiting increased behaviors. However, there was no care plan in place to address these behaviors. The social worker confirmed the absence of behavior care plans for R130 and R145, and the Director of Nursing acknowledged the expectation for such plans to be in place. Resident R149, with hemiplegia and hemiparesis following a stroke, used a pommel cushion in their wheelchair, but this was not included in their care plan, as confirmed by the Director of Nursing. Resident R153, with unspecified dementia and chronic obstructive pulmonary disease, was observed with inconsistencies in oxygen and CPAP use. Despite having orders for CPAP and oxygen use, these were not reflected in the care plan. The registered nurse and unit manager confirmed the lack of a documented order for daytime oxygen use, highlighting a gap in the care plan. The facility's policy mandates comprehensive care plans to meet residents' medical, nursing, and psychosocial needs, which were not adhered to in these cases.
Medication Management and Security Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly dated and labeled with a resident identifier when opened, as observed in four of seven medication carts. Specifically, a latanoprost eye dropper vial was not dated when opened, and a dorzolamide eye dropper vial was also not dated. Additionally, a Trelegy inhaler was found without a date or resident identifier. These observations were made during interactions with various nursing staff, who acknowledged the discrepancies. The facility's policy requires that expiration dates be documented on medication containers, and multi-dose vials should be labeled for single-patient use. Furthermore, the facility did not secure medication carts properly, as three of the 14 medication carts were found unlocked and unattended. This was observed on multiple occasions, with staff acknowledging the expectation that medication carts should be locked when unattended. The Director of Nursing confirmed that the facility's policy mandates that all medications be stored securely, including locking medication carts when not in use. These lapses in medication management and security were identified through direct observation and staff interviews.
Failure to Secure Resident Information on Medication Carts
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical information, as observed on multiple occasions. On several instances, medication carts with computers displaying residents' personal information were left unattended. This occurred outside various room numbers, with the computer screens unlocked and visible to anyone passing by. Additionally, a piece of paper containing a resident's personal information was found on top of one of the medication carts. Interviews with staff, including LPNs and the Director of Nursing (DON), revealed that the expectation was for computers to be locked or logged off when unattended to comply with HIPAA regulations. Despite the facility's policy requiring users to log off or lock computers when leaving a workstation, staff members were observed not adhering to this protocol. LPN A mentioned that staff should log off or close laptops when stepping away, while LPN B acknowledged that leaving computers unlocked was not typical practice. The DON confirmed that the expectation was for computers to be closed to prevent unauthorized access to resident information. These observations and interviews indicate a failure to consistently implement the facility's policy on securing personal information, leading to the deficiency.
Lack of Physician Order for Daytime Oxygen Use
Penalty
Summary
The facility failed to obtain a physician order for oxygen administration for a resident with chronic obstructive pulmonary disease and unspecified dementia. The resident was observed using a continuous positive airway pressure (CPAP) machine at night and wearing oxygen via nasal cannula during the day. However, there was no physician order for the daytime oxygen use. The resident's medical records indicated an active order for oxygen at two liters when the CPAP was in use, but no orders for oxygen via nasal cannula during the day were found. Interviews with facility staff, including a registered nurse, the Director of Nursing, and a unit manager, confirmed the absence of a physician order for daytime oxygen use. The staff believed there was an order, but upon review, it was discovered that no such order existed. The facility's policy requires a physician order for oxygen therapy, which was not adhered to in this case, leading to the deficiency.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide necessary restorative services to a resident, identified as R139, to maintain or improve their range of motion and mobility. The resident, who was admitted with diagnoses including urinary tract infection, weakness, and a need for assistance with personal care, had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognition. Despite an active order for restorative nursing services dated 6/4/24 and a care plan initiated on 4/1/2024, which included specific exercises for the resident, the last recorded restorative service was on 5/30/24. The resident reported feeling stiffer and expressed concern about losing joint function due to the lack of therapy services. Interviews with the Restorative Coordinator (RC J) revealed that the resident was supposed to receive restorative care after physical therapy services ended, but the maintenance plan due to start on 6/18/24 had not been implemented. RC J admitted to not knowing the current services being provided to the resident and confirmed that the care plan was outdated and lacked progress notes. The facility's policy on Restorative Nursing Services mandates that residents receive necessary care to maintain their highest practicable physical, mental, and psychosocial well-being, but this was not adhered to in the case of R139.
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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 Port Huron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Port Huron | 8.1 mi | ★★★★★ | 0 | 0 |
| Regency On The Lake - Fort Gratiot | 8.1 mi | ★★★★★ | 0 | 0 |
| Medilodge Of St. Clair | 12.2 mi | ★★★★★ | 16 | 0 |
| Medilodge Of Richmond | 19.6 mi | ★★★★★ | 1 | 0 |
| Medilodge Of Yale | 21.5 mi | ★★★★★ | 0 | 0 |
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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.