Average — CMS composite of the measures below.
The next survey window likely opens around March 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 North Woods Nursing Center during CMS and state inspections, most recent first.
Incomplete staff illness surveillance documentation was found when the DON and RCN confirmed that the Employee Surveillance Log, call-off notices, and Infection Control Maps did not consistently capture required details such as symptom onset, date last worked, and unit worked. Multiple staff illness events involving GI symptoms, respiratory symptoms, and RSV were missing from the log, entered late, or lacked key information, and the surveillance records were kept in separate locations rather than together.
Call Light Out of Reach: A resident with dementia, HTN, and DM2 had her call light repeatedly observed draped over a lamp shade on a table at the foot of the bed and out of reach while she was lying in bed. Her care plan stated she was able to use the call light for assistance.
Medication administration was not completed according to orders and nursing standards for several residents. A resident with cardiac conditions received midodrine outside ordered BP parameters, a resident with diabetes was given insulin glargine without proper pen preparation and injection technique, and two residents receiving Norco had MAR documentation problems involving a dose recorded as given without a corresponding controlled drug record and another dose left undocumented without explanation.
Pressure injury care and documentation were not completed as required for three residents. One resident with an open area to the buttocks had no documented RP or provider notification, no comprehensive wound assessment, and no clear record of dressing changes or reassessment before the treatment was discontinued as resolved. A second resident with a stage 2 pressure ulcer did not receive the required weekly wound measurement, and a third resident with MASD had a missed ordered treatment with no documented reason in the EMR.
The facility failed to maintain general cleanliness and repair of the premises. In the Nourishment room, the ice machine drain line had a whitish gel-like substance coming out of it, a 1-foot piece of coving was missing next to the ice machine, and the wall behind it had bubbling paint. In the Housekeeping/Mechanical closet, a 12-inch by 10-inch section of paint was chipping on the wall next to the mop sink.
Unsafe Wheelchair Transport: Surveyors observed staff propelling residents in wheelchairs without proper foot pedal use, including one resident transported without foot pedals and another with a foot behind the pedal. The NHA stated staff were to push residents with the foot pedals on and their feet on the pedals, and that transporting residents without their feet on the pedals was not safe practice.
Failure to change and store respiratory tubing per policy affected three residents receiving respiratory care. A resident with RSV had a disposable nebulizer mouthpiece and tubing left on the mattress and used beyond the weekly change date, while two residents with CHF/COPD-related conditions had oxygen tubing observed lying on the bed or wrapped around an E tank, not dated and not secured in a clean bag. The DON stated tubing not in use should be dated, changed weekly, and stored in a clean bag or receptacle.
The facility did not provide documentation showing that battery-powered emergency lighting was tested annually for 90 minutes and function tested monthly for 30 seconds, as required by NFPA standards. No records of these tests were available during the survey, and this was confirmed by the Director of Facilities.
Staff did not perform required 30-day inspections on portable fire extinguishers in multiple areas, including the attic, Therapy Storage room, and Boiler room, as confirmed by observation and interview with the Director of Facilities.
The facility failed to follow infection control practices during peri-care for two residents and medication preparation. CNAs used contaminated gloves to handle various items and did not sanitize surfaces after care. An RN dispensed medication without hand hygiene, handling pills with bare hands. These actions were against the facility's infection control practices.
The facility failed to obtain and document vital signs before administering medications for two residents. One resident with diabetes did not have blood sugar levels checked before receiving insulin, and another with hypertension did not have blood pressure assessed before receiving Bisoprolol. Staff interviews confirmed the lack of documentation, despite facility policy requiring vital signs to be taken when medication administration is contingent upon them.
A facility failed to timely report and investigate a witnessed incident of staff-to-resident abuse involving a resident with dementia and other conditions. The incident, where an RN was observed restraining a resident and making inappropriate comments, was not reported to the DON until 11 days later. During this time, the RN continued working, potentially exposing residents to further abuse. The delay in reporting and investigation led to a deficiency citation.
A facility failed to provide written notification and obtain consent for a room change for a resident with dementia and Alzheimer's, leading to potential emotional distress. The resident became upset and agitated when she attempted to return to her old room, resulting in an incident of aggression towards staff. The room change was due to incompatibility with her previous roommate, but there was no documentation of consent from the resident's POA or any issues with the previous roommate.
A resident with dementia and Alzheimer's was verbally and physically abused by an RN, who restrained the resident's arms and made derogatory comments. The incident was witnessed by multiple staff members, but the facility delayed reporting it to the state agency and allowed the RN to continue working. A skin assessment showed bruising on the resident's arms following the incident.
Incomplete Staff Illness Surveillance Documentation
Penalty
Summary
The facility failed to implement an effective and current system of surveillance for staff illnesses to identify possible communicable diseases and infections and prevent the spread of illness or outbreak. During interview, the DON stated that when an employee called off, the call-off notice was completed and sent to Human Resources, and if the absence was illness related, the Infection Control Preventionist reviewed it. The DON also stated that the Employee Surveillance Log was supposed to include all facility staff and document symptoms, onset date, date last worked, and unit worked, but the documentation reviewed did not consistently contain those details. Review of the 2026 Infection Control Binder showed that the March and April tabs contained only staff Call off Notice forms. The DON confirmed that the Infection Control Maps were kept in the ICP office rather than in the binder, and that the line list was printed from the charting system, meaning the required employee surveillance documentation was not accessible in one location. The March Infection Control Map was a floor plan with color coding for symptom categories, but it did not include dates of symptom onset, resident exposure, or the correlated staff member. The DON also confirmed that the map did not adequately identify the unit the staff member last worked. Review of March and April call-off notices and the Employee Surveillance Log showed multiple staff illness events that were missing required information. Several staff members with symptoms such as nausea, diarrhea, fever/chills, vomiting, congestion, cough, sore throat, body aches, headache, and RSV were not listed on the log at all or were added late. For many entries, the date of symptom onset, the date last worked, and the unit or department worked were not documented. One CNA with RSV was not added to the log until several days after the call-offs, and another staff member’s onset date was entered incorrectly. The facility assessment stated that infection surveillance would identify trends and types of infections for residents and staff, and the infection control policy required continuous collection and screening of data, but the reviewed records did not show a complete or timely surveillance system for staff illnesses.
Call Light Out of Reach
Penalty
Summary
The facility failed to ensure a resident's call light was within reach to accommodate her needs and preferences. Resident #60 was an elderly female with diagnoses including dementia, high blood pressure, and type 2 diabetes, and her care plan stated that she was able to utilize the call light for assistance. During multiple observations, the resident was lying in bed while her call light was draped over the shade of a small lamp on a table at the foot of the bed, out of her reach. This condition was observed on 4/06/26 at 12:03 PM and 1:03 PM, on 04/07/26 at 8:10 AM and 2:20 PM, and again on 04/08/26 at 8:24 AM.
Medication Administration and Documentation Errors
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and nursing professional standards of practice for 4 residents reviewed for medication administration. The report identified errors involving blood pressure parameters for midodrine, improper insulin glargine administration technique, and inaccurate documentation of controlled substance administration and withholding on the MAR. For one resident with atrial fibrillation, hypertension, and biventricular heart failure, midodrine 10 mg ordered three times daily with instructions to hold if systolic blood pressure was greater than 120 was administered multiple times outside the ordered parameters, including when blood pressures were above 120. The order was later changed to midodrine 5 mg three times daily with the same hold parameter, and the medication was documented as given when the resident’s blood pressure was 126/60. For another resident with type 2 diabetes mellitus with diabetic polyneuropathy, an RN prepared insulin glargine but did not prime the pen needle before injection and did not hold the pen against the skin for 10 seconds to ensure full delivery of the dose. For two residents receiving Norco for chronic pain, one resident’s 6:00 PM dose was documented as administered even though the controlled drug record showed no tablet was dispensed, and another resident’s 5:00 AM dose was left blank on the MAR with no documentation explaining that the dose was withheld.
Pressure injury care and documentation failures
Penalty
Summary
The facility failed to implement its pressure injury policy for three residents with skin breakdown. Resident #32, a female with muscle wasting and atrophy and a guardian/decision maker, was found with an open area to the right buttocks during personal care, and a treatment order was entered. However, the record did not show that the responsible party or practitioner was notified of the newly identified pressure injury, and there was no comprehensive wound assessment documenting the wound location, size, wound bed, exudate, odor, edges, peri-wound condition, tunneling/undermining, or pain. The physician communication book entry was not dated or initialed, and the resident’s EMR did not show documentation of dressing change dates or a reassessment documenting resolution before the treatment was discontinued as resolved. Resident #50, a female admitted with a diagnosis of pressure ulcer of the buttocks stage 2, did not have the required weekly wound measurement completed. The facility policy required pressure ulcers to be reassessed and measured at least weekly, but the last wound measurement in the record was completed on 3/30/26, and there was no documentation of a comprehensive wound assessment on 4/6/26. The Nursing Home Administrator confirmed the wound measurement had not been completed and stated the CCC was completing wound measurement currently. Resident #55, a female with cerebral palsy and muscle wasting and atrophy, had an order for MASD to the bilateral buttocks with zinc ointment to be applied every shift and as needed. The April treatment record showed the treatment was not completed on 4/1/26, and there was no documentation in the EMR explaining why it was missed. The Regional Clinical Nurse confirmed the treatment had not been documented as completed and reported the agency nurse believed another nurse had completed the treatment.
Premises Not Maintained in Clean and Repaired Condition
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises. During observation in the Nourishment room, the drain line for the ice machine had a whitish gel-like substance coming out of it, and the Dietary Manager stated that maintenance was responsible for cleaning and maintaining the ice machines. The Maintenance Supervisor later observed the same gel-like substance and stated that it had happened before after the ice machine had been cleaned and believed it might be the cleaning product interacting with minerals in the well water. In the same area, a 1-foot piece of coving was missing from the wall-floor juncture next to the ice machine, and paint was bubbling on the wall behind the ice machine, which the Maintenance Supervisor confirmed. In the Housekeeping/Mechanical closet on the main hall, a 12-inch by 10-inch section of paint was chipping on the wall about 3 feet off the floor next to the mop sink, and the Maintenance Supervisor confirmed the chipping paint.
Unsafe Wheelchair Transport
Penalty
Summary
The facility failed to safely transport residents in wheelchairs for 2 residents reviewed for accidents and hazards. Resident #7, a female admitted to the facility on [DATE], was observed on 04/06/2026 at 11:00 AM being propelled by CNA Q in her wheelchair without foot pedals from her room to the nurses' station. Resident #5, a male admitted to the facility on [DATE], was observed on 04/08/2026 at 8:13 AM being propelled by CNA L into his room with his left foot behind the foot pedal. During another observation on 04/07/2026 at 4:45 PM, while exiting the building with 2 other healthcare surveyors, a facility staff member was observed propelling a resident in a wheelchair down the 100 unit with her feet behind the foot pedals. During interview on 04/08/2026 at 12:39 PM, the NHA stated staff were to push residents in wheelchairs with the foot pedals on and with their feet on the foot pedals, and that pushing residents without their feet on the foot pedals was not safe practice. A copy of the facility's wheelchair safety/foot pedals policy was requested on 4/8/26 at 12:32 PM but was not received prior to survey exit.
Failure to change and store respiratory tubing per policy
Penalty
Summary
The facility failed to change and store respiratory equipment according to physician orders and facility policy for three residents receiving oxygen or nebulizer therapy. For Resident #42, who was admitted after a fall and had tested positive for RSV, a disposable nebulizer mouthpiece and tubing dated 03/23/26 were observed lying on the mattress next to the resident’s pillow with clear liquid still in the medication cup. The resident had an order for albuterol sulfate nebulization every 6 hours as needed for dyspnea, and the facility policy stated nebulizer tubing and delivery systems are changed weekly and as needed, which meant the tubing should have been changed on 03/30/26. The EMAR showed the resident received a nebulizer treatment using the disposable mouthpiece and tubing after that date. For Resident #52, who had diagnoses including CHF, COPD, and permanent atrial fibrillation, oxygen tubing was observed lying on the bed and not contained in a clean plastic bag while the oxygen concentrator was running. For Resident #73, who had diagnoses including chronic systolic CHF, atrial fibrillation, and anxiety, oxygen tubing not in use was wrapped around a portable oxygen tank, was not dated, and was not secured in a clean bag. The DON stated that oxygen tubing not in use is expected to be secured in a clean bag with the date written on the tubing and that oxygen tubing is dated and changed weekly. The facility policy for oxygen use and storage stated that cannulas and humidifier bottles are changed weekly and as needed, dated when changed, and stored in a receptacle when not in use.
Failure to Document Required Emergency Lighting Tests
Penalty
Summary
The facility failed to provide documentation that all battery-powered emergency lighting was tested annually for 90 minutes and function tested monthly for 30 seconds, as required by NFPA 101, 7.9.3.1.1. During a record review, no activity reports or documentation of these tests were available for surveyor review. These findings were confirmed through an interview with the Director of Facilities at the time of the record review. No information regarding specific patients, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K291 Emergency Lighting Element 1: Action taken to identify residents: No residents were identified. Element 2: Identification of other residents: All occupants could be affected in the event of an electrical power failure. Element 3: (1) Measures Taken: The Administrator or designee will conduct and document the needed annual 90-minute testing of the facility's battery-operated emergency lighting. Element 3: (2) Measures Taken: The Administrator or designee will conduct and document the needed monthly 30-second testing of the facility's battery-operated emergency lighting. Element 4: Monitoring: The Administrator or designee will compile a report of the battery-operated emergency lighting test for review and recommendations by the Quality Assurance Performance Improvement Committee monthly, three times, and periodically thereafter. The Administrator will assume responsibility for attained compliance.
Failure to Perform Required 30-Day Fire Extinguisher Inspections
Penalty
Summary
Facility staff failed to ensure that portable fire extinguishers were selected, installed, inspected, and maintained in accordance with NFPA 10 standards. On March 6, 2025, during an observation at approximately 12:23 PM, it was found that the fire extinguisher located in the attic space had not been checked at least every 30 days as required by NFPA 10, 7.2.1.2. Additionally, several other fire extinguishers throughout the facility, including those in the Therapy Storage room and two in the Boiler room, were also missing documentation of 30-day inspections. These findings were confirmed through an interview with the Director of Facilities at the time of observation.
Plan Of Correction
K355 Portable Fire Extinguishers Element 1: Action taken to identify residents: No residents were identified. Element 2: Identification of other residents: All occupants could be affected in the event of an electrical power failure. Element 3: Measures Taken: The Administrator or designee will add the attic fire extinguisher locations on the monthly fire extinguisher log. The Administrator will also verify that all the fire extinguishers are verified from the outside contracted annual fire sprinkler inspection that was performed on the facility fire extinguisher. Element 4: Monitoring: The Administrator or designee will compile a report of the monthly inspections of the fire extinguishers for review and recommendations by the Quality Assurance Performance Improvement Committee monthly, twice, and periodically thereafter. The Administrator will assume responsibility for attained compliance.
Infection Control Deficiencies in Peri-Care and Medication Preparation
Penalty
Summary
The facility failed to adhere to proper infection control practices during the provision of peri-care for two residents and while preparing medications for administration. For Resident #46, who has profound intellectual disabilities and is dependent on total assistance, certified nurse aides (CNAs) N and O were observed using two washcloths to clean the resident's genitalia and then placing them on the over-bed table without sanitizing it afterward. CNA N, after completing peri-care, did not remove contaminated gloves and proceeded to touch various items, including the broda chair, gait belt, the resident's clothing, and bed linens, and also handled the tube feed and abdominal binder with the same gloves. For Resident #2, who has spastic quadriplegic cerebral palsy and a history of urinary tract infections, CNA J used a washcloth to clean stool from the resident's bottom multiple times without changing gloves. CNA J then touched various items, including a cupboard and a bottle of baby powder, with the same contaminated gloves. Additionally, CNA J placed a packet of remedy protect zinc oxide in her pocket with contaminated gloves, which she later removed with bare hands. Furthermore, RN M was observed not performing hand hygiene while dispensing medication, handling pills with bare hands, and placing them into a medication cup for administration, which was against the facility's practice as confirmed by the Director of Nursing.
Failure to Document Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice by not obtaining and documenting vital signs prior to medication administration for two residents. Resident #6, a female with diabetes mellitus, had orders to receive Insulin Lispro with meals, contingent upon her blood sugar levels being above 110. However, on multiple occasions, her blood sugar was not assessed before the administration of insulin at 8:00 AM, as required. The Director of Nursing reported that the nurse responsible for administering the insulin documented the medication as given without proper blood sugar assessment, and there was no documentation explaining the lack of assessment on one occasion. Resident #51, a male with hypertension, was prescribed Bisoprolol Fumarate, which was to be held if his heart rate was below 60 or systolic blood pressure was below 90. The medication was to be administered at 8:00 AM and 4:00 PM, contingent upon these parameters. However, the resident's blood pressure was not assessed prior to the administration of the medication on several occasions, and the Medication Administration Record inaccurately reflected blood pressure readings that were not taken at the time of administration. The Nursing Home Administrator confirmed the absence of documentation for these missing assessments. Interviews with staff revealed that both CNAs and licensed nurses are responsible for obtaining vital signs, and the electronic medical record system prompts nurses to input these vital signs. Despite this, the facility's policy on medication administration, which requires vital signs to be taken if medication administration is contingent upon the results, was not followed. This led to the deficiency in professional standards of practice for medication administration.
Delayed Reporting and Investigation of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to timely report and investigate a witnessed incident of staff-to-resident abuse involving a resident with dementia, psychotic disturbance, mood disturbance, anxiety, claustrophobia, and Alzheimer's. The incident occurred when a Registered Nurse (RN) was observed holding the resident's wrists down in a wheelchair and making inappropriate comments. Despite the incident being witnessed by multiple staff members, it was not reported to the Director of Nursing (DON) until 11 days later. During this period, the RN continued to work several shifts, potentially exposing the resident and others to further abuse. Interviews revealed that a housekeeping staff member and an activities aide witnessed the incident but delayed reporting it due to uncertainty and reliance on the RN's assurance that he would inform the DON. The DON was informed of the incident on two separate occasions but did not report it to the State Agency until a second housekeeper expressed concerns about the RN's aggressive behavior. The facility eventually suspended the RN pending investigation, but the delay in reporting and investigating the abuse resulted in a deficiency citation.
Failure to Provide Written Notification and Consent for Room Change
Penalty
Summary
The facility failed to provide advanced written notification and obtain consent for a room change for a resident, resulting in potential emotional distress. The resident, who had been diagnosed with dementia, anxiety, and Alzheimer's, was moved from her original room without documented consent from her Power of Attorney (POA). The resident became upset and agitated when she attempted to return to her old room, leading to an incident where she was verbally and physically aggressive with staff. Despite attempts to redirect her, the resident only calmed down after being moved to a different area and given medication. Interviews with facility staff revealed that the resident's room change was due to incompatibility with her previous roommate, although there were no documented altercations between them. The Social Worker claimed to have informed the POA about the room change but could not find any documentation to support this. The lack of documentation and consent for the room change highlights the facility's failure to honor the resident's rights, as there was no evidence of any issues with the resident's previous roommate in the electronic medical record.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse by staff. The incident involved a registered nurse (RN) who was reported to have restrained a resident's arms and made derogatory comments. The resident, who had a history of dementia, Alzheimer's, and anxiety, was admitted to the facility with these diagnoses. On the evening of the incident, the resident was upset about a room change and became verbally and physically aggressive. Multiple staff members witnessed the RN restraining the resident and making inappropriate comments, but the incident was not reported immediately. The facility's investigation revealed that the RN continued to work several shifts after the incident before being suspended. Witnesses reported that the RN held the resident's wrists down and made statements indicating frustration with the resident's behavior. The resident was visibly upset, screaming, and crying during the incident. A skin assessment conducted the day after the incident showed bruising on the resident's upper extremities, which was attributed to a recent behavioral episode. The facility's policy on abuse reporting was not followed, as the incident was not reported to the state agency until several days later. The delay in reporting and the failure to immediately suspend the RN after the initial report of abuse were significant factors in the deficiency. The facility's policy requires immediate reporting of abuse allegations, but in this case, the report was delayed, and the RN continued to work with residents during the investigation period.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Farwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Clare | 7.7 mi | ★★★★★ | 5 | 0 |
| Medilodge Of Mt. Pleasant | 18.7 mi | ★★★★★ | 6 | 0 |
| The Laurels Of Mt. Pleasant | 19.2 mi | ★★★★★ | 2 | 0 |
| Isabella County Medical Care Facility | 19.2 mi | ★★★★★ | 8 | 0 |
| Gladwin Pines Nursing And Rehabilitation Center | 21.8 mi | ★★★★★ | 16 | 0 |
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