Mackinac Straits LTC: Resident Broke Femur in Van - MI
The woman, identified in inspection records as Resident 10, was transported in the facility van on October 1, 2025. At some point during that trip, she sustained a fracture to her left femur. Three days later, on October 4, she underwent surgical repair. During the procedure, she received three units of blood. She spent time in the intensive care unit at an acute care hospital before returning to the facility on October 8.
A nurse called the hospital the morning after surgery to check on her. The progress note from that call, timestamped October 5 at 10:26 a.m., recorded that she was still in the ICU.
The nursing home administrator told inspectors on October 15 that he already knew, before they arrived, that Resident 10 had not been secured with a safety belt during the transport. The facility's own investigation had turned up the reason: her wheelchair was not rated for use in the van, and staff had been unable to find a belt or harness that would fit it. So they transported her anyway.
When inspectors asked for documentation showing that the certified nursing assistant and the transport aide involved had been trained on how to transport residents in wheelchairs, the administrator said he could not provide it. The training records did not exist, or could not be found, or both.
The facility's own written policy, updated October 2, 2025, three days after the incident that sent Resident 10 to the hospital, states that every resident will be secured with a seatbelt or with wheelchair tie-downs and a wheelchair seatbelt, and that no resident will be transported in the facility van if her wheelchair cannot be safely secured. The policy the facility wrote after the fracture describes exactly what the facility failed to do before it.
By the time inspectors completed their visit, the administrator said the facility had ordered four new wheelchairs for use during transport and planned to train all transport staff and require them to demonstrate competency once the chairs arrived. He also said the facility had stopped transporting wheelchair-bound residents in the van entirely until that training happened.
Federal inspectors cited the violation at the "actual harm" level, meaning the failure caused real injury to a real person, not a theoretical risk. Few residents were affected, according to the citation, but the one who was affected had surgery, a blood transfusion, and days in an intensive care unit.
What the inspection record does not answer is how long the facility had been transporting residents in wheelchairs that weren't rated for the van, or whether staff had ever raised concerns about the fit of the equipment before October 1. It does not say whether anyone checked the wheelchair's compatibility with the van before that trip, or whether the absence of a usable seatbelt was noticed and set aside, or simply never noticed at all.
Resident 10 was back at the facility by October 8. She had been in the ICU six days earlier.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mackinac Straits Long Term Care Unit from 2025-10-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 2026 · Our methodology
Mackinac Straits Long Term Care Unit in St. Ignace, MI was cited for violations during a health inspection on October 15, 2025.
The woman, identified in inspection records as Resident 10, was transported in the facility van on October 1, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.