Huron Woods Nursing Center: X-Ray Never Done - MI
By the time anyone sorted out what had happened, the resident, identified in inspection records only as R1, had already been discharged to a hospital for other reasons. The chest x-ray that the family had requested, that a nurse had attempted to order, that a radiology company had apparently received, existed only as an entry in a portal with no results attached to it.
State inspectors documented the failure during a complaint inspection at Huron Woods on May 27, 2026.
The breakdown involved two separate systems that, at the time, didn't talk to each other cleanly. Nurses had to enter orders into Point Click Care, the facility's internal records platform, and then separately enter the same order into the All-Stat portal used by the outside radiology company. According to the Director of Nursing, a nurse placed the order in the facility system but failed to complete the entry on the All-Stat side. The DON described it plainly: "I know there was an issue with us placing orders and receiving faxes. I believe there is a communication gap between us and All-Stat."
The DON said the systems have since been integrated, but that integration wasn't in place when R1's family made their request.
RN D, who spoke with inspectors the afternoon of May 27, said she believed she placed the order on January 16, 2026, after speaking directly with All-Stat. She said the technician told her they would send the order out and then call back with an approximate arrival time. That call never came before her shift ended. She did not follow up.
RN D said she had assessed R1's lung sounds that day and found them clear but diminished. She described her standard process for handling family care requests: check the resident's code status, do an assessment, notify the physician, get orders, then call the family back. Whether she notified a physician about the family's request is not addressed in the inspection record.
LPN H, interviewed fourteen minutes after RN D, offered a different account of her own role. She said that when a family requests something without a clear clinical indication, her practice is to contact the on-call person and give them a report. She believed the on-call person told her they would contact the family's daughter the following day. She also said she could have left a note in the communications book for the doctor to follow up on their next visit. She could not remember whether she had done that.
"Whether or not I did that I cannot remember," LPN H told inspectors.
The All-Stat portal, reviewed during the inspection, showed that a chest x-ray order for R1 had been entered with a service date of January 17, 2026. No results were attached to it. The x-ray was never completed.
The DON confirmed that no other chest x-ray orders had been placed through All-Stat for R1 prior to that date. The order on January 17 was the only one, and by that point, R1 was already gone.
What the family's request was based on, what symptoms or concerns prompted them to ask for the x-ray in the first place, and what ultimately happened to R1 after hospitalization are not detailed in the inspection record. What the record shows is a gap between what a family asked for and what the facility delivered, stretched across at least two days, involving at least two nurses, one outside vendor, two software systems, and no completed diagnostic result.
The DON, asked directly whether the nurse should have notified the practitioner when the family made the request, said yes: "Typically, if a family is requesting some care we would notify the practitioner and go off their recommendations."
That notification, if it happened, produced no order until January 17. The order produced no x-ray. The x-ray produced no results. And R1 was already in the hospital.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Huron Woods Nursing Center from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 12, 2026 · Our methodology
Huron Woods Nursing Center in Kawkawlin, MI was cited for violations during a health inspection on May 27, 2026.
State inspectors documented the failure during a complaint inspection at Huron Woods on May 27, 2026.
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.