Huron Woods Nursing Center

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent facility-acquired pressure ulcer/skin injuries for two residents (Resident #103, Resident #105) of 3 residents reviewed, resulting in the development of bilateral heel ulcers/injuries for both Resident #103 and Resident #105 with the verbalization of pain and frustration regarding care.

Inspectors wroteThis citation pertains to intake Number 2796974. Based on interview and record review, the facility failed to implement physician's orders for one resident (Resident #1) of three residents reviewed, resulting in a chest x-ray not being performed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents' Advanced Directives' code status was documented and accessible in the medical record for 2 residents (Resident #3 and Resident #5) of 8 residents reviewed for Advanced Directives. Findings Include: Resident #3 (R3):A record review of R3's [NAME] Data Set assessment (MDS) dated [DATE] revealed a brief interview mental status (BIM's) score of 11 of 15, which indicated R3 was moderately cognitively impaired. R53 was admitted to skilled nursing on [DATE] with diagnoses of Inflammatory disorder of scrotum, diabetes mellitus type 2, chronic atrial fibrillation (irregular heartbeat), malignant neoplasm of left main bronchus (left lung cancer), need for assistance with personal care and spinal stenosis of cervical and lumbosacral regions. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate notice of non-coverage and maintain documentation for three residents (#56, #58, #59) of five residents reviewed, resulting in the lack of full disclosure related to Medicare rights and the inability to appeal the discharge in the time frame allotted by Medicare.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that diabetic foot care was provided for one resident (R34) of one resident reviewed for ancillary services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that oxygen was ordered, and care planned for 1 resident (Resident #9) of 2 residents reviewed for respiratory care. Findings Include: Resident #9: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #9 was admitted to the facility on [DATE] with diagnoses: Heart failure, history of a stroke, left side weakness, hypertension, hypothyroidism, COPD, diabetes, depression and anxiety. The MDS assessment dated [DATE] revealed the resident had mild cognitive decline with a Brief Interview for Mental Status/BIMS score of 12/15 and needed assistance with all care. On 2/17/2026 at 3:39 PM, during a tour of the facility Resident #9 was observed lying in bed awake, an oxygen concentrator was running with oxygen set at 3 liters per minute. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that Certified Nursing Assistants (CNA) yearly performance reviews were conducted for two of five CNA's reviewed, resulting in the lack of yearly education training.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective in-service nurse aide training program, that ensured continued compliance with educational training of 12 hours required annually for aides employed at the facility for 1 of 5 certified nursing assistants (CNA) resulting in continued non-compliance.

Inspectors wroteThis Citation Pertains to Intake 1341963. Based on interview and record review, the facility failed to implement and operationalize policies and procedures to ensure physician supervision of medical care for one (#701) of one resident reviewed, resulting in lack of physician and/or advanced practice Health Care Provider (HCP) assessment and treatment of an alteration in skin integrity.

Inspectors wroteThis Citation Pertains to Intake Number MI00153102. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure safe transfer utilizing a mechanical lift (device to move a dependent individual from one surface to another) and ensure planned interventions were in place for fall prevention, for one resident (#701) of three residents reviewed, resulting in Resident #701 experiencing a fall during a mechanical lift transfer resulting in an intraventricular hemorrhage (IVH- bleeding into the ventricles of the brain).

Inspectors wroteThis citation pertains to Intake Number MI00150598. Based on observation, interview and record review, the facility failed to prevent repeated falls for one resident (Resident #101) of 4 sampled residents, resulting in Resident #101 sustaining repeated falls from her wheelchair

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to ensure a clean and sanitary ice machine and 2) Failed to ensure safe service and holding food temperatures during a breakfast meal for all residents who consumed food, resulting in unsafe serving food temperatures with the likelihood of continued unsafe temperature food service.

Inspectors wroteBased on interview and record review, the facility failed to respond to residents' needs timely and in a dignified manner for an anonymous group of residents, resulting in feelings of having to wait, needing to engage call lights over again to get help and call light complaints going unresolved by management.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignified Activities of Daily Living (ADL) care for one resident (Resident #6) of 3 residents reviewed for ADL care, resulting in soiled clothing, bedding and bathroom.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely assessment and implementation of interventions for pressure ulcer prevention for one resident (Resident #5) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and operationalize a comprehensive Restorative Nursing Program (RNP) for two residents (Resident #15 and Resident #30) of three residents reviewed, resulting in a lack of communication and implementation of planned RNP per Therapy recommendations, Resident #15's verbalization of increased pain and decreased Range of Motion (ROM), and Resident #30 developing a contracture (permanent tightening of muscles, tendons, skin, and tissues causing stiff and immobile joints), and the potential for further functional decline, diminished mobility, and unnecessary, increased pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the availability and provision of fluids to maintain appropriate hydration for one resident (Resident #5) of three residents reviewed, resulting in Resident #5 not having fluids available and verbalizations of thirst.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a thyroid hormone medication was given appropriately for one resident (Resident #14) of five residents reviewed for unnecessary medications, resulting in abnormal lab values and complaints of signs and symptoms of hypothyroidism.

Inspectors wroteBased on interview and record review, the facility failed to implement an infection control program including comprehensive outcome surveillance, including monitoring of initial infection signs/symptoms and ongoing surveillance and monitoring of potential infections, resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the likelihood for spread of microorganisms and illness for all 47 facility residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision to prevent falls and implement meaningful interventions for three residents (Residents #16, Resident #36, Resident #46), resulting in injuries, pain, and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clean heater vents and windows free of dirty buildup, spider webs and cobwebs for multiple rooms, resulting in dirty buildups on heater vents above residents' beds and dirty windows.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow and create a person-centered comprehensive care plan, for one resident (Resident #16), resulting in an unkempt appearance and undocumented showers.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the development of facility-acquired Stage II pressure ulcers for three resident (Residents #9, Resident #13, Resident #33) while residing at the facility, resulting in Resident #9 acquiring a pressure ulcer of the right/left buttocks , Resident #13 acquiring a pressure ulcer of the upper back, and Resident #33 acquiring a Stage II pressure ulcer of the coccyx with the likelihood for pain and discomfort and prolonged illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe medication storage and that narcotic reconciliation was completed for Medication Cart #1 and ensure that expired insulins were disposed of, resulting in an unlocked medication cart and unreconciled narcotics with likelihood of expired insulin use, narcotic diversion and medication theft or misuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide and document Activities of Daily Living (ADL) care for two residents (Residents #16 and Resident #25), resulting in an unkept appearance and lack of personal hygiene, and a possible decrease in mood.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the provision of daily care for one resident (Resident #15) of one resident reviewed, resulting in a lack of concise and accurate shower documentation, Resident #15's hair having a greasy appearance, and feelings of shame and embarrassment utilizing the reasonable person concept.

Inspectors wroteBased on observation, interview and record review, the facility failed to offer activities per care plan for one resident (Resident #25), resulting in unkempt nails with the likelihood of increased behaviors, boredom and overall decreased wellbeing.

Inspectors wroteBased on interview and record review, the failed to prevent the development of facility-acquired Urinary Tract Infections (UTI) for two residents (Resident #9, Resident #16), resulting in the likelihood for bladder/kidney injury and/or antibiotic drug resistant organisms (MDRO's).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure supervision with dining and ongoing assessment, monitoring, and documentation/implementation of interventions and recommendations of nutritional needs for two residents (Resident #13 and Resident #15) of three residents reviewed, resulting in a lack of appropriate positioning and supervision when eating, a lack of implementation of Speech Therapy (ST) recommendations for swallowing/eating for Resident #15, a lack of documentation and timely identification/revision of nutritional interventions to prevent significant weight loss for Resident #13, and the likelihood for ongoing weight loss, choking, and a decline in overall health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly administer 3 inhalers for one resident (Resident #41), resulting in only 1 puff of Albuterol given and not waiting the proper time in between the 3 inhaled medications with the likelihood of decreased efficacy of the medications.