Huron Woods Nursing Center

In the surveyor’s words

From the most serious findings on record at Huron Woods Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 28, 2026

  Based 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. Findings include: Resident #103: Record review of Resident #103's Minimum Data Set (MDS) dated [DATE] revealed a female resident with a Brief Interview of Mental status (BIMS) score of 15 out of 15, cognitively intact and able to make her own medical decisions. Medical diagnoses included: hypertension, renal insufficiency, neurogenic bladder, diabetes, thyroid disorder, paraplegia and quadriplegia, and others. […]

• Actual harm, isolatedF689May 22, 2025

  This 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). Findings include: Resident #701 Review of intake documentation revealed a concern that Resident #701 had a fall with head injury while being transferred with a mechanical lift. […]

• Actual harm, isolatedF689Nov 30, 2023

  Based 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 . Findings include: Record review of the facility 'Accident/Incident Report Fall management' policy, dated 6/2018, revealed the purpose was to establish a standard of accident/incident completion and to evaluate the facility responsibility to make every effort to decrease the likelihood of a recurrence by investigating incidents, understand how they occur and applying appropriate action. Record review of the facility provided form CMS-802 MDS Resident Matrix, dated 11/28/2023, revealed a census of 47. […]

• No harm, potential for more than minimal, widespreadF812Feb 19, 2026

  Based 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. Findings include: On 02/18/2026 at 8:44am during the initial kitchen tour with Corporate Dietician F observed the drain line to the ice machine sitting directly in the drain. According to the 2022 Food Code, 5-202.13 Backflow Prevention, Air Gap, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch).On 02/18/2026 at 12:25pm during lunch observation, observed a tray with purees individually… […]

• No harm, potential for more than minimal, widespreadF812Nov 21, 2024

  Based 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. Findings include: On 11/20/24, at 8:00 AM, an observation of the back dining room revealed the breakfast meal was already in the warmer. […]