Canal View - Houghton County
Government - County
197 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
28/100
#269 of 422 in MI
Photo by Richard DeLacy
Photo by Richard DeLacy
Photo by Bradley Leffler
1 / 5 photos
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Canal View in Hancock, Michigan, has a Trust Grade of F, indicating significant concerns about the quality of care provided, which places it in the poor category. It ranks #269 out of 422 facilities in Michigan, placing it in the bottom half of all nursing homes in the state, but it is #2 out of 4 in Houghton County, meaning there is only one local option that is better. The facility is showing an improving trend, having reduced its number of issues from 10 in 2023 to 5 in 2024. Staffing is a strong point, rated 5 out of 5 stars, with a 45% turnover rate that is on par with the state average, suggesting that staff are relatively stable and familiar with residents' needs. However, there are serious concerns, including a critical incident where a resident with severe cognitive impairment exited the building unsupervised, and another case where a resident suffered a leg fracture due to improper transfer procedures. Additionally, one resident developed a stage 3 pressure injury due to inadequate treatment, highlighting ongoing issues with care quality.
- Trust Score
- F
- In Michigan
- #269/422
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 45% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $39,988 in fines. Lower than most Michigan facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 70 minutes of Registered Nurse (RN) attention daily — more than 97% of Michigan nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 17 deficiencies on record. Higher than average. Multiple issues found across inspections.
28/100
Bottom 37%
Review needed
10 → 5 violations
★★☆☆☆
2.0
Overall Rating
★★★★★
5.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 10 issues
2024: 5 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Michigan average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 45%
Near Michigan avg (46%)
Higher turnover may affect care consistency
Federal Fines: $39,988
Above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 17 deficiencies on record
1 life-threatening 2 actual harm
Nov 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that appropriate interventions were in place to prevent a bu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that appropriate interventions were in place to prevent a burn for one Resident #70 (R70) of ten residents reviewed for burns resulting in the potential for further burns, pain and disfigurement.
Findings include:
Resident #70 (R70)
Review of R70's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 7/20/20, with active diagnoses that included: coronary artery disease, hypertension, heart failure, diabetes mellitus, and anxiety disorder. R70 scored a 7 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment.
Review of facility incident notes, read in part . per video review of the day 10/25/24 .R70 was seating in the dining tower for supper. R70 was observed picking up a bowl from the table and holding it over her chest while spooning something into her mouth. R70 puts the spoon and bowl back on the table and began to fan the clothing protector that was on [R70's] chest .A copy of the supper meal ticket that day was reviewed, and tomato soup was on the menu .Certified Nurses Aide (CNA) .recalls serving soup to [R70].
Review of facility document titled Hot Food Temperature Log dated 10/2024, read in part . (10/25/24) food item tomato soup .temp 188 degrees Fahrenheit.
Review of R70's Incident report dated 10/25/24 revealed [R70] was unable to rate pain, but does state there is some there . Other info .Hot beverage -spillage.
Review of R70's Hot liquid assessment dated [DATE], read in part . There exists a high probability to cause the resident to spill a liquid every time a resident handles a hot liquid, the resident is deemed at high risk with hot liquids .Resident is at high risk for liquid spills due to .muscle weakness . [Resident} is not safe to have hot liquids without a lid
Review of R70's care plan did not reveal any intervention to prevent further burns from hot soup.
During an interview on 11/19/24 at 10:04 a.m., R70 touched her chest and stated that is where my burn was .
During an interview on 11/20/24 at 1:38 p.m., the Nursing Home Administrator (NHA) acknowledged that R70 received a burn from hot soup.
During an interview on 12/20/24 at approximately 3:15 p.m., the Director of Nursing (DON) stated, I have not considered safety related to hot soup as the hot liquid assessment was only for drinks.
Review of facility policy titled Hot Liquids Policy last revised 5/2024, read in part . Residents will be assessed for management of hot liquids to determine risk for hot liquid spills .the facility's hot liquid assessment addresses lid use on hot liquids .lids should be placed on hot liquids .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide adequate pain management for one Resident (#30) of two residents reviewed for pain management resulting in R30 experi...
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Based on observation, interview, and record review, the facility failed to provide adequate pain management for one Resident (#30) of two residents reviewed for pain management resulting in R30 experiencing uncontrolled pain during a routine dressing change. Findings include:
Resident 30 (R30)
Review of R30's face sheet revealed the following diagnosis: low back pain.
Review of R30's Minimum Data Set (MDS) assessment, dated 9/4/24, revealed a Brief Interview for Mental Status (BIMS) assessment of 9 (0-15) indicating moderately impaired cognition. R30 had no rejections of care, was dependent on staff for all cares except substantial/maximal assistance for upper body dressing, and had an unhealed pressure ulcer, not present on admission.
Review of R30's Electronic Medication Administration Record (EMAR), revealed the following, Morphine Sulfate (concentrate) Oral Solution 20 MG/ML (milligrams per milliliters) Give 0.25 ml by mouth every 2 hours as needed for pain . (5 mg) .
Review of R30's Treatment Administration Record (TAR), revealed the following, Pressure injuries to coccyx: Cleanse ., pat dry, apply (brand name dressing) to wound bed after moistening with NS (normal saline), then apply 4 x 4 (brand name) dressing. Check daily on every shift and change if there is ANY exudate shadow. Change on shower day, also, (Tuesday am) . R30 was receiving daily dressing changes.
On 11/19/24 at 11:07 AM, an observation was made of R30 receiving a dressing change. R30 was observed to be crying out, Ow, Ow, Ow, (repeatedly) .I can't do it .I want my son .
Review of R30's MAR, dated 9/26/24 through 11/18/24, revealed no documentation of medication being provided prior to receiving dressing changes on the following dates:
a.)
September 28th and 29th,
b.)
October 1st, 2nd, 3rd, 4th, 9th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, 18th, 20th, 23rd, 25th, 26th, 27th, and 28th,
c.)
November 3rd, 6th, 8th, 9th, 11th, 15th, 17th, and 18th.
Review of R30's care plan, dated 9/10/24, read in part, .I have pain related to my osteoarthritis, coccyx wound .I will not have an interruption in normal activities due to pain through the review date .Evaluate the effectiveness of pain interventions Review for compliance, alleviating of symptoms, dosing schedules and my satisfaction with results, impact on functional ability and impact on cognition .Monitor/record/report to Nurse my complaints of pain or requests for pain treatment .Notify physician if interventions are unsuccessful or if current complaint is a significant change from my past experience of pain. Observe and report changes in usual routine, sleep pattens, decrease in functional abilities .
On 11/19/24 at 11:10 AM, an interview was conducted with Certified Nursing Assistant (CNA) D and was asked about R30's discomfort during the dressing change observation and replied, It is hard for them to roll on their right side., which was the side CNA D had to R30 roll on. During the dressing change R30 also stated, It hurts so bad while cleaning the wound. I can tell when it hurts. R30 also refused their shower on 11/19/24.
On 11/19/24 at 3:10 PM, an interview was conducted with R30 in their room regarding their pain during the dressing change that morning and how they were feeling now and replied, Pain is ok right now. This morning it was worse during the dressing change and hurt bad during that time.
On 11/19/24 at 3:27 PM, an interview was conducted with CNA D who was asked about R30 and her pain during dressing changes. CNA D agreed R30 had increased pain with dressing changes, with rolling on their side and with changing their incontinence brief. CNA D was asked if they have ever let nursing know about R30's pain issues observed while providing cares for R30 and replied, No, I don't think so.
On 11/20/24 at 9:05 AM, an interview was conducted with Registered Nurse (RN) E who was asked about R30's pain with dressing changes. RN E replied, I'm not sure why they haven't had an increase in pain medication or why it is not scheduled prior to their dressing changes as that is when they need it most. I did pre-medicate them. When they are resting, they are not in any pain. Just pain with movement and the dressing changes.
On 11/20/24 at 12:20 PM, an interview was conducted with the Assistant Director of Nursing (ADON) A who was asked about R30 and the observation of R30 crying out during the dressing change. The ADON A replied, If they were having that much pain during dressing change after being pre-medicated then that was not enough medication.
On 11/20/24 at 1:49 PM, an interview was conducted with the Director of Nursing (DON) who was asked about pain management and re-assessment after implementation of medication when pressure ulcer and dressing changes started for R30 and replied, Normally discuss with quarterly reviews. The DON reviewed the progress notes for R30 and confirmed a lack of any discussion or follow up in care conference or reviews regarding R30's pain management. The DON stated, It should be scheduled prior to each dressing change if they are in that much pain. The DON was going to address R30's pain with the physician.
Review of policy titled, Pain Assessment and Management, dated 11/2024, read in part, The facility will keep its residents as pain free as possible so they can achieve their highest level of function and quality of life. Pain relief measures will be implemented to comply with professional standards of practice, focusing on comprehensive person centered care planning to include the resident's goals and preferences . D. When assisting residents with ADL's (Activities of Daily Living), direct care staff should observe for pain by assessing for signs and symptoms of pain and or verbally inquiring about a resident's pain, such as: intensity, duration, frequency, location, onset, pattern etc. Documentation and follow-up should occur as needed . F. A plan for pain and symptom management will be developed based upon the assessment data . G. Nursing should evaluate pain status, interventions and effectiveness of pain interventions and document in the nursing notes and the EMAR as applicable. Update the Physician as needed .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure expiration dates were present on multi-dose medications and biologicals and failed to remove expired medications from t...
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Based on observation, interview and record review, the facility failed to ensure expiration dates were present on multi-dose medications and biologicals and failed to remove expired medications from the active supply in one medication cart of four medication carts reviewed, resulting in the potential for administration of expired medications and biologicals and the potential to have a reduced medication effect.
Findings include:
A review of the 200 Hall medication cart with Licensed Practical Nurse (LPN) C on 11/19/2024 at 1:54 p.m. revealed the following:
A multi-dose Trelegy Ellipta (inhaled medication used to treat asthma and chronic obstructive pulmonary disease) 200-62.5-25 MCG (microgram) inhaler with 22 doses out of 30 doses remaining. Further review of the inhaler and the box housing the inhaler revealed no date indicating when the medication was first opened or when the medication would expire.
An open insulin aspart (rapid-acting insulin) FlexPen with 75 units out of 100 units remaining. The insulin pen and the clear plastic bag housing the pen contained no legible date indicating when the medication was first opened or when the medication would expire.
An open container of latanoprost (medication used to treat glaucoma) eye drops with a written expiration date of 11/16/2024, indicating the medication expired three days prior to the observation.
During an interview at the time of the observation, LPN C reported there were no open dates written on the multi-dose Trelegy Ellipta inhaler or the insulin aspart FlexPen, so she was unable to determine if or when the medications expired. LPN C confirmed the open container of latanoprost eye drops were expired and should have been removed from the medication cart and a new container ordered from the pharmacy.
Review of the facility policy titled, Medication Storage, Labeling, Dating, Expirations, Destructions, and Returns, last revised 12/2023, revealed the following: Once a medication or biological package is opened . Record the date opened on the primary medication container (vial, bottle, inhaler) and storage packaging if, once opened, the item has a different expiration date than the manufacturer expiration date . Apply an expiration label (i.e. neon orange or yellow) when the medication has a shortened expiration date once opened (i.e. less than 30 days) . Facility should destroy or return all discontinued, outdated/expired or deteriorated medications or biologicals .
Apr 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to utilize appropriate dementia care techniques in the provision of care and services to one Resident (R3) of three residents re...
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Based on observation, interview, and record review, the facility failed to utilize appropriate dementia care techniques in the provision of care and services to one Resident (R3) of three residents reviewed for dementia care. This deficient practice resulted in the potential for escalation of behaviors by use of physical force to ensure resident complied with staff care. Findings include:
This deficiency pertains to Complaint Intake #MI00143128, which alleged facility staff were being physically aggressive and neglectful of R3 while residing in the facility locked Alzheimer's unit.
Observation of surveillance video, in the presence of IT (Information Technology) Director (Staff) E showed the following staff/resident (R3) interactions:
12/16/2023: At 4:39 p.m., R3 had fallen asleep in a straight-backed chair. He was leaning forward as he was sleeping. At 4:40 p.m., two unidentified facility staff members (unknown names) grabbed R3 underneath the armpits (one on each side) and dragged him forcibly across the floor. R3 appeared to be resisting the move, as his feet were out in front of him, in a skiing position as they moved him across the room. The staff members placed R3 in a softer chair and he resumed sleeping. Review of the surveillance video confirmed R3 was not checked on by facility staff between 4:40 p.m. and 8:16 p.m., when he fell out of the chair onto the floor. Staff did not assist R3 from the floor in the congregate dining room of the Alzheimer's unit for five minutes.
2/20/24: At approximately 7:35 p.m., R3 was seen to gently touch another Resident. Two unidentified facility staff (same as observed in the above surveillance video) grabbed R3 by his arms and tried to physically redirect the Resident to his room. R3 is seen pulling away repeatedly as staff grip him tightly by the arms. R3 resisted strongly and pushed one of the staff members against the wall. Staff held him tightly by the arms and put him into his room.
3/26/24: At approximately 6:20 p.m. R3 can be seen in the congregate dining room of the Alzheimer's unit, reaching for a bowl of soup on the kitchen counter. The soup is quickly moved out of R3's reach, and R3 then reaches and holds the water pitcher. Resident Care Coordinator of the Alzheimer's unit (Staff) B is observed grabbing the water pitcher in R3's hand and struggling to take the water pitcher from the resident as they both move back and forth and from side to side as Staff B pulls the pitcher from R3 and water spills onto the floor. It appeared as a tug of war between R3 and Staff B.
During an interview on 4/24/24 at 10:51 a.m., Staff E was asked about social work services in the facility. Staff E stated, We haven't had a (licensed) social worker since [Former Staff Name] left. We have a Social Worker Tech and a Social Worker Designee. We do not have an actual social worker.
During an interview on 4/24/24 at 11:40 a.m., Registered Nurse (RN) G, who was working in the Alzheimer's unit, was asked how they would handle a resident who was resisting attempts to relocate them. RN G stated, We would stop and wait for them - give them time to decide what they wanted to do and try to talk them into the move. It would not be appropriate to drag them from one chair to another. When asked about attempting to remove something from a Resident's hands, RN G stated, I would not wrestle with the resident. You try light pressure on their arm - try to talk them into giving it to you.
During an interview on 4/24/24 at 12:23 p.m., Staff B was asked about the 3/26/24 incident with R3 when they tried to physically grab and remove the water pitcher from R3. Staff B stated, That is what I thought would be most appropriate because he (R3) was super angry. When asked about movement of a resident by grabbing them under the arms and forcing them to move, Staff B stated, A resident should not be grabbed under his arms. We tell our staff we should walk away. He (R3) does better if you just walk away . It is not acceptable behavior to pull or push a resident against their will . That day (with the pitcher) I told the girl he was in front of to turn away, and he eventually let go of the pitcher. Staff B was informed this Surveyor had observed the surveillance video of the altercation between R3 and themselves in the attempt to remove the pitcher from R3. When asked what Staff B would instruct her staff in the unit, in regard to attempting to physically force a resident to relinquish an item like the water pitcher, Staff B stated, I would probably tell them to let him be and walk away. When asked who the dementia care expert in the facility was, Staff B stated, I don't know if we have a dementia expert in the building. [Former Interim Nursing Home Administrator] was supposed to do a training to get me certified (in Dementia Care). (It is) supposed to be still in the works. Staff B confirmed they had begun working as the manager of the Alzheimer's unit in January of 2024. Staff B also confirmed no licensed social workers were currently employed by the facility.
Review of the [Name of Facility] Resident Services Handbook, distributed upon admission to each facility resident or resident representative, revealed the following, in part: Social Services: The Facility employs Licensed Social Workers to assist both the residents and their families. The Social Workers provide assistance with application, resident admissions, and provide for the psychosocial needs of residents as well as prepare the residents for discharge.
During an interview on 4/24/24 at 12:44 p.m., Social Services Designee (Staff) K confirmed they were responsible for oversight of R3 in the Alzheimer's unit. Staff K said they were hired in March of 2023, and confirmed the Resident Services Handbook had been distributed to all new facility admissions for the last four years. When asked who was the dementia care expert that would handle challenging resident behaviors in the Alzheimer's unit, Staff K named previous Interim NHA L, who he indicated also had a specialty in Social Work. When asked to provide documentation of Interim NHA L's direct participation with behavioral interventions specific to R3, Staff K was unable to provide any documentation supporting Interim NHA L's participation with R3's behavioral interventions. Staff K stated, She (Interim NHA L) has been here, but I don't know if she has seen [R3]. When asked for Staff K's educational background, Staff K said he had worked for a regional mental health agency for 15 years and had a bachelor's degree in psychology. When asked about the appropriateness of a tug of war in attempting to remove an item in the possession of a resident, Staff K stated, Absolutely not, I would not play tug of war over an item a resident had. A water pitcher they will probably put down eventually. Physically they could get hurt and emotionally they could as well. That is like the worst thing you could do - one of them at least I would say - to play tug of war with a resident.
During an interview on 4/24/24 at 12:52 p.m., when asked if a resident should be pulled by them armpit across the floor, Staff K stated, No, they should not pull the resident up by his shoulder (and drag him across the floor). Good God, I hope this isn't happening here. The armpit thing is not good. A resident should not be left for four hours in a chair . we encourage a resident to make their own choices even in [the Alzheimer's Unit]. Physical restraint is the last resort.
During an interview on 4/24/24 at 1:49 p.m., Staff K returned to the conference room where this Surveyor was located and stated, [RN M], on the third floor (non-dementia floor) is the dementia expert. I was told by the Director of Nursing today. We could definitely use her . as much as I am embarrassed to say it - I didn't know that until today.
During an interview on 4/24/24 at 2:10 p.m., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) both acknowledge it was not acceptable to physically push/pull a resident against their will. The ADON stated, You walk away if you are not in the middle of moving (them). The DON and ADON stated they use specific dementia training videos for education of the Alzheimer unit's staff, and agreed those training videos would not recommend struggling with a resident to remove something from them unless it posed a very serious danger.
Review of the ADL (Activities of Daily Living) Care of Dementia Unit Residents policy, last approved 12/2023, revealed the following, in part: . 6. A variety of approaches, such as task segmentation, should be utilized in assisting the dementia unit residents with ADLs. 7. Approaches will be in accordance with dementia care principles. Dementia care resources should be kept on the unit for staff use .
Review of the [Alzheimer's unit] marketing information found online and provided by the facility on 4/24/24 revealed the following, in part: .Our secure memory care unit provides a specially designed living and program environment for residents in the early to middle stages of Alzheimer's disease or dementia. Change in memory is normal with age, but when that change becomes worrisome as a loved one begins having difficulty communicating, thinking, and reasoning, our specially trained nursing team at [Alzheimer's Unit Name] is here to help them with day-to-day living . Residents are respected and honored with their individual preferences and schedules .
Mar 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00142963.
Based on observation, interview, and record review the facility failed to provide a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00142963.
Based on observation, interview, and record review the facility failed to provide a safe transfer for one Resident (R1) of three residents reviewed for accidents and hazards. This deficient practice resulted in hospitalization for a right, lower leg fracture. Findings include:
Resident #1 (R1)
Review of the history and physical from the hospital dated 2/16/24, revealed R1 experienced pain in her leg and then transferred to hospital where an X-ray was performed on right knee.
Review of progress note from the hospital records dated 2/17/24, stated R1 sustained a fracture of the proximal tibial metadiaphysis fracture near the knee in the larger of the two bones in the lower leg. The report also stated R1 was in pain despite the use of Morphine and Roxicodone (Oxycodone).
Review of the Facility Reported Incident (FRI) Investigative Summary dated 2/15/24, at 10:07 a.m , revealed Certified Nursing Assistant, (CNA) D and CNA E entered the room of R1 to assist with a transfer from the bed to wheelchair without the use of a gait belt (safety belt for transfers/walking). R1 experienced a fall during the transfer.
Review of R1's Minimum Data Set (MDS) assessment, dated 5/10/23, revealed admission to the facility on 7/2/2020, with active diagnoses that included: expressive aphasia, (difficulty speaking) hemiplegia (one-sided paralysis) following cerebral infarct (stroke) affecting right dominant side, obesity, and unsteadiness on feet. R1 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition. R1 had unclear speech, was sometimes able to be understood and always able to understand others.
During an interview on 3/5/24 at 3:15 p.m , R1 confirmed two people attempted to help them out of bed on 2/15/24. R1 stated two CNA's (D & E) attempted to transfer them out of the bed into a wheelchair. When asked if they fell during the attempted transfer, R1 pointed to the ground and nodded her head yes. When asked about pain, R1 acknowledged pain in the right leg during the night which worsened the next day. R1 expressed an increase in severe pain to her leg the next day and was then transferred to Emergency Department (ED) on 2/16/24.
Record review of the physical therapy initial evaluation at hospital dated 2/17/24 reflected that R1 had no active movement of the right upper or lower extremity. The report also stated that patient had an incident at the nursing home where they dropped R1.
During an interview on 3/6/24 at 9:44 a.m., CNA D was asked to explain the details of the incident with R1. CNA D stated CNA E assisted and explained how they attempted to transfer R1 from a sitting position on the side of the bed to a wheelchair positioned on the right side of R1(paralyzed right side) on 2/15/24. CNA D stated they assisted R1 to a standing position and pivoted R1 on the right leg and the left leg buckled. CNA D confirmed they had not placed a gait belt on R1 prior to the attempted transfer and were unable to support the resident without the gait belt and the resident fell to the floor. CNA D was asked to demonstrate the position of the wheelchair R1 would use when transferring from the bed to wheelchair. CNA D placed the wheelchair on R1's right (non-weight bearing) side. Note: R1's right leg was paralyzed, and they were unable to pivot safely.
During an interview on 3/6/24 at 10:07 a.m , CNA E acknowledged assisting CNA D with transferring R1 from the bed to the wheelchair on the morning of 3/15/24. CNA E stated that R1 was raised to a standing position without a gait belt. R1 attempted to pivot on the right leg which gave out and R1 fell to the floor. When asked when the gait belt was placed on R1 CNA E said it was placed on R1 after the fall to the floor. CNA E did not know why the gait belt was not used prior to the attempted transfer. CNA E stated, We didn't have a gait belt (on R1), but we should have . I have always used a gait belt with R1 in the past. CNA E stated, [CNA D] told me not to tell the nurse, because [CNA D] said it was not a fall (because they lowered her to the floor). CNA E said R1's legs were crossed with the right leg over the top of the left leg, underneath the bed and R1 was crying. CNA E stated, I was concerned [R1] may have been hurt because she was crying, and she does not randomly cry like that. I thought she may have been hurt. I wanted to tell the nurse, but I remember what CNA D said - not to tell the nurse. CNA E stated they were not educated or observed during resident transfers for proper techniques and safety when asked. CNA E was asked to demonstrate the position of the wheelchair R1 would use when transferring from the bed to wheelchair. CNA E' placed the wheelchair on R1's right (non-weight bearing) side. (Note: R1's right leg is paralyzed and unable to pivot safely.)
On 3/6/24 at 10:50 a.m., during a telephone interview family member (FM) G confirmed R1 was non weight bearing on her right side. FM G stated [R1] would not have been able to bear any weight on [the] right side. [R1] would step out on [the] left leg which was the only leg that would bear weight.
During an interview on 3/6/24, at 11:26 a.m., Rehab Director C was asked about the use of gait belts and said, I do new hire orientation. Even if there is one CNA (doing a transfer) I tell them they must use a gait belt. You never do anything without a gait belt. Even those residents who are refusing, you need to go to the nurse and get assistance.
During the same interview with Rehab Director C was asked to demonstrate the position of the wheelchair R1 would use when transferring from the bed to wheelchair. Rehab Director C placed the wheelchair on R1's left (weight bearing) side to safely transfer R1 into the wheelchair.
Record review of the Physical Therapy assessment dated [DATE] and R1's care plan dated 4/27/23 revealed, at the time of the fall, R1 required extensive assist with two people for transfers with a third person to stand by.
On 3/6/24, at 11:50 a.m., Assistant Director of Nursing (ADON) A provided a policy/procedure titled Basic Guidelines and Safety Procedures for all Transfers. In the Procedure is states: use a transfer/gait belt during transfers.
On 3/6/24 at 11:50 a.m., the DON and ADON A were asked to demonstrate how to safely transfer R1. The DON and ADON placed the wheelchair on the left side (weight bearing) side of R1 to safely transfer R1 into the wheelchair. The DON was asked what R1's transfer status was prior to the fall on 2/15/24. The Director of Nursing (DON) stated, Transfer status was two assist (two staff members to assist) I believe. The DON said resident transfers performed by CNA D and CNA E were not monitored or observed following the fall on 2/15/24. The DON and Assistant Director of Nursing (ADON) agreed all CNAs involved knew they needed to use a gait belt during resident transfers.
Dec 2023
9 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficiency pertains to Facility Reported Incident (FRI) MI00141290.
Based on observation, interview, and record review, the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficiency pertains to Facility Reported Incident (FRI) MI00141290.
Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement which resulted in the likelihood of serious harm, injury, impairment, or death to one Resident (R102) out of one resident reviewed for safety and supervision.
Review of the facility Investigation Summary Conclusion: [R102] exited the main door of Woodland Haven (secured Alzheimer's unit) unattended . [R102] was observed to have exited the (main entrance) of the building .He was outside of the building for a total of one minute and thirty-four seconds .
Review of R102's Minimum Data Set (MDS) assessment, dated 9/13/23, revealed R102 was admitted to the facility on [DATE] with current, active diagnoses of non-traumatic brain dysfunction, Alzheimer's dementia, and depression. R102 scored 5 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severely impaired cognition. R102 was independent with ambulation.
Review of facility surveillance showed the following movement of R102 on 11/28/23 following his unobserved and unattended exit through the alarmed secured Alzheimer's unit main entrance/exit doors:
11:57:08 p.m. - R102 pushed on the alarmed (30 second) egress bar on the door, attempted to push buttons on the keypad to the right of the door, wheelchair maintains contact with the egress bar and the door opens.
12:00:00 a.m. - R102 walks out the first set of main entrance/exit doors from the facility. The interior door to the small foyer, and the exterior door are not alarmed.
12:01:00 a.m. - R102 exits the foyer out of the building through the second set of entrance/exit doors.
12:01:14 - Registered Nurse (RN) Y walks to the secured Alzheimer's unit exit door and is observed re-setting a sounding door alarm. RN Y leans to the left and the right as she appears to look outside the exit door through a narrow window. RN Y did not open the secured Alzheimer's unit exit door to look for any potential resident elopement from the facility. R102 is seen exiting out of the facility as RN Y is re-setting the door alarm in the secured Alzheimer's unit.
12:02:37 - R102 comes back inside the foyer between the first and second sets of entrance/exit doors. R102 is unable to get back inside the facility because the second set of entrance doors were locked, with no method of contacting facility staff present inside the small foyer. R102 is seen repeatedly pulling on the interior entrance door for the following seven minutes, unable to enter the facility.
12:08:00 - Pharmacy Technician (who had delivered medications to the facility) exited the interior entrance/exit door pushing a cart. R102 holds the door open for the Pharmacy Technician, who says thank you as observed by her mouth movements, and confirmed by IT Director S, present during the electronic surveillance review.
12:09:10 - R102 re-enters the facility interior entrance door he was holding open, and the door closes behind him.
12:10:59 - R102 sits down in a chair in the front sunroom.
12:19:52 - R102 gets up and moves to a loveseat in view of the nurses' station on the 1st floor.
12:21:36 - House Supervisor/RN U positioned near the elevators, sees R102 and approaches him.
12:23 - RN U uses her phone to telephone (presumably) secured Alzheimer's unit staff.
12:24:34 - RN Y leaves secured Alzheimer's unit to retrieve R102 from the front lobby.
12:29:30 - R102 was returned to the secure Alzheimer's unit by RN Y.
Following review of all surveillance video pertaining to R102's elopement from the facility on 11/28/23, in the presence of IT Director S, it was confirmed R102 was unattended and unsupervised for 21 minutes following exit from the secured Alzheimer's unit.
Review of Wunderground.com for daily weather history near the facility at; wunderground.com/history/daily/us/mi/[city name]/[air navigation identifier]/date 2023-11-28, revealed a temperature of 18 degrees Fahrenheit with a wind speed of 18 miles per hour (mph) gusting to 26 mph, resulting in a wind chill temperature of 2.4 degrees Fahrenheit as calculated on the National Weather Service Wind Chill Calculator at the time (12:00 a.m. on 11/28/23) of R102's elopement from the facility.
Review of RN Y's Witness Statement Form and accompanying phone interview conducted by the DON, dated 11/29/23, revealed the following, in part:
When putting away meds (medications) away after delivery she heard like a faint dog whistle sound. Opened conf. (conference) room door to alarm going off. She (RN Y) walked to door, turned off code. No one was in hall .didn't know Res (R102) was outside, just thought he was in the lobby . Code alert on placed (on R102) at 0700 (7:00 a.m.) .
Review of the facility Code Alert/Resident Elopement policy, last revised 06/2023, revealed the following, in part:
Elopement occurs when a resident leaves the premises or a safe area without authorization . and/or any necessary supervision to do so. It is the policy of this facility to assure a safe environment and well-being for residents residing in our facility. Staff members are responsible to immediately respond when the Code Alert/Door Alarm system is activated .
ELOPEMENT RISK ASSESSMENT: .A code alert transmitter will be applied, as appropriate to any resident deemed at risk for elopement . 5. A photo of the resident will be maintained in the MAR (Medication Administration Record) for reference by staff if consent to photo is obtained. An additional copy should be placed in facility Elopement Risk books/binders. 6. All Residents residing in (secured Alzheimer's unit) are considered at elopement risk being that it is a lock down unit. Colored pictures are on file in the MAR for reference if photo was allowed. No Elopement risk binder needed for this area.
ELOPEMENT PREVENTION: 1. Residents identified to be at risk for elopement will have a Code Alert transmitter placed on them unless otherwise determined by the Interdisciplinary Team. 2. Each nursing unit will maintain a list of residents wearing Code Alerts. 3. Nursing staff will document any elopement attempts or other wandering behavior as needed. 4. The Interdisciplinary Team will monitor each resident's mood and behavior and revise care plans as needed .
RESPONSE TO CODE ALERT/DOOR ALARMS: 1. When the Code Alert/Door Alarm sounds, the nearest staff from any location should immediately respond: a. Immediately check the area around the alarmed door. B. Look inside and proceed out the door to the surrounding areas on all sides as application. C. Go around corners and be sure no resident exited the building. 2. If no one is in sight, thoroughly check the perimeter (walk around the entire building checking surrounding parking areas). Check adjacent lots also. 3. If no one is found around the alarmed door or outside, account for all residents on each nursing unit by visual check. Someone must physically see each and every resident and report whereabouts to the licensed nurse in charge .
RETURN OF RESIDENT: A licensed nurse will place a Code Alert transmitter on the resident if one is not already in place .
Review of an email correspondence from Unit Manager/RN U to the DON (Director of Nursing) on 11/28/23 at 3:27 a.m., revealed the following, in part: During night shift tonight - 0015 (12:15 a.m.) I was heading to the main elevator and noticed someone sitting in the front lobby. I went to check out the situation. I recognized that it was [R102] who resides in (secured Alzheimer's unit). He was sitting on the couch, wearing his boots and light weight jacket. He had his walker sitting in front of him with his shoes and socks sitting on seat of the walker . I called (secured Alzheimer's unit) nurse on my [Name Brand] phone and alerted her that he was in the lobby. She was un-aware (sic) he was missing .He is not listed in our facility Elopement Risk Binder and doesn't wear a code alert. Wanted to bring this to your attention. Signed by RN U on 11/29/23.
Review of emails to the DON on 11/28/23 revealed facility head counts, as directed in the facility elopement policy were not performed to ensure all facility residents were present in the facility, including secured Alzheimer's unit, until 9:30 a.m. on two units, and 9:45 a.m. on the remaining unit.
Family Member (FM) T was not notified of the elopement of R102 from the building until 11/28/23 at 11:45 a.m.
During an interview on 12/5/23 at 3:11 p.m., the DON confirmed, after their review of all surveillance video, staff needed additional training on the Code Alert/Resident Elopement policy. The DON stated, If an alarm is going off you do not stop; you continue until you find who set off the alarm . The alarm was going off - she was sorting off her (pharmacy) delivery, (and) she (RN Y) did not see who went out the door (secured Alzheimer's unit alarmed exit door). She (RN Y) should have told the aides [Certified Nurse Aides (CNAs)] to get a head count, and I would have ran (sic) until I found out who set the alarm off .
During an observation and interview on 12/6/23 at 7:49 a.m., Maintenance Director V and Maintenance (Staff) W performed alarm testing of the alarmed egress door from secured Alzheimer's unit in the presence of this Surveyor. Egress from secured Alzheimer's unit was timed and verified to be a 30 second, delayed release. Maintenance Director V said the egress door was also equipped with a code alert alarm, which would activate and prevent the door from opening, if the resident had a Code Alert alarm in place on them. When asked if residents would be visible if they were in the outer hallway (outside of the egress door), Maintenance Director V stated, No, they would not be visible. When asked about the outside egress door, Maintenance Director V said the interior facility entrance door had a Code Alert alarm but would only sound and prevent the door from opening if the resident was wearing a Code Alert. When asked what would happen if a resident got outside, Maintenance Director V stated, That would not be good, and confirmed the resident would be unable to re-enter the building at night as the button to sound the alarm was located on the outside of the building and no button or staff contact information was present in the foyer. Maintenance Director V said the interior egress door at the front entrance locked at 8:00 p.m. each night and were not unlocked until 8:00 a.m. in the morning.
During a telephone interview on 12/6/23 at 9:37 a.m., Family Member (FM) T was asked if there were any concerns related to R102's care in the facility. FM T stated, They (administrative staff) addressed the 'Alcatraz escape' (11/28/23 elopement from the facility). When things happen like this, they do not call us right away. They call the next day. Quite a bit of time goes by (before we are notified) .They said he had been putting on his boots and jacket and saying I got to go they are coming to get me. He walked outside. We were in the middle of that winter storm .It was one minute 34 seconds he was outside .The whole time of his escape was 31 and 1/2 minutes .He was only unsupervised for 9 minutes they told me .
During an interview on 12/6/23 at 12:20 p.m., when asked to review the facility Code Alert/Resident Elopement policy, the Nursing Home Administrator (NHA) said he interpreted the policy to mean all (secured Alzheimer's unit) residents are considered elopement risks and therefore should have a Code Alert placed to prevent elopement from the facility.
During an interview on 12/7/23 at 8:36 a.m., secured Alzheimer's unit Resident Care Coordinator/MDS/RN M was asked for R102's Care Plans and any knowledge she had regarding R102's elopement on 11/28/23. RN M stated, I was out of town. I woke up to an email (regarding R102's elopement and said (to myself) 'How, how, how?' (did R102 elope). RN M said R102's Elopement Care Plan was initiated on 11/29/23, and prior to that date R102 did not have an elopement care plan. RN M stated, If I had known he was having multiple elopement attempts I would have put a code alert on him.
Review of R102's Progress Notes revealed the following Behavior Note entries related to exit-seeking behaviors by R102 during November of 2023, prior to the elopement:
11/4/23 - 13:00 (1:00 p.m.), Resident with some exit seeking behaviors. Walked to Home 2, telling staff, I couldn't open the door. Walked around looking for a way out .
11/13/23 - 21:37 (9:37 p.m.), Resident seen by home one entrance doors, when asked if he needed something resident responded I'm trying to get out, I can't get out .
11/24/23 - 18:42 (6:42 p.m.), Resident exit seeking this evening. Found standing behind home one doors and trying to keep them open when someone enters .
During an interview on 12/7/23 at 11:15 a.m., when asked to review R102's Behavior Notes, Assistant Director of Nursing (ADON) L acknowledged that R102 did have exit-seeking behaviors in November 2023, prior to the elopement, which did not prompt the development or implementation of an elopement Care Plan or interventions.
During a telephone interview on 12/11/23 at 11:42 p.m., CNA X, who was working in the facility at the time of R102's elopement, was asked to describe any details she recalled about the incident. CNA X said she was on break and did not know anything was going on until the nurse popped her head in the door and said [R102] got out . the next day I had talked to [the DON] and I heard he had gotten outside. When asked about completion of a head count, CNA X stated, No, we did not do a headcount. At the time the protocol would be to do a headcount; go out the door and look around. When I found out what was going on he had already been found . I talked to the administrator. I think anybody that comes over to the (secured Alzheimer's unit) - everyone should have a Code Alert. If he would have had one of those (Code Alert) on, he would not have gotten out. I think everyone in (secured Alzheimer's unit) should have a Code Alert .
The Immediate Jeopardy began on 11/28/23 at 12:00 a.m., when inadequate supervision and failure to implement the elopement policy resulted in R102's elopement from the facility outside into inclement weather. The Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy on 12/6/23 at 12:20 p.m. This Surveyor confirmed, by observation and interview, that the Immediate Jeopardy was removed on 12/6/23 at 4:30 p.m., but noncompliance remained at the potential for more than minimal harm due to sustained compliance that has not been verified by the State Agency.
The Immediate Jeopardy that began on 11/28/23 at 12:00 a.m., was removed on 12/6/23 at 4:30 p.m., when the facility took the following actions to remove the immediacy:
1. Education Coordinator was provided with a new form that will be given to all new oncoming nurses and contract nurses with pertinent information for daily floor nursing.
2. Code alerts applied to all residents that reside in (secured Alzheimer's unit), care plans updated.
3. Additional education to all staff in regard to the closure of (secured Alzheimer's unit) main doors.
4. All staff education complete.
5. Several elopement drills continue to be completed since elopement and will continue to be reviewed in QAPI (Quality Assurance Process Improvement).
Date Facility Asserts likelihood for Serious Injury or Death No Longer Exists: 12/6/2023.
On 12/06/23 at 7:02 AM, an attempt to enter the facility via the front/main entrance was made. The door from the outside opened into a foyer area where another door leading into the building was found locked and inaccessible. A search for information regarding entry was conducted with no signs or other sources of information available indicating how entry to the building was to be accomplished. Located on the outside of the building and to the left of the doors, a door bell button was located. This button was pushed multiple times. No staff responded to the bell. A return to the foyer and additional search for information regarding entry was made. The interior door remained locked with no staff responding to the door bell. Approximately 8 minutes after the attempted and failed entry, as staff person entered the foyer and stated she had witnessed the attempted entry, and offered to use her key to open the door. On 12/6/23 at approximately 7:16 AM the Nursing Home Administrator (NHA) arrived near the door. An interview was conducted at this time. The NHA stated visitors coming to the building when the doors were locked, were supposed to the call the nurses' station on first floor. No information regarding a phone number or instructions for contacting the nurses' station could be found. At 11:13 AM, an interview with Receptionist Staff B was conducted related to the locking of the main entrance doors. Staff B stated the doors are generally locked at 8:00 PM and are unlocked the following morning around 8:00 AM. Staff B was not aware of any communication procedure to allow visitors access after the doors were locked.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing of a pressure injury and prevent the development of an additional pressure injury for one resident (R73) of two residents reviewed for wounds. This deficient practice resulted in harm when R73 developed a stage 3 pressure injury to the coccyx in addition to an existing facility-acquired pressure injury on the coccyx. Findings include:
Resident 73 (R73) was admitted to the facility on [DATE] with diagnoses that included but were not limited to: need for assistance with personal care, contracture of the right shoulder, contracture of the left shoulder, dependence on wheelchair, symptoms and signs involving cognitive functions and awareness, catatonic schizophrenia, dementia with psychotic disturbance, and others.
The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded R73 as not having any pressure injuries. The MDS assessed R73 with functional limitation in range of motion to both arms and legs. The MDS coded R73 as being fully dependent on staff for ADL (activities of daily living) tasks and functional mobility, including but not limited to toileting hygiene, bed mobility, sitting, and transfers. R73 was assessed on the MDS as always incontinent of bowel and bladder.
On 12/7/23 at 7:30 a.m., R73 was observed in the dining room sleeping in her wheelchair prior to breakfast. A cushion was observed on the seat of the wheelchair. R73 had a palm protecting orthotic device in her left hand and an elbow extension orthotic device on her left upper arm. There was a full-body mechanical lift sling directly under R73. Registered Nurse C (RN C) was questioned regarding the condition of R73's skin. RN C stated R73 had a SDTI wound (Suspected Deep Tissue Injury) on the coccyx (tailbone). RN C said [brand name dressing, an adhesive foam dressing] was being used to treat the wound in accordance with facility standing orders. RN C further said the wound was on R73's coccyx (tailbone). RN C said she completed R73's treatment and dressing change the evening of 12/6/23.
On 12/7/23, a document in R73's medical record, WOUND - WEEKLY OBSERVATION TOOL, dated 12/5/23, was reviewed. The document noted the following assessment information: R73's coccyx wound was acquired on 12/5/23. The wound was identified as SDTI pressure injury with granulation tissue (beefy, red tissue) and necrotic tissue (brown, black, leather, scab-like). The wound had a small amount of serosanguineous (fluid that is light pink to red) drainage and measured 7.5 cm (centimeters) x 2.5 cm x unable to determine depth. Under the evaluation section of the document, First observation was entered. There were no additional wound forms or documents noted during this review on 12/7/23.
On 12/7/23 R73's current physician orders were reviewed. There was no treatment order for the pressure injury on R73's coccyx. The Treatment Administration Record (TAR) for December 2023 contained the order, Check [brand name dressing] to coccyx every shift. Change every 3 days and PRN (as needed) every shift. D/C (discontinue) when resolved. The treatment order had a start date of 12/2/23 and a D/C date of 12/5/23. The treatment was last signed out on day shift 12/5/23. There were no other orders for treatments or dressing changes on the TAR for the pressure injury on R73's coccyx.
The Director of Nursing was interviewed on 12/7/23 at 12:32 p.m. regarding expectations and standard of practice when a standing order was implemented. The DON said she would expect the order to be documented in the medical record on the Medication Administration Record (MAR) or the TAR, depending on the order to be initiated. The DON stated her expectation is that the order would be added to the MAR or TAR and signed out on the MAR or TAR but not documented in progress notes.
R73's medical record was reviewed with the following progress note entries:
12/2/23 at 11:43 p.m.: Res. Coccyx is moist and fragile. [Brand name foam dressing] placed for protection.
12/3/23 at 04:46 a.m.: Repositioning every 2 hours. 12/5/23 at 03:49 a.m.: Continuing to off-load pressure and reposition every 2 hours. [Brand name foam dressing] to coccyx area remains CDI. 12/5/23 at 7:13 p.m.: Resident has current skin issues. Skin issue: pressure ulcer/injury. Skin issue location: coccyx. Pressure ulcer/injury stage: suspect deep tissue injury - depth unknown.
On 12/07/23 at 1:58 p.m., R73's wound care was observed being completed by RN C with Certified Nursing Assistant D (CNA D) assisting with positioning of R73 to a right side-lying position. There were areas of redness observed across R73's back, buttocks, and upper posterior thighs. These areas were indented and coincided with the straps and edges of the mechanical lift sling. RN C assessed the areas and said they were caused by R73 sitting up too long in the wheelchair. CNA D said R73 was in her wheelchair before breakfast. CNA D admitted she had not provided any incontinence care or pressure-reducing endeavors such as repositioning to R73 from the time R73 was placed in her wheelchair before breakfast until R73 was placed in bed for wound treatment observation at 1:58 p.m.
During treatment observation on 12/07/23 at 1:58 p.m., RN C removed a dressing with an unreadable date from R73's coccyx. There were two pressure injuries observed: one pressure injury (PI #1) on the superior coccyx near the sacrum, and one pressure injury (PI #2) on the inferior coccyx approximately two centimeters below PI #1. The dressing RN C had removed from PI #1 contained no exudate or drainage. There was no dressing on PI #2. RN C measured PI #1 and determined the wound to be 7.5 cm x 2.5 cm. P1 #1 presented as an unstageable pressure injury with yellow, stringy slough (yellow, stringy tissue) adhering to approximately 2.5 cm x 1.0 cm of the wound bed which obscured the depth of the wound. RN C stated the treatment was a [brand name dressing]. When asked regarding the treatment of PI #2, RN C appeared surprised. The surveyor informed RN C there was a second wound inferior to PI #1. RN C assessed R73's coccyx and said PI #2 was brand new. She stated, I didn't notice it when I did the dressing change this morning. RN C measured PI #2 with surveyor observing. RN C stated, it's a stage 3. Surveyor observed PI #2 measurement as 1.0 cm x 0.8 cm. PI #2 was located on the coccyx below PI #1 and had no drainage. PI #2's wound base contained an area of yellow slough approximately 0.2 cm x 0.2 cm in the inferior portion of the wound. RN C said she was going to use [brand name dressing] on PI #2 based on standing orders for wound care. RN C then completed treatments for PI#1 and PI#2 using [brand name dressing]. RN C said [brand name dressing] is not a good choice for these wounds. And said she planned on contacting the NP or physician for a change in treatment orders. Surveyor informed RN C that there was no treatment order for PI #1 or PI #2. RN C said she would ensure orders were obtained and entered onto R73's TAR.
Facility standing orders were reviewed. The physician signature and date lines of the standing orders form were blank. The standing orders contained directives for pressure injury treatments for stage 1, stage 2, and stage 3/stage 4 pressure injuries. SDTI was not mentioned or addressed in the standing orders. The standing orders for a stage 3 pressure injury were: notify physician for treatment and/or wound consult orders. There was no mention of [brand name dressing] for stage 3 or stage 4 pressure injuries.
A progress note was entered into R73's medical record on 12/7/23 at 2:24 p.m. The note read, Situation: Call placed to [name of nurse practitioner] who is taking calls for [name of physician] at this time. Updated on new stage 3 wound on coccyx just inferior to wound #1 on coccyx. Inquiring about what dressing to utilize. Background: Current dressing is [brand name dressing] per standing order. Has wound care consult for wound #1 on coccyx. Assessment/Appearance: New stage 3 wound inferior to coccyx wound #1. Measures 1cm x 0.8cm x <0.1 cm. Full thickness wound with 100% serosanguineous. Surrounding skin with black color an scaly. No foul odor. See wound UDA for details. Recommendations: [name of nurse practitioner] ordered wound consult for new wound #2 on coccyx. She will also consult wound care for new dressing orders, and call us back.
A WOUND - WEEKLY OBSERVATION TOOL, dated 12/7/23, was entered into R73's medical record. The document assessed PI #2 as a stage 3 pressure injury inferior to PI #1 on the coccyx, measuring 1.0 cm x 0.8 cm x 0.1 cm with black, scaly peri-wound tissue. The evaluation section documented that the 12/7/23 assessment of PI #2 was new wound, first observation.
The policy Care of Pressure Sores [injury], dated as effective 10/2023, was reviewed. The policy said, in part: 1. Change the resident's position as least every 2 hours, depending on the resident's need. Some residents will need to be turned more frequently. Chair-bound residents should be repositioned/encouraged to off-load every hour.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report resident-to-resident incidents involving physical altercatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report resident-to-resident incidents involving physical altercations for seven Residents (R50, R52, R66, R84, R119, R102, and R120) of nine residents reviewed for reporting of abuse. This deficient practice had the potential for undetected abuse, and adverse outcomes. Findings include:
R50
Review of the Minimum Data Set (MDS) assessment, dated 11/02/23, revealed R50 was admitted to the facility on [DATE], with diagnoses including dementia, anxiety, and depression. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 8/15, which indicated moderate cognitive impairment. R50 required moderate assistance with toileting and was independent with walking and transfers.
Review of R50's progress note, dated 10/17/23 at 1:56 p.m., revealed, [R50] was sitting on the couch in the TV (day) room when a male resident [R119] walked behind her and hit her on the top of the head. Staff reports .male resident [R119] started hollering and a CNA [unnamed] witnessed a male resident strike [R50] on the top of the head. [R50] states, 'A man hit me. I was just sitting here watching TV and I never even looked at him and he hit me. It scared me .' The note indicated R50 was fearful of R119.
R119:
Review of R119's MDS assessment, dated 9/19/23, revealed admission to the facility on 9/13/23, with diagnoses including Alzheimer's disease, arthritis, and insomnia. R119 required one-person assistance for toileting, and supervision for transfers and walking. R119 was unable to participate in the BIMS cognitive assessment and was rarely or never understood nor understood others. The behavioral assessment revealed R119 demonstrated physical and verbal behaviors directed at others, other behaviors not directed at others, wandering behaviors, and rejection of care behaviors which significantly intruded on the privacy of others, and significantly disrupted care or the living environment.
Review of R119's progress note, dated 10/16/23 at 4:01 p.m. showed R119 was aggressive towards facility staff, including, .[R119] hit her [CNA unnamed] with a flat hand to the head and attempted to put his hands around her neck. [Nurse] put up hands up between the [CNA] and the resident and tried to divert his attention .[R119] [swore] and [R119] hit me in the back of the head .
Note: This staff incident occurred a day before the incident between R50 and R119.
R52
Review of R52's MDS assessment, dated 8/16/23, revealed R52 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and mild intellectual difficulties. R52 required supervision with toileting and walking and was independent with transfers. The BIMS assessment revealed a score of 4/15, which showed R52 had severe cognitive impairment. The behavior assessment showed R52 had verbal behaviors one to three days a week during the look-back period.
Review of R52's Accident and Incident report, dated 9/24/23 at 9:15 p.m. provided by the Director of Nursing (DON), revealed, .[R52] was in the sunroom. Another resident was walking the unit .and had an interaction with [R52]. Camera footage noted on Page 2 showed the following: .[R119] reaches down a [sic] slaps [R52] on her left knee and [R52] kicks [R119] in the left leg .
R66
Review of R66's MDS assessment, dated 10/25/23, revealed R66 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease and depression. The assessment revealed R66 was independent with transfers, walking and toileting. The BIMS assessment revealed a score of 12/15, which indicated moderate cognitive impairment.
Review of R66's progress note, dated 11/24/2023 at 3:33 p.m., revealed, .This nurse was called to the Home 2 [secured unit] dining room by a CNA, saying that a lady punched another resident. This resident [R66] had been sitting at a table when a male resident [R119] was walking by her and started rubbing her arm. [R66] said I punched him .
R84
Review of R84's MDS assessment, dated 5/5/23, revealed R84 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease and osteoporosis (brittle bone disease). The assessment revealed R84 required supervision with transfers, toileting, and walking. The BIMS assessment revealed a score of 4/15, which revealed severe cognitive impairment. The behavioral assessment revealed other behaviors not directed at others one to three times during the look-back period.
Review of R84's Accident and Incident report, dated 11/27/23, revealed .Observed [R84] upset that .resident [R120 - a second resident] was in her room sitting on her bed. [R84] stated, [R120] hit me; get him away from me. [R120] was very confused and difficult to redirect. Writer and CNA [unnamed] assisted [R120] to stand and escorted him out of the room . R84 sustained two scratches on her face from the physical altercation.
R120
Review of R120's MDS assessment, dated 10/3/23, revealed R120 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, arthritis, and cognitive communication deficit. R120 required set up with toileting and was independent with walking and transfers. R120 was unable to participate in the BIMS assessment and was rarely or never understood nor understood others. The behavioral assessment revealed R120 demonstrated physical and verbal behaviors directed at others, other behaviors not directed at others, wandering behaviors, and rejection of care behaviors which significantly intruded on the privacy of others, and significantly disrupted care or the living environment.
Review of a progress note, dated 10/8/23, revealed, [R120] wandering/pacing .[R120] wandering from room to room, lying in other resident's beds. Was in a female resident's bed .[R120] out [of his room] to another man's bed near his room. A roommate of that other resident [unnamed] found this resident in the wrong bed and said he chased [R120] out. [R120] spit toward him .This is not a new behavior for [R120] .
Review of R120's progress note, dated 10/15/23, revealed, This nurse [unnamed] [was informed] by staff that [R120] initiated physical aggression toward another resident [R102] .
R102
Review of camera footage transcript, dated 10/18/23, provided by the DON, revealed R102 pushed R120 away.
During an interview on 12/8/23 at approximately 2:00 p.m., the DON and the Assistant Director of Nursing (ADON), RN L, were asked about each of the physical resident-to-resident incidents perpetrated by male residents R119 and R120 towards residents on the secured memory care unit. Surveyor reviewed concerns regarding several residents involved in resident-to-resident physical altercations, and the lack of reporting the incidents involving residents R50, R52, R66, R84, and R102 to the State Agency. Both reported they understood the concern and the need to report resident-to-resident physical altercations to the State Agency.
Review of the policy, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, revised 03/2023, revealed, [Facility] will not tolerate Abuse, Neglect, and Exploitation of its residents . All incidents and allegations of Abuse, Neglect, and Exploitation, Mistreatment of a Resident .incidents that result in serious injury, and all injuries of Unknown Source must be reported immediately to the Administrator and Director of Nursing .b. [State Agency]. If abuse or serious bodily injury is alleged. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to [State Agency] immediately, but not later than two hours after the allegation is made .The Administrator, Director of Nursing, or designee will notify [State Agency] of all other alleged violations that do not involve abuse or serious bodily injury, as soon as possible, but in no event later than twenty-four hours from the time the incident/allegation was made known to the staff member .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to fully investigate resident-to-resident incidents involving physic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review, the facility failed to fully investigate resident-to-resident incidents involving physical altercations for seven Residents (R50, R52, R66, R84, R119, R102, and R120) of nine residents reviewed for investigating abuse allegations. This deficient practice had the potential for undetected abuse, and adverse outcomes. Findings include:
R50
Review of the Minimum Data Set (MDS) assessment, dated 11/2/23, revealed R50 was admitted to the facility on [DATE], with diagnoses including dementia, anxiety, and depression. The Brief Interview for Mental Status (BIMS) assessment revealed a score of 8/15, which showed R50 had moderate cognitive impairment. R50 required moderate assistance with toileting and was independent with walking and transfers. The behavioral assessment showed no behaviors.
Review of R50's progress note, dated 10/17/23 at 1:56 p.m., revealed, [R50] was sitting on the couch in the TV (day) room when a male resident [R119] walked behind her and hit her on the top of the head. Staff reports .male resident [R119] started hollering and a CNA [unnamed] witnessed a male resident strike [R50] on the top of the head. [R50] states, 'A man hit me. I was just sitting here watching TV and I never even looked at him and he hit me. It scared me .
R119
Review of R119's MDS assessment, dated 9/19/23, revealed R119 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, arthritis, and insomnia. R119 required one-person assistance for toileting, and supervision for transfers and walking. R119 was unable to participate in the BIMS cognitive assessment and was rarely or never understood nor understood others. The behavioral assessment revealed R119 demonstrated physical and verbal behaviors directed at others, other behaviors not directed at others, wandering behaviors, and rejection of care behaviors which significantly intruded on the privacy of others, and significantly disrupted care or the living environment.
Review of R119's progress note, dated 10/16/23 at 4:01 p.m. showed R119 was aggressive towards facility staff, including, .[R119] hit her [CNA unnamed] with a flat hand to the head and attempted to put his hands around her neck. [Nurse] put up hands up between the [CNA] and the resident and tried to divert his attention .[R119] [swore] and [R119] hit me in the back of the head .
R52:
Review of R52's MDS assessment, dated 8/16/23, revealed R52 was admitted to the facility on [DATE] with diagnoses including dementia, depression, and mild intellectual difficulties. R52 required supervision with toileting and walking and was independent with transfers. The BIMS assessment revealed a score of 4/15, which showed R52 had severe cognitive impairment. The behavior assessment showed R52 had verbal behaviors one to three days a week during the look-back period.
Review of R52's Accident and Incident report, dated 9/24/23 at 9:15 p.m., provided by the Director of Nursing (DON), revealed, .[R52] was in the sunroom. Another resident was walking the unit .and had an interaction with [R52]. Camera footage noted on Page 2 showed the following: [R119] reaches down a [sic] slaps [R52] on her left knee and [R52] kicks [R119] in the left leg .
R66:
Review of R66's MDS assessment, dated 10/25/23, revealed R66 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease and depression. The assessment revealed R66 was independent with transfers, walking and toileting. The BIMS assessment revealed a score of 12/15, which indicated moderate cognitive impairment.
Review of R66's progress note, dated 11/24/2023 at 15:33 (3:33 p.m.), revealed, .This nurse was called to the Home 2 [secured unit] dining room by a CNA, saying that a lady punched another resident. This resident [R66] had been sitting at a table when a male resident [R119] was walking by her and started rubbing her arm. [R66] said I punched him .
R84:
Review of R84's MDS assessment, dated 5/5/23, revealed R84 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease and osteoporosis (brittle bone disease). The assessment revealed R84 required supervision with transfers, toileting, and walking. The BIMS assessment revealed a score of 4/15, which revealed severe cognitive impairment. The behavioral assessment revealed other behaviors not directed at others one to three times during the look-back period.
Review of R84's Accident and Incident report, dated 11/27/23, revealed .Observed [R84] upset that .resident [R120 - a second resident] was in her room sitting on her bed. [R84] stated, '[R120] hit me; get him away from me.' [R120] was very confused and difficult to redirect. Writer and CNA [unnamed] assisted [R120] to stand and escorted him out of the room . R84 sustained two scratches on her face from the physical altercation.
R120
Review of R120's MDS assessment, dated 10/03/23, revealed R120 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, arthritis, and cognitive communication deficit. R120 required set up with toileting and was independent with walking and transfers. R120 was unable to participate in the BIMS assessment and was rarely or never understood or could understand others. The behavioral assessment revealed R120 demonstrated physical and verbal behaviors directed at others, other behaviors not directed at others, wandering behaviors, and rejection of care behaviors which significantly intruded on the privacy of others, and significantly disrupted care or the living environment.
Review of a progress note, dated 10/8/23, revealed, [R120] wandering/pacing .[R120] wandering from room to room, lying in other resident's beds. Was in a female resident's bed .[R120] out [of his room] to another man's bed near his room. A roommate of that other resident [unnamed] found this resident in the wrong bed and said he chased [R120] out. [R120] spit toward him .This is not a new behavior for [R120] .
Review of R120's progress note, dated 10/15/23, revealed, This nurse [unnamed] [was informed] by staff that [R120] initiated physical aggression toward another resident [R102] .
R102
Review of camera footage transcript, provided by the Director of Nursing (DON), dated 10/18/23, revealed R102 pushed R120 away.
During an interview on 12/08/23 at approximately 2:30 p.m., the DON and the Assistant Director of Nursing (ADON), RN L, were asked about each of the physical resident-to-resident incidents perpetrated by male residents R119 and R120 towards residents on the secured memory care unit. Survey team reviewed concerns regarding several residents involved in resident-to-resident physical altercations, and the lack of completed investigations involving the victims, residents R50, R52, R66, R84, and R102. Both reported they understood the concern, had no formal analysis of the data they collected (such as a root cause analysis), or a statement of conclusion, including if abuse and/or allegations of abuse were substantiated or unsubstantiated, per their policy.
Review of the policy, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, revised 03/2023, revealed, [Facility] will not tolerate Abuse, Neglect, and Exploitation of its residents . It is the facility's policy to investigate all alleged violations involving abuse, neglect, exploitation, mistreatment of a resident .as well as injuries of unknown source, in accordance with policy .The Director of Nursing is the Chief Investigative Officer. In the absence of the Director of Nursing, the ADON and/or Nursing Supervisor assumes the role of chief Investigative Officer. 1. Time frame for investigation. The investigation must be completed within five (5) working days, unless there are special circumstances causing the investigation to continue beyond 5 working days .Investigation protocol. The investigation of the incident shall generally take the following actions: Interview the resident, the accused, and all witnesses .Obtain a statement from the resident, if possible, the accused, and each witness .Obtain all medical reports and statements from physicians and/or hospitals, if applicable .Documentation: Evidence of the investigation shall be documented. Reach a conclusion. After completion of the investigation, all of the evidence should be analyzed, and the Administrator (or his/her designee) will make a determination regarding whether the allegation or suspicion is substantiated Timing: The results of the investigation will be reported to the Administrator, and a final report will be submitted to [State Agency] no later than five (5) working days after discovery of the incident (excluding holidays, Saturday, and Sunday). The final report should include sufficient detail of the investigation to show the facility conducted a thorough investigation. The outcome of the investigation should state what effect the incident had on the resident. The facility should identify corrective actions (e.g., disciplinary action, in-service to staff, care plans updated, etc.) .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to maintain medication storage areas free of expired medications and securely store medications, for one of two medication rooms...
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Based on observation, interview, and record review, the facility failed to maintain medication storage areas free of expired medications and securely store medications, for one of two medication rooms and three of three medication carts reviewed for medication storage. This deficient practice resulted in the potential for administration of lessened efficiency medications. Findings include:
On 12/6/23 at 4:30 PM, medication cart B on the first floor was inspected. In the second drawer beneath the medication cards an observation was made of several loose pills identified as; one quetiapine 25 mg (milligrams), one pantoprazole 40 mg, one acetaminophen 325 mg, one baclofen 5 mg, and two other pieces of unidentified pills. In the first drawer an observation was made of a bottle of cetirizine with a worn, unreadable expiration date. Registered Nurse (RN) C confirmed night shift routinely cleaned medication carts, and no loose pills or pieces should be left in the medication cart and should be stored accordingly.
On 12/6/23 at 4:45 PM, the medication store room on the first floor was inspected with RN F. In the cupboard an observation was made of 38 expired acetaminophen suppositories with lot number 0G6671 and expiration date 6/2023. RN F verified the medication was expired and no expired medications were to be kept in the medication storage room if expired.
On 12/6/23 at 4:55 PM, RN F provided this Surveyor with a check list titled, Monthly Expiration Checklist for the first floor medication room and was incomplete for the month of December. A second document was provided titled, Med Room/Med Cart Weekly Audit for the first floor and was dated completed on December 3rd, 2023. RN F was asked if the audits for expired medications and clean medication cart were being performed, and why there were still expired medications and loose pills in the medication carts and replied, There should not be any.
On 12/6/23 at 5:00 PM, medication cart A on the first floor was inspected. In the second drawer beneath the medication cards an observation was made of one loose lisinopril 20 mg.
On 12/6/23 at 5:30 PM, medication cart B on the third floor was inspected. In the second drawer beneath the medication cards an observation was made of loose pills identified as; one sertraline 50 mg, one metoprolol 50 mg, and one other piece of an unidentified pill. In the third drawer an observation was made of two bottles of glucose control solution, one for high range and the other for low range with both dated as opened on 8/30/23. In the first drawer an observation was made of a bottle of cetirizine with a worn, unreadable expiration date.
On 12/6/23 at 5:45 PM, an interview was conducted with RN G. RN G was asked how long the glucose control solution was good for after opening it and replied, I am not sure I would have to check. I think until it expires. I will find out. RN H Unit Manger was asked how long the solution was good for and replied, I will find out from pharmacy. Both RN G and RN H confirmed that the glucose testing solution was only good for 3 months after opening and that the solution was no longer ok to use to ensure the glucometer was calibrated properly and was past expiration for almost a week. RN H also confirmed night shift routinely cleaned medication carts, and no loose pills or pieces should be left in the medication cart and should be stored accordingly.
On 12/7/23 at 8:50 AM, an interview was conducted with the Nursing Supervisor for the third floor RN E. RN E provided a document titled, Monthly Expiration Checklist for the third floor medication room and was incomplete for the months of March, June, November and December 2023. A second document was provided titled, Med Room / Med Cart Weekly Audit for the third floor, was dated December 2023, and was incomplete for the first week. RN E was asked if the audits for expired medications and clean medication cart were being performed, and why there were still loose pills in the medication carts and replied, Carts should be cleaned regularly, and medications should not be loose.
Review of facility document titled, Common Short Date Medication Expirations and Labeling, read in part, .Stock Items .Glucometer Test Strips and Control Solutions .Expiration 3 months .
Review of facility policy titled, Medication Storage, dated 11/2023, read in part, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by:
1. Failing to ensure four packages of lunch meat were disposed of after the expiration date stamped by the packager.
2. Failing to ensure resident care staff on the locked units were wearing hair restraints when they entered the kitchen, during meal service.
These deficient practices have the potential to result in food borne illness among any and all 124 residents of the facility. Findings include:
1. On 12/05/23 at approximately 1:35 PM, observations were made in the walk in cooler in the main kitchen on ground floor. Four packages of lunch meat were observed on a shelf in the walk in cooler, two containing ham and two containing roast beef. The packages of ham had use by/freeze by date of 11/6/23, and the two roast beef packages had use by/freeze by date of 11/20/23. Both packages were bloated. An interview with Certified Dietary Manager (CDM) A was conducted at this time who acknowledged the packages of lunch meat should have been discarded.
The FDA Food Code 2017 states: 3-101.11 Safe, Unadulterated, and Honestly Presented. FOOD shall be safe, unadulterated,
2. On 12/05/23 at approximately 5:05 PM, the evening meal was observed in the locked unit's dining areas. An open steam table was being used to hold hot food in a kitchen area. Direct care staff were observed in and around the steam table, while the food was uncovered, [NAME] about. None of these staff had their hair restrained.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to complete a comprehensive facility-wide assessment that included an assessment and determination of staffing levels based on resident acuity...
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Based on interview and record review, the facility failed to complete a comprehensive facility-wide assessment that included an assessment and determination of staffing levels based on resident acuity, and training programs that would be provided to facility staff. This deficient practice resulted in the potential for insufficient staff and staff training necessary to care for residents. Findings include:
Review of the 43 page Facility Assessment 2023-2024 provided by the Nursing Home Administrator (NHA) on 12/5/23 at 15:49 (3:49 p.m.) revealed Section II. Staffing, Training, Services & Personnel were all documented as Evaluated with the following Sufficiency Analysis Summary, in part: Staffing patterns have been reviewed on [Staffing Name Program]. The facility continues to utilize [Name Brand] Learning platform for annual and supplemental training . For additional information see attachments . No attachments were present with the Facility Assessment. Staffing levels based on acuity were not delineated in the Facility Assessment, nor were the required staff trainings offered to facility staff.
During an interview on 12/8/23 at 1:00 p.m., the NHA confirmed the Facility Assessment provided on 12/5/23 did not have any of the required staff trainings specified within the document. The NHA said he had updated the Facility Assessment, that same day 12/8/23, to include all of the required staff trainings. The NHA also acknowledged the Facility Assessment did not include the staffing levels required and or currently utilized based on resident acuity. Necessary staffing level needs were neither numerically nor verbally described in the Facility Assessment document. The NHA said he had not updated the Staffing section of the assessment but would be working on inclusion of the information in the updated Facility Assessment. The NHA said he was aware that this information was to be completed and part of the Facility Assessment, but he had only been employed by the facility since September 2023 and there were many tasks to accomplished in the last several months.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
.
Based on interview and record review, the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members...
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.
Based on interview and record review, the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. This deficient practice resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues, placing all 124 residents in the facility at risk for quality care concerns. Findings include:
During an interview on 12/08/23 at 11:00 the QAPI process was discussed with the Nursing Home Administrator (NHA). The NHA stated the QAPI team met at least quarterly and as needed to coordinate and evaluate quality assessment program activities. The attendance documents were reviewed for the 1/27/23, 4/27/23, and 10/28/23 meetings. No attendance documentation was found between April and October. The NHA had assumed his role recently and could not speak to the attendance during that time frame.
The facility Quality Assurance Performance Improvement (QAPI) Plan dated as last approved 12/2023, read in part The QA & A (Quality Assurance) Committee reports to the Administrator and Governing Body and is responsible for: 1) Meeting, at minimum, on a quarterly basis, more frequently if necessary .
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and record review, the facility failed to post the required accurate daily nursing staffing information. This deficient practice resulted in the inability of residents...
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Based on observation, interview, and record review, the facility failed to post the required accurate daily nursing staffing information. This deficient practice resulted in the inability of residents and visitors to determine the number of nursing staff available to provide resident care and had the potential to affect all 124 facility residents. Findings include:
During an observation on 12/6/23 at 1:06 p.m., the staffing posting was observed at the facility entrance with Registered Nurse (RN) R. There was no differentiation between the number of RN's working and the number of Licensed Practical Nurses (LPNs) working, to show whether an RN was scheduled to work in the facility for eight hours a day. This was noted on both the day and the night shift posting for 12/06/23.
Review of nursing staff postings, provided by the Director of Nursing (DON), from 11/21/23 through 12/5/23, showed a similar presentation, with no differentiation between RN and LPN coverage during the day and night shifts.
During an interview on 12/8/23 at approximately 1:45 p.m., the Assistant Director of Nursing (ADON), RN L, confirmed the facility had not been differentiating how many RNs verses LPNs worked in the facility daily via the nursing staff postings. RN L reported they understood the concern and had already worked on making a correction to the current nursing staff postings.
Review of the policy, Nursing Services and Sufficient Staff, revised 10/2023, revealed, It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's census, acuity, and diagnoses of the resident population will be considered based on the facility assessments. The facility will supply services by sufficient numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. A. Except when waived, licensed nurses. B. Other nursing personnel, including but not limited to nurses aides .6. Except when waived, the facility must use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. 7. The Director of Nursing or designee will post the daily nursing staff numbers in the front lobby of the facility .
Sept 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure the safety of one Resident (R1) of four residents reviewed for falls, safety, and adeq...
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Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure the safety of one Resident (R1) of four residents reviewed for falls, safety, and adequate supervision. This deficient practice resulted in the unauthorized exit from the secure Alzheimer's unit and the potential for injury for R1. Findings include:
Review of the facility incident investigation report revealed, in part: On 5/21/23, [R1] was observed exiting the building from the north exit door of the dementia unit, on the underside of the building .Upon video review, it was determined that [R1] exited her room at 10:55 (a.m.) . As Resident (R1) emerged from her room, she looked around for a moment and headed straight for the North wing exit door. Resident was out of view on the camera in Woodland (secure Alzheimer's unit) but was seen again at 11:01 exiting the north exterior door under Woodland Haven. It is assumed Resident (R1) was able to navigate the stairwell without any difficulty. You can see her walking out the door with her 4 wheeled walker . (when) asked how she got down the stairs with her walker she (said) that she 'threw it down the stairs' .
The investigation summary further detailed .[R1] had an Elopement Evaluation completed upon admission (in the fall of 2022) and scored a '0' (zero) . Staff completed an Elopement Evaluation on 5/21/2023 and [R1] scored a '1' due to the elopement that happened on that day. A code alert was placed to [R1's] wrist, care plan updated, and 15-minute checks were initiated.
During an interview on 9/27/23 at 8:53 a.m., the Director of Nursing (DON) and Assistant Director of Nursing (DON) both acknowledged R1 had exited the secure Alzheimer's unit via the north exit door, traveled down two flights of stairs (20 steps) and exited the facility from the unalarmed exit door on the floor beneath the Alzheimer's unit. Staff on the unit did not realize R1 had exited the facility. R1 was intercepted outside the facility by staff returning to work through the basement exit door. The DON and ADON confirmed R1 had spent 6 minutes in the stairwell between the floors after leaving the secure dementia unit without supervision.
Review of R1's Minimum Data Set (MDS) assessment, dated 4/19/23, revealed R1 was admitted to the facility Alzheimer's unit, Woodland Haven, on 10/27/22 with diagnoses that included the following, in part: Alzheimer's disease, hearing loss, essential tremor, spinal stenosis of lumbar region, and degenerative joint disease involving multiple joints. R1 had severely impaired cognition and required supervision with setup help for ambulation in their room, corridor, and on the unit with the use of a four-wheeled walker (4WW).
Review of R1's Care Plans revealed the following, in part:
1. Focus: I have impaired cognitive function/impaired thought processes r/t (related to) Alzheimer's and Moderate Dementia without behavioral disturbance. Date Initiated: 11/04/2022. Due to my cognitive loss, it is expected that I explore my surroundings. Attempt to redirect me as much as able. If you feel I could possibly come into harm's way. Date Initiated: 12/12/2022) . I use a code alert to assist in keeping me safe within the facility. Staff to monitor per facility policy. Date Initiated: 05/21/2023 (date of exit from building).
2. Focus: I have an ADL self-care performance deficit r/t my cognitive loss secondary to my Alzheimer's DX (diagnosis). Date Initiated: 10/31/2022 . AMBULATION: I am independent with my 4WW - report unsteadiness as I have a hx (history) of falls. Date Initiated: 10/31/22.
Review of the facility Video Time Line (sic) revealed the following, in part:
10:55:02 Resident [R1] exits her bedroom.
10:55:41 Resident is at the North wing door but out of view of the camera.
It is between these times, which is assumed, Resident (R1) navigates the stairwell.
11:01:38 Resident (R1) emerges from the exterior door, underneath Woodland Haven.
Observation of the North exit door in Alzheimer's unit on 9/27/23 at 9:45 a.m., with Director of Facilities (Staff) C, showed the North exit door functioned properly. Staff C said the previous maintenance director had completed all of the facility door audits and found all door functioning properly. The North exit door in the unit had functioned properly each time door alarm checks were completed.
Review of the facility door alarm audit forms, confirmed all door alarms have been tested by maintenance staff, and documented as properly sounding when exit, through the doors, was attempted.
Review of the facility Code Alert/Resident Elopement policy, Last Revised 06/2023 (after R1's exit from the building), revealed the following, in part: Elopement occurs when a resident leaves the premises or a safe area with authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so . All Residents residing in Woodland Have are considered at elopement risk being that it is a lock down unit .
During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:
1. Every resident's Elopement Evaluation assessment was reviewed throughout the facility. All 28 residents in Woodland Haven had a new Elopement Evaluation completed and care plans were reviewed, as needed. Elopement risk books/binders were reviewed.
2. The Maintenance Department monitored and logged the functioning of all door alarms and the Code Alert System weekly per policy. Following R1's elopement this was performed twice daily for two weeks and then once daily for two weeks without incident.
3. All staff education was initiated on [online healthcare education source] for wandering and elopement re-education. Individual staff that were working on the unit that day were also educated separately in regard to supervision of residents.
4. Code Alert/Resident Elopement facility policy was reviewed by the DON and revised on 5/26/23,
5. The DON/ADON (Assistant Director of Nursing) monitored the completion of resident elopement assessments were completed once weekly x (times) 6 weeks.
6. Director of Facilities ensured door alarms were functioning properly, without incident x four weeks and then weekly, per policy, thereafter.
7. Audited records will be reviewed by the Risk Management/Quality Assurance Committee until such time consistent substantial compliance was achieved as determined by the committee.
8. Correction Action Completion Date: 5/30/23.
The facility was able to demonstrate monitoring of the corrective action and maintained compliance.
Oct 2022
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to prevent the misappropriation of a controlled medication, by Licensed Practical Nurse, (LPN) I, for one Resident (#92), from two reviewed fo...
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Based on interview and record review, the facility failed to prevent the misappropriation of a controlled medication, by Licensed Practical Nurse, (LPN) I, for one Resident (#92), from two reviewed for abuse. This deficient practice resulted in the potential for untreated pain and unidentified clinical complications. The facility self-identified the deficient practice and put corrective actions in place. The facility was found to be in substantial compliance during the survey ending 10/5/22 and was given past noncompliance with no citation written. Findings include:
The facility investigation, not dated, revealed Resident #92 reported he did not receive his morning diuretic medication on 9/28/22. The Resident reported the omission was the second one in a matter of days. The facility immediately began an investigation, which included interviews, video surveillance review and controlled substance reconciliation reviews.
The video surveillance review showed LPN I never entered Resident #92's room on the night shift on 9/28/22 but signed out and dispensed the diuretic medication as well as a controlled pain medication. The surveillance further showed LPN I took the medications from the cart and was visualized orally ingesting, what appeared to be the medications dispensed for Resident #92.
LPN I was immediately terminated by the facility, and the staffing agency through which her employment was procured was notified, as well as the local police, the State Agency, and the Nursing Licensing Board.
The policy Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 4/2022, revealed, .[Facility] will not tolerate Abuse .of its residents or the Misappropriation of Resident Property .
Resident #92, as well as other potentially affected Residents were thoroughly assessed for adverse outcomes. The facility self-identified the deficient practice, responded per its abuse policy and immediately put into place a plan of correction, which included:
1: Assessment of Resident #92, with appropriate follow up; notifications to local law enforcement, State Nursing Licensing Board, State Agency and the Resident.
2: Other potentially affected Residents were assessed with complete medical record reviews and controlled substance reconciliations and appropriate follow up.
3: Nursing staff were educated on the facility Drug and Alcohol Abuse Policy, including signs and symptoms to be aware and report. Staff were also educated regarding self-reporting and resources available through Employee Assistance and Health Professional Recovery programs.
4: Pharmacy conducted reviews for point of use and medication administration records for any discrepancies. Mock surveys remained ongoing through the facility's Quality Assurance Performance Improvement (QAPI) program.
Interviews were conducted with nursing staff on 10/4/22 at 3:03 p.m. and 3:08 p.m. respectively with Registered Nurse (RN) J and LPN K, and RNs L and M, which confirmed staff knowledge of and retention of education regarding signs and symptoms of drug diversion/on shift use, employee assistance programs and reporting of suspected violations. Posters, information, and hotline numbers were seen posted at each nursing conference room. Medication carts were reviewed and controlled substances reconciled.
The facility was granted past non-compliance and was deemed compliant at F602 on 9/29/22.
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CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review the facility failed to ensure communication/documentation occurred with hospice service s...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .
Based on interview and record review the facility failed to ensure communication/documentation occurred with hospice service staff for one Resident (#115) of two residents reviewed for hospice services. This deficient practice resulted in the potential for a lack of coordination of comprehensive services and unmet needs. Findings include:
A review of the medical record for Resident #115 revealed an admission date of 9/2/22 with diagnoses including cancer, coronary artery disease, and heart failure. The Minimum Data Set (MDS) dated [DATE] indicated Resident #115 was receiving hospice services. The Resident Roster printed on 10/3/22 indicated Resident #115 was on hospice. The facility care plan for Resident #115 included: I have a terminal prognosis r/t (related to) a diagnosis of prostate cancer. I am on hospice services.
During an interview on 10/05/22 at 8:14 AM, Licensed Practical Nurse (LPN) H stated Resident #115 was admitted on hospice 9/3/22 and there were no records. LPN H said, They did not send us anything. I will call and have them send over the documents. LPN H described the hospice services received by Resident #115 as multiple nurse and nurse aide visits per week, some weeks even coming daily. LPN H stated, The nurse came at least three days a week, but I am not sure as I don't work every day. The ward clerk (Staff) A reviewed the medical record and could find no plan of care and no paperwork at all from the hospice provider. Staff A stated, I have not received anything from them. Staff A and this surveyor went to Resident #115's room and viewed the hospice folder. A sheet titled NURSE'S PROGRESS NOTES was included in the folder but it was blank. A sheet titled MEDICATION ADMINISTRATION LOG was also present in the folder and was also blank. No documentation of hospice services provided from 9/3/22 to 10/5/22 was found.
During an interview on 10/05/22 at 10:02 AM, the Director of Nursing (DON) stated she would expect the hospice visit notes and hospice plan of care would be available for the facility staff as soon as they were ready.
The facility policy titled Coordination of Hospice Services dated as reviewed 9/2021 read in part: When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff . 6. The facility will maintain communication with hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities.
The Hospice agreement titled: Consent to Assignment read in part, .Hospice and Facility shall communicate with one another regularly and as needed for each particular Hospice patient . Each party is responsible for documenting such communications in its respective clinical records to ensure that the needs of Hospice patients are met 24 hours per day . Hospice must develop and maintain a system of communication and integration to . (4) provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings .
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Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 2 harm violation(s), $39,988 in fines, Payment denial on record. Review inspection reports carefully.
- • 17 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $39,988 in fines. Higher than 94% of Michigan facilities, suggesting repeated compliance issues.
- • Grade F (28/100). Below average facility with significant concerns.
Bottom line: Trust Score of 28/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Canal View - Houghton County's CMS Rating?
CMS assigns Canal View - Houghton County an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Michigan, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Canal View - Houghton County Staffed?
CMS rates Canal View - Houghton County's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 45%, compared to the Michigan average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Canal View - Houghton County?
State health inspectors documented 17 deficiencies at Canal View - Houghton County during 2022 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 13 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Canal View - Houghton County?
Canal View - Houghton County is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility operates independently rather than as part of a larger chain. With 197 certified beds and approximately 124 residents (about 63% occupancy), it is a mid-sized facility located in Hancock, Michigan.
How Does Canal View - Houghton County Compare to Other Michigan Nursing Homes?
Compared to the 100 nursing homes in Michigan, Canal View - Houghton County's overall rating (2 stars) is below the state average of 3.1, staff turnover (45%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Canal View - Houghton County?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Canal View - Houghton County Safe?
Based on CMS inspection data, Canal View - Houghton County has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Michigan. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Canal View - Houghton County Stick Around?
Canal View - Houghton County has a staff turnover rate of 45%, which is about average for Michigan nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Canal View - Houghton County Ever Fined?
Canal View - Houghton County has been fined $39,988 across 2 penalty actions. The Michigan average is $33,479. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Canal View - Houghton County on Any Federal Watch List?
Canal View - Houghton County is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.