Canal View - Houghton County
Canal View - Houghton County in Hancock, MI — inspection on September 25, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the Coordination of Hospice Services policy, effective 11/2024, revealed the following, in part: Policy - When a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being . 9.
All residents receiving hospice will continue to receive the same facility services as residents who have not elected hospice . 10.
The facility will immediately contact and communicate with hospice staff, attending physician/practitioner and the family resident representative regarding any significant changes in the resident's status, clinical complications or emergent situations .
Review of the Medication Administration policy, effective 3/2025, revealed the following, in part: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .
Administration should occur within 60 minutes prior to or after scheduled time, unless otherwise ordered by physician, or given per individual resident circumstances or preferences as applicable .
Review of the Pain Assessment and Management policy, effective 12/2024, revealed the following, 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 .G.
Nursing should evaluate pain status, interventions and effectiveness of pain interventions and document in the nursing notes and EMAR as applicable.
Update the Physician as needed. H.
When giving PRN pain medications, nursing should document follow-up assessment in the EHR. I.
Non-pharmacological interventions for pain (i.e., repositioning, massage, turning lights off, warm cloth, etc.) should be attempted and documented appropriately.
These may be used alone or in combination with pharmacological interventions.During the exit conference, at approximately 3:10 p.m., in the presence of the NHA, DON and Corporate Compliance Officer U. the NHA and DON acknowledged LPN E should have assessed the effectiveness of the Morphine Sulfate and Lorazepam both administered at approximately 7:30 p.m., to determine if additional interventions and/or medications were necessary to provide comfort during the dying process.
The NHA acknowledge and agreed that nursing documentation should have included assessment of the resident's condition.
This Surveyor expressed concern that R1's primary nurse, LPN E did not enter the resident's room after administration of Morphine Sulfate and Lorazepam, until more than two hours later, and no assessment of her comfort level was performed or documented.During a return telephone interview on [DATE] at 5:33 p.m., Friend D, who was present with R1 on the evening of her passing, was asked to provide details of the evening of [DATE].
Friend D stated, .around 8:00 p.m. she [R1] started breathing a lot heavier, but by 8:30 p.m. she was gasping for air.
Between 8:30 p.m. and 9:20 p.m., she would literally sit up and cry out and say ,‘Please help me I can't breathe. I can't breathe'. [A family member] went out to talk to one of the med techs that was on that night, to ask if [R1] could get her morphine dose .
She (R1) would shoot up, sitting right up and begging for us to help her . we waited . and were told she (nurse) could not give another dose (of morphine) .
The last hour was the worst thing I have ever seen in my whole life. It would be one thing if she wasn't asking us for help, but she was begging us to help her and there was nothing we could do.
The nurse never came back into the room after giving the morphine at 7:30 p.m.
The nurse did not come back in until a half hour after [R1] was already gone.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Canal View - Houghton County
1100 Quincy Street Hancock, MI 49930
SUMMARY STATEMENT OF DEFICIENCIES
Review of R2's Care Plans revealed the following, in part: DO NOT leave me unattended as I have fallen in the past.
Two people must remain with for the entire toileting duration.
Date Initiated: 08/17/2023 .
Revision on 05/16/2025.
Review of the facilities' Investigation Summary revealed the following interventions to prevent recurrence and ensure residents' safety, in part: .Staff members will remain with the residents throughout the entire toileting process.
During clothing changes, staff will remain contact guard assist to ensure stability and prevent loss of balance. A commode with armrests will be used to provide additional support and stability during toileting.
Random audits will be conducted daily for 2 weeks, 3x's week for 1 week, 2x week for 1 week and 1x a week for 1 week for a duration of 5 weeks to ensure adherence to the updated protocol and care plan requirements .
Facility ID: