Canal View - Houghton County

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

is breakthrough pain . Promote a calm, supportive environment by actively listening to myself/family when expressing feelings . (all) Initiated: [DATE REDACTED]. 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 Resident 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 REDACTED] at 5:33 p.m., Friend D, who was present with Resident R1 on the evening of her passing, was asked to provide details of the evening of [DATE REDACTED]. Friend D stated, .around 8:00 p.m. she [Resident 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 [Resident R1] could get her morphine dose . She (Resident 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 [Resident R1] was already gone.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Canal View - Houghton County

1100 Quincy Street Hancock, MI 49930

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure adequate toileting assistance to prevent a fall, for one Resident (Resident R2) of three residents reviewed for falls. This deficient practice resulted in a fall with major injury, including fractured facial bones and subdural hematoma. Findings include: This deficiency pertains to Intake 2625013,Review of Resident R2's Electronic Medical Record, revealed Resident R2 was admitted to the facility on [DATE REDACTED], with diagnoses that included the following, in part: Alzheimer's disease with late onset, dementia with agitation, dementia with anxiety, reduced mobility, need for assistance with personal care, stiffness of right hip, stiffness of left hip, and stiffness of right knee. Resident R2 score 0/15 on the Brief Interview for Mental Status (BIMS) performed in August of 2025, reflective of severe cognitive impairment.Review of the Incident Report dated 9/14/25 at 1545 (3:45 p.m.), revealed the following: .Incident Description: . CNA (Certified Nurse Aide) called this nurse into common bathroom stating resident fell on floor. Upon entering the bathroom resident (Resident R2) was observed lying face down on bathroom floor bleeding from the head. Resident assessed with assistance of CNA for bleeding and pressure applied to laceration on right side of head.

Attempted to get blood pressure twice but unable to related to positioning and resident crying out. Charge nurse informed of situation and took control of notifying EMS (Emergency Medical Services) and family .

Immediate Action Taken: Pressure applied to laceration and transferred to ER (emergency room) via EMS . 9/17/25 Notes: .The resident was assisted to the toilet in the shower bathroom by [CNA's J and I] with an EZ Stand. While standing, [Resident Resident R2] was unable to wait and soiled his clothing. [Resident R1] was then seated

on the toilet. CNA I exited the room, and CNA J continued assisting the resident by changing his soiled clothing. A towel was placed on the floor to prevent slipping. While removing clothing from the resident's legs he leaned to the right, lost balance, and fell. Resident R1 sustained lateral and floor (sic) right orbital wall fractures, right zygomatic arch fracture (a break in the bone that forms the lower part of the cheekbone and extends to the temple), right maxillary sinus wall fracture, and a subdural hematoma. Root cause: Care plan was not followed. Resident is care planned to have two caregivers present for the entire toileting process .

Intervention: CNA was re-educated on the importance of adhering to the resident's care plan. The care plan was updated to specify use of commode with two-person assist for the full toileting duration and contact guard assist during clothing changes. Therapy will evaluate residents. Review of Resident 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 .

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