Canal View - Houghton County

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 1/26/2026 at 1:45 PM, during initial kitchen walk through with Dietary Data Tech D, an open container of sour cream was observed in an upright cooler. Written in marker on the outside of the container was Sour Cream O with a slash mark through the O (for date opened) 1/25/26, then below that X 2-18-26 for a total of 25 days. Dietary Data tech D stated the last date X was the date the product was to be thrown out. On 1/26/2026 at 3:40 PM, a bag of milk was observed in the bulk milk dispenser in the 1st floor kitchen dining area with a dispose by date sticker of 2/3/26, which is a total of 8 days since it was opened. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that environmental equipment utilized by residents was maintained in a manner that allowed equipment to be appropriately cleaned and sanitized for seven Residents (#34, #120, #103, #11, #18, #53, & #138) of eight residents reviewed for a clean, sanitary and homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adaptive dining equipment for six Residents (#82, #26, #33, #59, #16 & #115) of seven residents reviewed for adaptive dining equipment needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent worsening and the development of a pressure ulcer for one Resident (Resident #53) of one resident reviewed for pressure ulcer development.

Inspectors wroteBased on observation, interview and record review, the facility failed to use foot pedals to safely propel three wheelchair dependent Residents (#33, #115 and #126) of five residents reviewed for safe wheelchair mobility.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate toileting assistance to prevent a fall, for one 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.

Inspectors wroteThis deficiency pertains to Intake 2574829. Based on observation, interview and record review the facility failed to provide comfort care based on the individual's personalized care plans, for one Resident (R1) of one resident reviewed for quality of care. This deficient practice resulted in unaddressed anxiety and fear related to shortness of breath during the dying process.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteThis 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.

Inspectors wroteThis 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.