Future Care Canton Harbor

Inspectors wroteBased on observations and interviews with facility staff, it was determined the facility failed to protect residents' personal health information from being publicly displayed. This was found to be evident for 3 (Resident # 4, # 30, and # 136) of 3 residents observed with Covid precaution signs posted during the facility's survey.

Inspectors wroteBased on observations, record reviews and interviews with the resident family and facility staff, it was determined the facility failed to provide documentation of a resident refusal to get out of bed. This was found to be evident during observations of 1 (Resident # 6) of 2 residents reviewed for activities during the survey.

Inspectors wroteBased on complaints, reviews of active and closed medical records, reviews of the residents' electronic medical records, and interviews with staff members, it was determined that the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident in 3 (Resident #2, #6, #10) of 11 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint and reviews of a closed medical record, it was determined that the facility staff failed to follow a physician's order to administer an antibiotic for 3 days, a total of 6 doses. This was evident for 1 (Resident #6) of 11 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, reviews of a closed medical record, reviews of the resident's electronic medical records, and interviews with facility staff members, it was determined that the facility staff failed to 1) update a resident's skin and wound care plan after being readmitted with actual stage II wounds, 2) document a resident's assessment timely demonstrating the healing or deterioration of a resident's Stage II wounds, and notifying the resident's physician and family of the resident's stage II wounds. This was evident in 1 (Resident #2) of 11 residents reviewed during a complaint survey.

Inspectors wroteBased on medical record review, administrative record review, and staff interview; it was determined that the facility failed to protect a cognitively impaired resident (resident #1) from physical abuse from a facility staff member. This was evident for 1 of 5 residents reviewed for abuse during a complaint survey. This failure to protect residents from physical abuse by a facility staff member resulted in an Immediate Jeopardy. However, the facility developed, initiated, and completed an acceptable plan of correction to prevent further abuse which met all elements of past noncompliance. The period of noncompliance began on 2/12/24 and ended on 2/20/2024.

Inspectors wroteBased on medical record review, administrative record review, and staff interview; it was determined that the facility failed to report the alleged abuse of a cognitively impaired resident (resident #1) to the proper authorities. This was evident for 1 of 5 residents reviewed for abuse during a complaint survey. The following terms are defined for comprehension of the investigative

Inspectors wroteBased on review of facility reported incident investigations and interview, it was determined the facility staff failed to thoroughly investigate allegations of abuse. This was evident for 1 (Resident #2) of 5 residents reviewed for abuse during a complaint survey.

Inspectors wroteBased on tour, observation, and interview, it was determined that the facility failed to secure and monitor chemicals in an active resident area. This was evident during a random tour on the 3rd floor of the facility.

Inspectors wroteBased on reviews of a Facility Reported Incident (FRI) and interviews, it was determined that the facility failed to thoroughly investigate allegations of abuse. This was evident for 6 (#4, #21, #57, #55, #106, & 455) out 21 residents reviewed for abuse.

Inspectors wroteBased on observation and interview with facility staff it was determined that the facility failed to serve food at appetizing temperatures. This was evident during 1 of 1 food test tray samples reviewed during an annual survey.

Inspectors wroteBased on observations, interviews with facility staff and review of facility records it was determined that the facility failed to: 1) store food in accordance with professional standards for food service and safety, and 2) keep complete kitchen records. This was found evident of 1 of 4 kitchen observation and 2 of 3 kitchen record reviews during the annual survey.

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical and nursing needs. This finding was evident for 2 of 4 residents (#103 and #146) review for care plan.

Inspectors wroteBased on interview and medical record review it was determined that facility staff failed to provide an explanation in the resident's medical record to demonstrate the absence of the resident from their care plan meetings and 2) update a resident's care plan to reflect a new diagnosis with recommended treatments. This was evident for 1 (Resident #99) out of 3 residents reviewed for care planning during the investigation portion of the survey.

Inspectors wroteBased on interviews and resident record reviews, it was determined that the facility failed to provide scheduled showers to residents. This was evident of 2 of 2 residents (Resident #398 and #108) reviewed for Activities of Daily Life (ADL) care on an annual and complaint survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility staff failed to ensure skin alterations were documented in the medical record. This was evident for 1 (#451) of 65 residents reviewed during the recertification survey. It was determined that the facility's failure to document the skin alterations resulted in past non-compliance which existed from 01/12/2023 until 01/29/2023.

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to provide respiratory care consistent with professional standards for oxygen administration. This was found evident of 1 out of 5 (Resident #128) residents reviewed for respiratory care during an annual and complaint survey.

Inspectors wroteBased on interview and record review it was determined that the facility failed to administer pain medications consistent with professional standards. This was found evident of 1 of 5 (Resident # 41) residents reviewed for pain management during the annual survey.

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to store medication in a locked compartment. This was found evident on 2 of 2 random observations.

Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to ensure that infection control practices and guidelines were followed. This was found to be evident for 3 (resident #474, 475 and #110) out of 65 residents reviewed for infection control.

Inspectors wroteBased on resident and staff interview, observation and medical record review, it was determined that the facility failed to develop and implement comprehensive person-centered care plans with measurable goals. This was evident for 12 (#38, #51, #53, #81, #127, #132, #6, #90, #130, #25, #59, #31) of 40 residents reviewed.

Inspectors wroteBased on observation and review of medical records, it was determined that the facility failed to perform appropriate revision to care plan goals and interventions as resident care needs became apparent or changed over time. This was evident for 6 (# 48, #53, #27, #110, #25, #437) of 40 residents reviewed.

Inspectors wroteBased on staff interview, observations and review of the medical record, it was determined that the facility staff failed to have an effective quality assessment and assurance (QAA) program based on repeat deficiencies related to ensuring a resident's dignity, accurate comprehensive assessments and the facilities ineffective QAA program.

Inspectors wroteBased on resident interview, observation and medical record review, it was determined that the facility staff 1) failed to ensure access to the nurse call bell for a resident who was dependent on nursing staff due to impaired mobility and 2) failed to ensure access to be able to turn the over the bed light on and off. This was evident for 5 (#51, #127, #6, #90, #388) of 32 residents observed in the initial resident pool.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was evident for 15 of 35 resident rooms observed during the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to conduct an accurate, comprehensive assessment by failing to assess a resident's cognition and mood on comprehensive MDS assessments and failing to accurately code a resident's dental status. This was evident for 7 (#6, #130, #110, #31, #42, #51, #53) of 40 residents reviewed. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on these individualized needs, and that the care is provided as planned to meet the needs of each resident.

Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to conduct an accurate assessment by failing to assess a resident's cognition and mood on quarterly MDS assessments. This was evident for 5 (#110, #31, #42, #51, #26) of 40 residents reviewed. The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.

Inspectors wroteBased on resident interview, medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#38) of 4 residents reviewed for dental status, 2 (#51, #53) of 9 residents reviewed for hospitalizations, 1 (#132) of 5 residents reviewed for accidents and 1 (#25) of 5 residents reviewed for unnecessary medications. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.

Inspectors wroteBased on record review, the facility failed to ensure that resident's pain was managed for 1 ( #131) of 3 residents reviewed for pain.

Inspectors wroteBased on medical record review and staff Interview, it was determined that the facility failed to ensure that a physician or nurse practitioner supervised the immediate care and needs for a resident with a pressure ulcer. This was evident for 1 (#29) of 5 residents reviewed for pressure ulcers.

Inspectors wrote2) Review of the medical record for Resident #132 on 1/30/19 revealed a physician's History and Physical note dated 12/3/18. The note was printed on 12/11/18. An 11/16/18 physician's History and Physical note was printed on 11/21/18. Further review of the medical record revealed a physician's progress note dated 12/20/18 was printed on 12/26/18, a 12/25/18 physician's progress note that was printed on 1/23/19 and a 1/2/19 physician's progress note that was printed on 1/23/19. The physician's progress notes were not in the medical record the day of the visit. The medical records clerk stated during an interview on 1/30/19 at 2:43 PM, the physician dictates the note and then it is sent over through a secure email. Every morning when I come in I print the physician's notes and give it to the charge nurse to file. [...]

Inspectors wroteBased on observation on [DATE] at 09:25 AM, it was determined the facility failed to properly store medications as evidenced by 1) failing to label and date medications when opened and 2) failing to discard a medication after the expiration date. This was evident in 4 of 4 medication carts observed.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to follow infection control practices and guidelines by 1) failing to label and store resident care equipment in a manner to prevent the development and transmission of disease 2) and failing to ensure that medications were administered in a hygienic manner. This was evident for 1 of 5 observed medication passes during medication administration and 3 of 15 resident room observed on Unit 3.

Inspectors wroteBased on observationt it was determined that the facility staff failed to treat a resident with respect and dignity by standing to feed a resident and not being at eye level. This was evident for 1 (#89) random observation.

Inspectors wroteBased on observation and interview with residents, it was determined that the facility failed to ensure that residents were treated with respect and dignity as evidenced by the failure of staff to knock on resident doors and request permission to enter prior to entry. This was evident for 1 of 5 observed medication passes during medication administration observation.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility staff failed to provide written notification of room/roommate change. This was evident for 1 (#437) of 5 residents reviewed for abuse.

Inspectors wroteBased on observation, it was determined that facility staff failed to assure that resident medical records remained private and confidential as evidenced by resident information being left visible on the medication administration computer while the nurse entered the resident's room to administer medications. This was evident for 1 of 5 observed medication passes during medication administration observation.

Inspectors wroteBased on review of resident and facility records and interviews with staff, it was determined that the facility staff failed to provide a safe resident environment free from abuse by failing to address a resident to resident altercation resulting in a second altercation. This was evident for 1 (#25) of 5 residents reviewed for abuse.

Inspectors wroteBased on review of resident and facility records and staff interviews, it was determined that the facility staff failed to immediately report allegations of abuse to the facility administrator and state agency. This was evident for 1 (#25) of 5 residents reviewed for abuse.

Inspectors wroteBased on review of resident and facility records and staff interviews, it was determined that the facility staff failed to investigate alleged abuse and prevent further potential abuse by failing to address an alleged resident to resident altercation resulting in a second allegation of assault. This was evident for 1 (#25) of 5 residents reviewed for abuse.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident for 3 (#51, #132, #130) of 9 residents reviewed for hospitalization.

Inspectors wroteBased on observation, family and staff interview and medical record review, it was determined that the facility staff failed to provide the appropriate care for activities of daily living to residents who were totally dependent on staff for all aspects of care. This was evident for 1 (#48) of 2 residents reviewed for activities of daily living.

Inspectors wroteBased on review of residents' medical records and interview with facility staff, it was determined that the facility failed to ensure that a physician's order for twice-daily blood glucose checks was performed for the first 7 days of the order. This was evident for 1 of 40 residents (Resident #7) reviewed during the investigation phase of the survey.

Inspectors wroteBased on resident and staff interview and medical record review, it was determined the facility failed to arrange follow-up consultation with eye care practitioner to ensure that the resident received proper treatment. This was evident for 1 (#38) of 3 residents reviewed with sensory problems related to vision and/or hearing problems.

Inspectors wroteBased on observation, medical record review and staff interview, it was determined the facility failed to ensure a resident with urinary incontinence received the appropriate services to achieve or maintain as much normal bladder function as possible. This was evident for 1 (#81) of 1 resident reviewed for bladder incontinence.

Inspectors wroteBased on review of the medical record and interview with staff, it was determined that the facility's consultant pharmacist failed to identify and report irregularities in the physicians orders during the monthly drug regimen review. This was evident for 1 (#25) of 6 residents reviewed for Unnecessary Drugs.

Inspectors wroteBased on review of the medical record and interview with staff, it was determined that the facility staff failed to ensure the residents drug regimen was free from unnecessary drugs. This was evident for 1 (#25) of 6 residents reviewed for Unnecessary Drugs.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication by failing to initiate a gradual dose reduction timely when prescribed. This was evident for 1 (#38) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observations of the facility's food service operations and staff interviews, it was determined that the facility failed to properly store an ice machine dispensing scoop and failed to utilize appropriate hair restraints for employees preparing meals for residents. This was noted in the facilities kitchen during random observations.

Inspectors wroteBased on review of the medical record and interview with staff, it was determined that the facility staff failed to maintain accurate medical records by failing to ensure a resident's smoking assessment was complete and accurate, failing to ensure a medication order was transcribed accurately and failing to ensure an accurate diagnosis list in the resident record. This was evident for 1 (#6) of 5 residents reviewed for accidents and 1 (#25) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and interview with facility staff, it was determined the facility staff failed to provide the resident/resident representative with a summary of the baseline care plan including the resident's medications and dietary instructions. This was evident for 12 (#53, #127, #132, #297, #130, #294, #7, #59, #78,#387, #388, #74) of 40 residents reviewed during the investigative stage of the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 2 (#387, #102, #51, #132, #130) of 9 residents reviewed that were transferred to an acute care facility.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to provide notice of the facility's bed hold policy to residents who were transferred to an acute care facility. This was evident for 4 (Resident #387, #102, #51, #132) of 9 residents reviewed for hospitalization.