Orchard Creek Skilled Nursing

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from neglect by facility staff for one Resident (#4) of one residents reviewed for abuse and neglect. This deficient practice resulted in actual harm when Resident #4 experienced unnecessary pain and persistent feelings of fear and anxiety.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being of residents.

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:Failing to label, date, and discard expired food in the reach-in refrigerator, walk-in refrigerator, walk-in freezer, and dry storage. Failing to ensure kitchen utensils were stored in a sanitary manner. Failing to ensure the ice cube machine/bin was free from mold accumulation. These deficient practices have the potential to result in food borne illness among any or all of the 17 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to annually review and update the required Facility Assessment, resulting in the potential for unidentified resources necessary to provide care and services to the resident population.

Inspectors wroteBased on interview and record review, the facility failed to obtain complete and comprehensive informed consents prior to the administration of psychotropic medications for three Residents (#4, #17, and #20) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to assure that procedures were developed and implemented for consistent and accurate processing of medication orders for two Residents (#8 and #15) of six residents reviewed for pharmacy services. This deficiency resulted in Resident #8 being administered the incorrect dosage of an anxiolytic medication and the potential for the inaccurate administration of an anticoagulant for Resident #15.

Inspectors wroteBased on observation, interview and record review, the facility failed to assure the implementation of Enhanced Barrier Precautions (EBP) according to physician order and current standards of practice for two Residents (#10 and #18) of four residents reviewed for EBP utilization.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective abuse training program for two out of five staff members reviewed for new hires and annual training.

Inspectors wroteBased on interview and record review, the facility failed to ensure a consent was signed for psychoactive medication use and an AIMS (Abnormal Involuntary Movement Scale) assessment was completed appropriately for one Resident (R12) of five residents reviewed for unnecessary medications. This deficient practice resulted in the potential for the unnecessary use of mind-altering medications, negative side-effects of medications and decreased quality of life.

Inspectors wroteThis citation pertains to Intake MI00137609. Based on interview and record review, the facility failed to prevent a fall for one Resident (#18) of one resident reviewed, resulting in Resident #18 falling with staff present and sustaining multiple fractures requiring hospitalization and surgery.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate advance directive information was in place for three Residents (R6, R9, and R10) of three Residents reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers. Findings Include: Review of the MICHIGAN DO-NOT-RESUSCITATE PROCEDURE ACT, Act 193 of 1996 (Revised 3-25-14), revealed, An order executed under this section shall be on a form described in section 4. The order shall be dated and executed voluntarily and signed by each of the following persons: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper label and dating of foods with the potential to effect 7 of 8 residents (1 resident receives nothing by mouth) resulting in the increased risk of food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of visitor to resident verbal abuse to the State Agency for one Resident (#6) of one resident reviewed, resulting in an allegation of abuse that was unreported to the State Agency and the potential for further abuse allegations to go unreported.

Inspectors wroteBased on observation, interview, and record review, the facility failed to investigate an allegation of visitor to resident verbal abuse for one Resident (#6) of one resident reviewed, resulting in an allegation of abuse that was not investigated and the potential for further abuse to occur.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive care plans for 2 Residents ( #5 & #12) of 7 residents reviewed resulting in the potential for unmet care needs. Resident #5 (R5) Review of the medical record revealed R5 was admitted to the facility on [DATE] with diagnoses that included type two diabetes with unspecified complications, Covid 19 and anemia in chronic kidney disease. The Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 10/13/23 revealed R5 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). In an observation and interview on 10/23/23 at 9:23 AM, R5 was seated in her room watching television. [...]

Inspectors wroteThe facility failed to assist residents/representatives to engage/participate in the care planning process, including attendance at care planning conferences with facility Interdiciplinary Team(IDT) for one Resident (R10), of seven residents reviewed, resulting in the liklihood of unmet care needs and delay in discharge planning.

Inspectors wroteBased on observation, interview and record review, the facility failed to: (1.) prevent Urinary Tract Infections (UTI's); (2.) failed to follow up with urology appointment; and (3.) provided catheter care per CDC standards of practice for one Resident (#10) of one resident reviewed for catheters and UTI's, resulting in the likelihood of signs and symptoms of catheter complications going unnoticed, catheter dislodgment, missed urology follow up appointment, and catheter associated urinary tract infection with hospitalization and prolonged illness.

Inspectors wroteBased on interview and record review, the facility failed to develop an abuse policy consistent with current regulatory language for reporting allegations of abuse to the State Agency, resulting in the potential for allegations of abuse to not be reported timely to the State Agency for all eight facility residents.

Inspectors wroteBased on interview and record review, the facility failed to annually review and update the facility-wide assessment to address the resident population, acuity, staffing levels, physical environment and risk assessment which had the potential to affect all 8 residents residing at the facility. This deficient practice resulted in the increased likelihood for insufficient resources to provide for resident care and emergency/disaster needs.