The Orchards at Big Rapids

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. Findings Include:On 04/20/2026 at 9:50am, observed in the residents' refrigerator located in East Hall nursing station, a 32-ounce container of Greek yogurt, that was half full, without a resident name or room number and without a date as to when the container was received or opened. When asked who was responsible for labeling the food with resident's information and the date, Dietary Manager (DM) N replied, if the food does not come from the kitchen, it is the responsibility of the staff, who placed the food in the refrigerator. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to properly clean 1 Residents (R36's) BiPap (Bilevel Positive Airway Pressure) machine (equipment use to assist in breathing), properly clean a facility glucometer (meter used to test blood sugar) after use and fully operationalize the facility legionella prevention plan and failed to follow Enhanced Barrier Precautions during wound care.

Inspectors wroteDuring observation, interview, and record review, the facility failed to provide privacy for 2 of 10 residents (R3 and R39) observed during medication administration.procedures.

Inspectors wroteThis citation refers to Intake 2724753 and Intake 2793094. Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.and did not report an allegation of abuse and a potential crime to law enforcement for 2 of 5 residents (R77 and R85) reviewed for abuse.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assess, monitor and properly treat a wound and medical condition, lymphedema for 1 resident (R36) of 3 residents reviewed for wounds and medical care.

Inspectors wroteBased on interview and record review, the facility failed to properly transport a resident in a wheelchair for 1 of 21 sampled residents (R39).

Inspectors wroteBased on observations, interview, and record review, the facility failed to have ongoing respiratory assessments and documentation of use of a BiPap (Bilevel Positive Airway Pressure) machine for 1 Resident (R36) of 1 Resident reviewed for respiratory equipment use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (5%) for 2 of 7 residents (R2 and R3) observed during the medication administration task.

Inspectors wroteBased on observation, interview, and record reviw, the facility failed to secure medications in 1 of 5 medication carts (200 Hall Medication Cart) or a medication room.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 21 sample residents (R85).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment potentially effecting 64 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of practice for medication administration for two of six residents (Resident #1 and Resident #17) reviewed for professional standards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary oxygen supplies in 3 (R19, R29 and R115) of 4 residents reviewed for respiratory care from a total sample of 17 residents.

Inspectors wroteBased on interview and record review, the facility failed to 1.) involve the resident representative in the psychotropic medication management process for 2 residents (Resident #3 and #45) and 2.) failed to monitor laboratory studies for 1 resident (Resident #33) out of 6 residents reviewed for psychotropic medication use.

Inspectors wroteBased on observation, interview, and record review the facility failed prevent a facility-acquired pressure ulcer, and measure, assess and promote the healing with an appropriate dressing change for one resident (Resident #63) of 1 resident reviewed for pressure ulcers. This deficient practice resulted in Resident #63 developing an unstageable pressure ulcer on the heel.

Inspectors wroteBased on interview and record review, the facility failed to 1.) Accurately document administration of controlled substances and 2.) Ensure that narcotic medications were administered following the physicians' orders for 4 residents (Resident #5, Resident #7, Resident #9, and Resident #54), reviewed for controlled substances, resulting in medication errors.

Inspectors wroteDeficient Practice Statement B This Citation pertains to Intake Number M100142728. Based on interview and record review, the facility failed to ensure that one resident (Resident #7) of 1 resident reviewed, received the medications necessary to prevent seizures.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure: 1.) Hand sink was being used and properly maintained 2.) Food contact surfaces were being maintained in a clean and sanitary condition free from contamination, and 3.) Effectively maintain food and non-food contact areas, affecting 67 residents, resulting in the increased likelihood for cross-contamination and bacterial growth.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a dignified dining experience for 2 residents (Residents #23) R23 and (Resident #63) R63 observed for dining.

Inspectors wroteBased on observation, interview and record review the facility failed to provide dependent residents with assistance to shower and with personal hygiene for 3 of 4 residents (Resident #23) R23, (Resident #47) R47 and (Resident #63) R63.

Inspectors wroteBased on observation and interview, the facility failed to properly utilize resident equipment for one resident (Resident #53), resulting in the potential for serious injury from falls or entanglement for residents not receiving assistance with propelling in wheelchairs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safeguard the confidentiality of medical records for 3 of 67 facility residents [Resident #11 (R11), Resident #14 (R14), and Resident #121 (R121)], resulting in the potential for unauthorized access to resident medical records, and the potential for the loss of resident privacy and confidentiality of their personal health information.

Inspectors wroteThis citation is related to intakes MI00135808, MI00140665, and MI00136503 Based on observation, interview, and record review, the facility failed to ensure (a) call lights were within reach and (b) fluids were offered between meals throughout the day, for one of four residents (Resident #120) reviewed for accommodation of needs, resulting in the potential for unmet needs, the inability to summon help urgently, and dehydration.

Inspectors wroteThis citation pertains to intake #: MI00136503 Based on interview and record review, the facility failed to 1.) accurately document the administration of controlled medications and 2.) ensure controlled medications were administered following the physician order for 5 residents (Resident #119, #122, #123, #125, and #126), reviewed for medication administration, resulting in controlled medications not being administered and the potential for overdose and/or ineffective management of pain, and the potential for drug diversion of controlled substances.

Inspectors wroteThis citation pertains to intake #: MI00138274 Based on interview and record review, the facility failed to 1.) allow a resident to return to the facility after an emergency room (ER) evaluation and 2.) notify the residents DPOA (Designated Power of Attorney) in writing of their appeal rights for 1 resident (Resident #105) reviewed for facility initiated transfers, resulting in Resident #105 being denied return to the facility, the inability of Resident #105's guardian to appeal the involuntary discharge, and the potential for increased stress and lack of appropriate and safe living accommodations.