The Orchards at Douglas Cove

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a significant change in 1 (Resident #102) of 3 residents reviewed for notification, resulting in the physician not evaluating Resident #102 when she experienced a significant weight gain, swelling of her legs, decreased functional abilities, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly identify a change in condition for 1 (Resident #102) of 3 residents reviewed for quality of care, resulting in Resident #102 experiencing unmanaged pain and swelling in her legs, decreased functional ability, frustration, and a 3-day hospitalization for treatment of her symptoms.

Inspectors wroteThis citation pertains to intake #2593174 and #2604697. Based on observation, interview and record review the facility failed to ensure residents received the necessary care and services (assessment, monitoring, and treatments) for PICC line (a long, thin tube inserted through a vein in the arm for long-term IV (intravenous) access to administer antibiotic medication) and non-pressure wounds for 2 of 6 residents (Resident #101 & #104) reviewed for quality of care, resulting in infection and the potential for worsening of medical conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide quality care and treatment for pressure ulcers, consistent with professional standards of practice for 1 resident (Resident #103) of 3 residents reviewed for pressure ulcer prevention and treatment, resulting in the potential for worsening of pressure wounds, and overall deterioration in health status.

Inspectors wroteThis citation pertains to intake #2593174 & 2604697. Based on observation, interview, and record review, the facility failed to provide necessary oxygen and CPAP (a device that delivers continuous positive airway pressure to ensure airway stays open during sleep) per physician orders and maintain oxygen tubing according to the standards of practice for 2 residents (Resident #101 & #104) of 4 residents reviewed for respiratory care, resulting in the potential for respiratory distress, the development and spread of respiratory infection and disease, and the exacerbation of respiratory conditions.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings Include: On 07/15/2025 at 9:16 AM, An initial tour of the kitchen found an increased accumulation of spillage and white flakey debris on the back portion of the floor and floor juncture of the walk-in cooler. On 7/15/2025 at 9:26 AM, Observation of the ventilation hood over the cook line found an accumulation of dust and debris on the filters. When asked when the hoods were cleaned lasts, a sticker on the system stated it was last serviced in March of 2025. When asked if facility staff take them down and clean them, Certified Dietary Manager (CDM) E stated, we don't take them down. [...]

Inspectors wroteThis citation contains two deficient practice statements, A & B.Deficient Practice Statement (DPS) ABased on observation, interview, and record review, the facility failed to effectively implement effective infection control measures which included Enhanced Barrier Precautions (EBP) per facility policy and Centers for Disease Control and Prevention (CDC) guidance, in 5 of 5 residents (Resident #27, #51, #2, #19, & #17) reviewed for infection control, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population. DPS B Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). [...]

Inspectors wroteBased on interview and record review the facility failed to develop comprehensive resident focused care plans based on the comprehensive assessment for 4 residents (Resident #2, #36, #6 and #16) of 12 residents reviewed for care plans, resulting in the potential for unidentified care needs.

Inspectors wroteBased on observation and interview, the facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120 F. This resulted in an increased risk of injury among residents in the facility. Findings Include: On 07/15/25 at 2:19 PM, observation of the boiler room, with Maintenance Director D, found outgoing hot water temperatures to the hall were observed at 118F, and the returning temperature was 110F. On 07/15/25 at 2:36 PM, observation and interview of the hand sink in the C hall shower room, found the hot water reached 130F while using a rapid read thermometer. When asked about taking regular water temperatures, MD D stated he has an assistant that takes the temperatures. On 07/15/25 at 2:40 PM, observation of the C hall dining room sink found the hot water reached 127.5F when tested with a rapid read digital thermometer. [...]

Inspectors wroteBased on observation, interview, and record review, the failed to inform the resident's responsible party in advance and schedule meetings to participate in the formulation of care plans with relevant disciplines (nursing, dietary, social services, and activities) related to assessed healthcare needs for 1 (Resident #16) of 12 sampled residents reviewed for notification of care planning resulting in ineffective communication and the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the resident's need for the security of a locked unit and prevent involuntary seclusion for 1 (Resident #16) of 1 resident reviewed for involuntary seclusion resulting in resident frustration.

Inspectors wroteBased on interview, and record review, the facility failed to provide rationale for the continued use of, and adequate documentation of monitoring, for the use of psychotropic medications for 2 of 5 residents (Resident #27, #6) reviewed for unnecessary medications, resulting in the increased potential for adverse side effects and inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence.

Inspectors wroteBased on interview and record review, the facility failed to implement regular device checks, monitor battery status, and complete functionality tests for their AED (automatic external defibrillator) machine in 1 of 3 residents (Resident #101) reviewed for essential equipment in safe operating condition, resulting in an inoperable device at the time of Resident #101's critical cardiac arrest emergency and the potential for essential equipment to not be operable in a time of need.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the facility dishwasher in an operable manner. This deficient practice had the potential to affect all 47 residents within the facility.

Inspectors wroteThis citation pertains to Intake: MI00149459 Based on interview and record review, the facility failed to ensure 3 of 22 nurse aides reviewed for nurse aide certification license became certified within four months of nurse aide training before continuing to provide resident care, resulting in the potential for inadequate or inappropriate resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received the correct foods as outlined on the planned, posted menu resulting in the potential for dissatisfaction with meal service and feelings of frustration. This deficient practice has the potential to affect all residents who consume food from the kitchen, out of a total census of 49.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: During the initial tour of the kitchen, at 9:15 AM on 7/16/24, it was found that the walk in coolers were dark and hard to see, especially in the back of the unit. When a flashlight was used, heavy accumulation of black debris was evident on the floor perimeter and especially around the wheels and rack legs of the storage shelves. When asked if he was aware of the black accumulation, Dietary Manager (DM) H stated it was hard to see until the flashlight was used. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to properly implement enhanced barrier and contact isolation precautions and the use of personal protective equipment for 4 of 4 residents (Resident #33, Resident #8, Resident #9, and Resident #41) reviewed for infection control, resulting in the potential for cross contamination and spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide equipment maintenance services in a dignified manner for 1 (Resident #29) of 5 residents reviewed for dignity, resulting in a potential for feelings of fear, frustration, and dehumanization.

Inspectors wroteThis citation pertains to intake number MI00143228 Based on interviews 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 for 1 (Resident #195) of 1 residents reviewed for abuse resulting in an allegation of misappropriation not being thoroughly investigated.

Inspectors wroteBased on interview and record review, the facility failed to identify and implement person-centered, non-pharmacological interventions for a resident receiving a psychotropic medication for 1 (Resident #17) of 5 residents reviewed for high-risk medication care planning, resulting in and the potential for unmet psychosocial needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received ordered medications as scheduled for 1 (Resident #245) of 3 residents reviewed for medication administration and standards of practice, resulting in the potential for worsening of health conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely and consistent nutrition/hydration status assessment, monitoring, or reassessment in 1 (Resident #1) of 5 residents reviewed for nutritional care and services, resulting in unassessed nutritional status, inadequate monitoring and follow-up of resident deemed to be at nutritional risk, and the potential for unidentified weight loss, nutritional status decline, and unmet nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician reviewed and responded to the consultant pharmacist's monthly medication regimen review (MRR) irregularity report recommendations for 2 (Resident #17, Resident #8) of 5 residents reviewed for medication regimen review, resulting in the registered pharmacist's recommendations not being addressed and the potential for negative medication side effects resulting from unaddressed recommendations.

Inspectors wroteBased on interview and record review, the facility failed to attempt a required Gradual Dose Reduction (GDR) of an antidepressant medication, in the absence of a documented contraindication, for 1 (Resident #17) of 5 residents reviewed for unnecessary medications, resulting in the potential that the resident is receiving the medication at an unnecessary dose or for an unnecessary length of time.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records included documentation that residents/resident representatives were educated, offered and/or received timely, the COVID-19 immunization as recommended by the Centers for Disease Control and Prevention (CDC) for 1 resident (Resident #29) of 5 residents reviewed for immunizations, resulting in the resident not being offered the Covid-19 immunization per CDC guidelines, and the potential for serious illness and complications from COVID-19 (SARS-CoV-2).

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a comprehensive care plan after a change in resident condition in 3 of 12 residents (Resident #6, #2, & #14) reviewed for comprehensive care plans, resulting in an inaccurate reflection of the resident's status, and the potential for unmet medical, physical, mental, and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nail care was completed per resident preference and plan of care in 1 of 2 residents (Resident #6) reviewed for Activities of Daily Living (ADL) care, resulting in the potential for dissatisfaction with care, hygiene concerns, skin damage, and low self-esteem.

Inspectors wroteThe facility failed to provide individualized activities designed to support the psychosocial well-being of 1 of 12 Residents (Resident #14) reviewed for activities, resulting in a potential for feelings of social isolation, loneliness, boredom, and depressed mood. Findings Include: Review of Revolutionizing the Experience of Home by Bringing Well-Being to Life: The [NAME] Alternative Domains of Well-Being, Copyright 2012, Rev. 2020, revealed The [NAME] Alternative defined one domain of wellness as Connectedness- the state of being connected; alive .engaged, involved . without meaningful interactions the individual can become disconnected .develop loneliness, helplessness, and boredom. Review of Sensory Stimulation: Sensory-focused Activities for People with Physical and Multiple Disabilities., [NAME], S., & Scope. ([NAME]). (2007). [NAME]: [...]