The Orchards at Northwest

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 03/08/2026 at 8:40 AM a tour of the kitchen was conducted with cook F who was serving as the acting manager for the day. On 03/08/2026 at 8:57 AM observed a plastic tube running from the ice machine drain line into the floor drain in the kitchen. The plastic drain line extended below the flood level rim of the drain, creating an improper air gap. On 03/08/2026 at 9:33 AM observed a black corrugated tube connected to the juice gun drain line leading into the floor drain in the kitchen. The tube extended down to the base of the floor drain, creating an improper air gap. [...]

Inspectors wroteBased on interview and record review, the facility failed to report staffing data to the payroll-Based Journal (PBJ) with the potential to affect all 117 residents residing in the building. This deficient practice resulted in the potential for staffing concerns leading to quality-of-care concerns.

Inspectors wroteBased on observation, interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 03/08/2026 at 1:12 PM observed an inoperable water fountain in the basement indicating possible stagnant water. On 03/08/2026 beginning at 1:21 PM a tour of the facility was conducted with Environmental Services Manager (ESM) K. On 03/08/2026 at 1:37 PM observed a hopper in the first-floor trash room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain general cleanliness and repair of the premises as well as proper storage of clean and sanitary supplies. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents. Findings Include:On 03/08/2026 at 10:28 AM observed the sink faucet releasing a trickle of water when turned on in the first-floor nutrition room. An interview at this time with District Manager I regarding the faucet found they were unsure how long the faucet had been operating in this condition. On 03/08/2026 at 11:08 AM observed nails screwed into the cabinet doors beneath the sink in the third-floor nutrition room. When the cabinet doors were opened, the nails were observed protruding through the wood and sticking out approximately one inch. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the smoking policy was implemented and practiced for one (R93) of one resident reviewed for accidents and hazards, resulting in (1.) smoking in the facility, (2.) smoking materials not stored in a safe place, (3.) potentially affect safe fire safety practices, (4.) and the potential for bodily harm. This deficient practice has the potential to affect all residents that reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistive dining equipment for one resident (R49) out of two residents reviewed for limited range of motion (ROM).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper skin care for two residents (R61 and R117) out of two residents reviewed for skin conditions who were dependent upon staff for performance of activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly assess the nutritional status and implement nutrition interventions for one resident (R12) out of one resident reviewed for dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent coordination of care between the facility and the contracted dialysis center for one resident (R12) out of one resident reviewed for dialysis services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to display current daily staff ratio information in a prominent area that was readily accessible for all 117 residents as well as visitors/vendors in the facility and ensure the proper retention of previous staff ratio postings.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication cart was secured in accordance with professional standards for one medication cart of six medication carts reviewed for medication storage and safety.

Inspectors wroteThis citation pertains to intake number 2715345. Based on observation, interview, and record review, the facility failed to provide two staff during a shower and failed to reposition in a safe manner one dependent resident (R400) of three residents reviewed for accidents, resulting in a fall from the shower bed to the floor with subsequent pain and a facial laceration requiring sutures.

Inspectors wroteThis citation pertains to intake number 2715345. Based on observation, interview and record review, the facility failed to ensure Certified Nursing Assistants were trained on repositioning techniques and implementing appropriate care when providing resident showers, resulting in one resident (R400) rolling off of the shower bed to the floor sustaining injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Clean surfaces in the kitchen that were visibly soiled; 2. Maintain easily cleanable floors in various areas of the kitchen; 3. Ensure properly working garbage disposal and sink faucet; 4. Ensure chemical solution (quaternary) was an effective sanitizer; 5. Ensure pans were clean and air dried before stacking. This deficient practice would affect any resident that consumed food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program.

Inspectors wroteBased on observation, interview and record review, the facility failed to continuously implement and operationalize a comprehensive infection control program, encompassing outcome and process surveillance, accurate data collection/documentation/analysis, resulting in a lack of accurate and comprehensive infection control tracking, surveillance and data monitoring/analysis and the potential for the spread of microorganisms, illness and other harmful pathogens among other residents that reside in the facility.

Inspectors wroteBased on interview, and record review the facility failed to maintain a continuous Antibiotic Stewardship Program that included monitoring antibiotic usage and following protocols for antibiotic use resulting in the potential for unnecessary medications and antibiotic resistance.

Inspectors wroteBased on interview and record review the facility failed to ensure continuity of care for the role of an Infection Control Preventionist (ICP) and ensure the ICP completed specialized training in infection prevention and control, resulting in the potential for knowledge deficits pertaining to current infection prevention and control standards, outbreaks going undetected because of inadequate infection control surveillance, and a delay in infection control data collection and summary.

Inspectors wroteBased on interview and record review the facility failed to screen residents for eligibility to receive the COVID 19 vaccine and/or booster, provide education regarding the COVID 19 vaccine and/or booster, and offer the COVID 19 vaccine and/or booster, resulting in residents not receiving the Covid-19 immunization, and the potential for decreased protection from SARs-CoV-2 virus and serious illness and complications among residents that reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with nail care, oral care, shaves, hair care, and body hygiene for five residents (R2, R49, R51, R108, and R112) out of nine residents reviewed for Activities of Daily Living (ADLs), resulting in unmet ADL needs. R2 On 1/6/2025 at 10:38 a.m., R2 was observed lying in bed alert and unable to be interviewed. The surveyor observed R2 with long, dirty, untrimmed fingernails on both hands, with dry scaly skin on bilateral legs and feet. There was white-colored, crusty residue on lips and near both eyes. R2 had matted, unkempt hair. A hospital bracelet dated 12/15/2024 was noted on R2's right arm. On 1/8/2025 at 9:52 a.m., during an interview in R2's room, licensed Practical Nurse (LPN) B rubbed across R2's head and confirmed the resident's hair was not combed and matted on the top and on the back. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergent or routine care that could cause negative outcomes. This deficient practice had the potential to affect all 120 residents in the facility.

Inspectors wroteBased on observations, interviews, and record review the facility failed to effectively clean and maintain the physical plant effecting all residents residing on the second floor and all residents who use the elevator, resulting in an unsafe, poorly functional environment with the potential for cross-contamination and bacterial harborage.

Inspectors wroteBased on interview and record review the facility failed to ensure annual Dementia Management and Abuse training were performed for three Certified Nurse Assistant (CNA) H, I and J out of five CNAs reviewed for in-service training resulting in the potential for unmet resident care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a call button was within reach for one resident (R178) reviewed for accommodation of needs, resulting in the resident not having a method to request assistance when needed.

Inspectors wroteBased on interview and record review the facility failed to ensure an Advance Directive was completed for one resident R14 of nine residents reviewed for advance directives resulting in the potential for inaccurate life sustaining measures or withholding medical treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician of a change in condition for one resident (R65) of six residents reviewed for bowel and bladder, resulting in the potential delay o care and treatment.

Inspectors wroteThis citation pertains to intake MI00147576. Based on interview and record review, the facility failed to ensure staff reported an injury of unknown source in a timely manner to the abuse coordinator for one resident (R125) out of two residents reviewed for abuse resulting in the untimely investigation of an injury of unknown origin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for a tracheostomy (a surgical opening in the neck to provide an airway to the lungs) for one resident (R175) reviewed for tracheostomy care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove broken and hazardous objects from one resident (R85) room to ensure safety of three residents reviewed for accident hazards, resulting in the potential for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper weight monitoring occurred for one resident (R20) deemed to be at nutrition risk out of six residents reviewed for nutrition status, resulting in the potential for compromise in nutrition status to go undetected. On1/6/25 at approximately 10:00 AM R20 was observed in bed. The resident could not be meaningfully interviewed due to severe cognitive impairment. The resident had an intravenous (IV) pole with a tube feeding pump attached. No tube feeding was present on the IV pole. According to R20's Electronic Health Record (EHR) the resident admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included fecal impaction, cerebral palsy acute and chronic respiratory failure, and anoxic brain damage. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to (1) have emergency tracheostomy (a surgical opening in the neck to provide an airway to the lungs) supplies readily available for one resident (R175) and (2) failed to consistently follow the physician's medical orders for tracheostomy care (R74) out of three residents reviewed for tracheostomy care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical supplies for one resident (R10) reviewed for tracheostomy (a surgical opening in the neck to provide an airway to the lungs) care were not expired. On [DATE] at 1:20 PM, R10 was observed in bed eating lunch. Licensed Practical Nurse (LPN) X entered the room with the State Surveyor to check for tracheostomy (trach) supplies. LPN X stated that R10 did not have a trach but R10 had a stoma. On [DATE] at 12:30 PM, R10 provided permission for a nurse and the Surveyor to look through the supplies in his room. On [DATE] at 12:34 PM, the contents of a multi-drawer storage cabinet located in R10's room were observed with the Director of Nursing (DON) and revealed the following: - One box of (Brand XX) HME expired [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and privacy, by not repairing broken window blinds for one resident (R35) of one resident sampled for visual privacy resulting in feelings of disrespect and the potential of exposure during care. Findings Include: On 1/06/25 at 11:56 AM, R35 was observed in bed on their back. R35 was covered with a sheet and was not wearing a gown. An interview was conducted with R35 regarding their stay in the facility. R35 stated that they don't have many complaints but would like window blinds to be fixed because it had been broken for a while and was covered with a soiled sheet. R35 said that although they like being next to the window, they did not like that someone could see them from the outside, especially at night. [...]

Inspectors wroteThis citation pertains to intake MI00141452. Based on observation, interview, and record review the facility failed to implement proper hand hygiene and glove use during wound care for one resident (R606) and failed to provide the proper receptable for the disposal of Personal Protective Equipment (PPE) for one resident (R608) out of 10 residents reviewed for infection control, resulting in the potential for increased cross-contamination of diseases which place a vulnerable population at high risk for infections.

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision to a cognitively impaired resident (R501) who eloped from the facility unbeknownst to staff for two hours resulting in the likelihood for serious harm, injury, impairment, or death. Findings Include: According to the Facility Reported Incident dated 2/2/24, R501 was unable to be located in the facility during midnight rounds on 2/2/24 at approximately 12:30 AM. A facility campus wide search was conducted and R501 was not located. The Facility's Investigation summary dated 2/7/24 concluded that on 2/1/24 at approximately 10:45 PM R501 had walked out the facility's front door that was unattended and triggered the front door alarm. Licensed Practical Nurse (LPN) A went to the front door and looked in the foyer area and out the window. [...]

Inspectors wroteThis citation pertains to inake MI00141101. Based on observation, interview, and record review, the facility failed to ensure call lights were within reach for two residents (R402 and R410) of four residents reviewed for accommodation of needs, resulting in unmet care needs and the potential for further unmet care needs.

Inspectors wroteThis citation pertains to intake MI00140791 Based on interview and record review, the facility failed to provide adequate supervision for one resident (R404) out of three residents reviewed for elopement which resulted in R404 exiting a store unsupervised while on a facility outing without staff knowledge and the potential for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure that two of five Certified Nurse Aides (CNA L and CNA M), whose in-service training files were reviewed, had the required annual dementia training within the required time period, resulting in the potential for unmet education needs, unmet resident care needs, and the potential for residents assigned to CNAs who have a diagnosis of dementia to not receive adequate care.

Inspectors wroteThis citation has two Deficient Practice Statements (DPS). DPS #1. Based on observation, interview, and record review the facility failed to calibrate (test using a control solution to ensure accuracy) for 3 of 5 glucometers (medical device used to measure blood sugar) in the facility resulting in the potential for inaccurate blood glucose readings.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve standardized portions for menu items and ensure palatable temperatures of food and coffee for six residents (R24 , R49 , R59, R70, R86, and R94) and for eight of eight residents who attended the confidential group meeting, resulting in complaints of small portions, cold food/coffee, and tasteless meals.

Inspectors wroteThis citation pertains to intake MI00139366. Based on interview, and record review the facility failed to prevent physical restraint use in one resident (R62) out of 10 residents reviewed for abuse resulting in the potential for physical and psychosocial harm.

Inspectors wroteThis citation pertains to intake MI00139366. Based on interview and record review, the facility failed to report allegations of abuse for one resident (R62) of ten total residents reviewed for abuse, resulting in allegations of abuse that were not reported to the State Agency timely and the potential for further allegations of abuse to go unreported, and not thoroughly investigated.

Inspectors wroteThis citation pertains to intake MI00135592. Based on interview and record review the facility failed to provide an arm rest on a resident's wheelchair for one resident (R119) out of nine residents reviewed for accidents, resulting in R119 falling from wheelchair and obtaining large hematoma (when an injury causes blood to pool and collect under skin).