The Orchards at Southgate

Inspectors wroteThis citation pertains to intake 2732359. Based on observation, interview and record review, the facility failed to verify tube placement and assess gastric residual prior to administering medication one resident (R402) of one resident observed receiving medications via peg tube resulting in the potential for aspiration respiratory compromise.

Inspectors wroteThis citation pertains to intake 2732359. Based on observation, interview and record review, the facility failed to ensure staff performed hand hygiene after removal of soiled gloves and prior to donning clean gloves during wound related care for one resident (R402) of three residents observed receiving wound care. This deficient practice had the potential to increase the risk of cross-contamination and infection transmission.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent and promote healing of a facility acquired unstageable pressure ulcer (a severe skin injury that occurs at the heel and cannot be accurately staged because the wound base is covered by dead tissue) for one resident (R4) of three residents reviewed for pressure ulcers, resulting in the development of an unstageable heel pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized anticoagulant (a blood thinner that prevents blood clots from forming but increase the risk of bleeding) comprehensive care plan for one resident (R103) out of five residents reviewed for injuries of unknown origin.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 80 residents who receive meal services (3 nothing by mouth residents, or NPO) out of the facility's total census of 77 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure feeding assistance were provided timely for two Residents (R23 and R69) of three residents reviewed for activities of daily living (ADLs), resulting in the residents not eating meal timely and the potential for the residents food to be served at an inappropriate temperature.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow-up with a dental recommendation for one resident with Medicaid benefits (R74) out of two residents reviewed for dental services resulting in R74 not having several broken/decayed teeth extracted and with complaints of tooth pain and tooth abscess and difficulty eating.

Inspectors wroteBased on observation and interview the facility failed to provide a safe, functional, and sanitary environment for the facilities census of 80 residents and its staff resulting in an increased potential for harm.

Inspectors wroteThis citation pertains to intake MI00142163. Based on observation, interview and record review the facility failed to provide adequate supervision. On January 15, 2024, at approximately 10:30 AM, R301 a cognitively impaired resident (BIMS of 4) eloped from the facility The recorded temperature that day was 9 degrees Fahrenheit. R301 walked down beside [NAME] Rd (A four lane highway) crossed Fort St (A six lane highway) and proceeded to (Name Redacted) Co-op Apartments (approximately 1.5 miles from facility). Director of Nursing called [NAME] Police at 11:22 AM, and it was reported resident was transported to the hospital at approximately 10:38 AM. This deficient practice resulted in the likelihood of serious injury, serious harm, serious impairment, or death related to being struck by a vehicle and/or exposure to extreme weather temperatures.

Inspectors wroteThis citation pertains to Intakes: MI00139241 and MI00139218. Based on interview and record review the facility failed to report an incident of elopement to the State Agency for one resident (R404) out of four residents reviewed for elopement risk, resulting in the potential for further incidents of unreported elopements.

Inspectors wroteThis citation pertains to intake MI00139241 and MI00139218. Based on interview and record review the facility failed to prevent an elopement for one resident (404) of four residents reviewed for elopement, resulting in R (404) exiting the facility without staff knowledge and the potential for injury and for other elopement risk residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement nutritional interventions for weight loss for one resident (R72) of four residents reviewed for nutritional parameters, resulting in a significant weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to (1) effectively clean multiple surfaces in the kitchen, (2) properly date-label food in the cooler and freezer, and (3) test the dish machine operating temperature prior to use. These deficient practices have the potential to affect all residents who eat food out of the kitchen resulting in the increased potential for cross-contamination, bacterial harborage, and increase potential for resident foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent proper working order of the facility walk-in freezer and reach-in cooler which had the potential to affect all residents that eat from the kitchen and kitchen operations.

Inspectors wroteThis citation pertains to Intakes MI00133548, MI00134508, MI00137641, MI00136260, MI00134591, MI00131114 Based on observation, interview, and record review, the facility failed to ensure meals were served at palatable temperatures for residents served from the 1st Floor-Short meal cart, resulting in potential dissatisfaction with the meal experience and unmet nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to provide timely financial statements to one (R329) of one resident reviewed for resident trust fund, resulting in the resident being uninformed about personal funds.

Inspectors wroteBased on interview and record review, the facility failed to immediately report an allegation of verbal abuse for one (R53) of 7 residents reviewed for abuse, resulting in an allegation of verbal abuse not being reported to the Nursing Home Administrator (NHA) or the State Agency timely and the potential for further allegations of abuse to occur, go unreported, and not thoroughly investigated.

Inspectors wroteBased on interview and record review the facility failed to accurately document the amount of administered enteral feedings (nutrition administered through tube into stomach) for one resident (R 37) out of three residents reviewed for nutrition, resulting in the potential for inaccurate nutritional intake and assessment. Findings Include: Record review of R37's face sheet revealed the admission into the facility on 8/28/18 with a pertinent diagnosis of gastrostomy status (tube surgically inserted into stomach). According to the Minimum Data Set (MDS) dated [DATE], R37 had impaired cognition and required total dependence for eating (nutrition intake). Record review of Medical Administration Record (MAR) dated for 7/1/23-7/31/23 documented the following order: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the physician was notified and involved in implementing nutritional interventions for significant weight loss for one resident (R72) out of four residents reviewed for weight loss. This deficient practice resulted in the potential for the lack of physician coordination with weight loss interventions and further nutritional decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper hand hygiene techniques when providing tracheostomy suctioning for one resident (R27) out of two residents sampled for tracheostomy care, resulting in the potential for R27 to develop a respiratory infection.