The Orchards at Wayne

Inspectors wroteThis citation pertains to intake 3073834 Based on observation, interview and record review, the facility failed to ensure staff adhered to Enhanced Barrier Precautions (EBP) by wearing the required personal protective equipment (PPE) during wound care for one resident (R1105) of three residents reviewed under EBP due to colonization or risk factors associated with multidrug-resistant organisms (MDROs). The failure to utilize required isolation gowns during high-contact resident care increased the risk of transmission of MDROs and other infectious pathogens among residents.

Inspectors wroteThis citation pertains to intake 3039764. Based on observation, interview and record review, the facility failed to protect R103's right to be free from verbal abuse by staff.

Inspectors wroteThis citation pertains to intake 3017670. Based on observation, interview and record review the facility failed to administer medications as ordered and failed to notify the physician when missed medications were not administered for one resident (R902) out of three residents reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a comfortable homelike environment for one resident (R87) out of four residents reviewed for safe, clean, homelike environment resulting in R87's personal items getting wet.

Inspectors wroteBased on interview and record review, the facility failed to ensure that an allegation of misappropriation of resident property for one (R35) of four residents reviewed for abuse was immediately reported to the State Agency. This failure resulted in the facility not reporting an allegation of missing funds, placing R35 at risk for further potential misappropriation and lack of external investigation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the care plan for one (R28) of four residents reviewed for behavior care plans to include R28's one on one sitter to monitor behaviors.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the physical environment in the dish room in a safe sanitary manner and repair and replace a warming device. This deficient practice had the potential to affect 106 of the 111 residents in the facility. On 9/23/25 at approximately 12:00 P.M. and on 9/24/2025 at 1:28 P.M., during an observation in the dish room the following were observed: The ceiling vents and adjacent ceiling tiles were soiled with ash, lint and residue. Visible strings of lint were attached to the vent covers. The plate warmer used during meal service was broken and not heating plates. The caulking between the dish room table and wall was cracked and detached from the wall. Cracked crevices were noted the entire length of the scrape table. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that only authorized health care professionals administered medication for one resident (R102) out of two residents reviewed for medication administration.

Inspectors wroteThis citation pertains to intakes MI00147383 and MI00147811. Based on observation, interview, and record review, the facility failed to ensure enough kitchen staff were available to prepare and serve meals in a timely manner.

Inspectors wroteThis citation pertains to intake number MI00147248. Based on interview and record review, the facility failed to initiate a Code [NAME] (Notification for a missing resident) in a timely manner for one resident (R703) that was missing from the facility, after identifying that the resident had left the faciity on 9/25/24, unbeknownst to staff, of five residents reviewed for elopement, resulting in the potential for serious injury or death from the resident being outside and unsupervised for an extended period of time.

Inspectors wroteThis citation pertains to intake MI00146507. Based on interview, and record review the facility failed to prevent a resident to resident physical abuse incident, for two sampled residents (R701 and R702) of three residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure kitchen sinks were in good repair and warm water was available for hand washing; 2. Properly date-label food stored in the walk-in cooler; 3. Ensure proper cooling of cooked, potentially hazardous (time-temperature for safety) food, mixed vegetables; 4. Ensure pans were properly cleaned; 5. Effectively clean surfaces in the kitchen and commercial ice machine; 6. Maintain cleanable walls in the kitchen; and 7. Ensure used meal trays were not placed on a meal cart during meal pass. These deficient practices had the potential to affect all the residents who consumed food from the kitchen and consumed ice from the ice machine, resulting in the potential for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose of rubbish and maintain cleanliness of the outside garbage area, resulting in a visually unappealing property and the potential for harborage of pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an appropriately sized wheelchair for one resident (R79) of one resident reviewed for accommodation of needs, resulting in discomfort. On 7/30/24 at 10:51 AM R79 was observed sitting in standard wheelchair (18-inch-wide seat) with abdominal girth and thighs resting directly on the metal part of the wheel chair arms. On 7/31/24 at 8:24 AM R79 was observed self-propelling in a standard wheelchair down the hallway. R79 was asked about her comfort in the wheelchair and stated My wheelchair is too tight. My legs push against the sides. I'm not comfortable. R79 said she was going to the dining hall for breakfast and spends most of the day in the wheelchair. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Responsible Representative (RR) of a facility-initiated discharge for one (R76) resident reviewed for transfer.

Inspectors wroteBased on observation and interview the facility failed to provide timely ADL (Activities of daily living) care to include nail care for one resident (R50) of six residents reviewed for ADL care resulting in dissatisfaction with care.

Inspectors wroteBased on interview and record review the facility failed to address Medication Regimen Review (MRR) recommendations timely for one resident (R54) of five residents reviewed for a medication regimen review, resulting in the potential for the continuance of unnecessary medications and lack of communication of recommended medication changes between pharmacist and physician.

Inspectors wroteThis citation pertains to Intake MI00142000 and MI00142648. Based on observation, interviews and record review, the facility failed to respond to a resident's call light in a timely manner for one resident (R616) out of four residents reviewed for call light response times, resulting in the potential for resident frustration and unmet care needs.

Inspectors wroteThis citation pertains to Intake MI00141842 and MI00142000. Based on observation, interview and record review, the facility failed to ensure pressure ulcer treatments were consistently provided as ordered for one (R616) out of three residents reviewed for pressure ulcers.

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 all residents who receive oral food meal services out of the facility's total census of 116 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately implement an antibiotic stewardship program when two residents (R45 and R53) reviewed for antibiotic stewardship had incorrect and incomplete information documented on the Infection Surveillance Report and Infection Line Listing resulting in the potential for inaccurate infection surveillance in the facility including communicable infections. This deficient practice has the potential to affect all residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal vaccination for three residents (R32, R119, and R45) out of 5 reviewed for immunizations resulting in the potential for respiratory infection.

Inspectors wroteBased on observation and interview the facility failed to ensure that all kitchen equipment is maintained in a safe, and originally approved operating condition resulting in an increased potential for harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure advanced directives were updated, accurate, and in place for two residents (R76 and R111) of four residents reviewed for advanced directives (a legal document that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for denial of the resident's right to have life sustaining or withheld decisions honored. Findings Include: Resident #76 Review of an admission record revealed, Resident #76 (R76) admitted to the facility on [DATE] with pertinent diagnosis which included Cerebral Ischemia, Moderate Protein-Calorie Malnutrition, and Dementia. Review of a Minimum Data Set (MDS) assessments, with a reference date of 4/18/23 revealed R76 had moderate cognitive impairment. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise an individualized, person-centered care plan for one (R76) of four residents reviewed for advance directives, resulting in the potential for residents receiving care to not meet their individualized needs and preference.

Inspectors wroteThis citation pertains to intakes MI00128176, MI00131385, and MI00134610 Based on observation, interview, and record review, the facility failed to ensure showers were provided consistently for two of 11 residents (R40 and R53) reviewed for activities of daily living, resulting in the potential for diminished dignity, alteration in skin integrity and body odors.

Inspectors wroteThis citation has two deficient practices. Deficient practice #1. This citation pertains to Intake MI00129935. Based on interview and record review the facility failed to properly assess a resident (R126) following a suspected fall of two residents reviewed for falls, resulting in the potential for an unidentified head injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent the development of pressure ulcers for two residents (R119 and R53) of eight residents reviewed for pressure ulcers resulting in R119 developing pressure ulcers identified as Deep Tissue Injuries (DTI) (intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister) on both heels and a stage 2 (Partial-thickness skin loss with exposed dermis) on the left lateral ankle along with the potential for R53 to develop additional pressure ulcers on heels.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure podiatry services and treatment were provided in a timely manner for one resident (R111) of one resident reviewed for foot care, resulting in discomfort and pain from elongated toenails.

Inspectors wroteThis citation pertains to intake MI00130600. Based on observation, interview, and record review, the facility failed to provide appropriate care and services for three residents (R53, R69, and R130) of five residents reviewed for foley care resulting in the delayed detection and treatment of urinary tract infection, the potential for urethral trauma, and the potential for urinary infections to go undetected.