The Orchards at Big Rapids

In the surveyor’s words

From the most serious findings on record at The Orchards at Big Rapids, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Feb 1, 2022

  This citation has two separate deficient practice statements, A. and B. A. Based on observation, interview and record review, the facility failed to: 1) have an accurate and timely infection tracking and monitoring system, 2) follow established COVID-19 testing guidelines per facility policy, 3) implement appropriate transmission-based precaution protocols (including Personal Protective Equipment [PPE] and resident room signage), and 4) practice appropriate hand hygiene. This deficient practice was identified as an Immediate Jeopardy (IJ) due to the failed facility COVID-19 tracking and testing systems had the likelihood to result in further infectious outbreaks for all residents and staff. […]

• Immediate jeopardy, isolatedF689Feb 17, 2023

  This citation has 3 DPS statements. This citation refers in part to MI00133328: DPS#1 Based on observation, interview and record review the facility failed to prevent accidents and hazards for 1 resident (R7) resulting in an Immediate Jeopardy (IJ) that began on 1/19/23, due to the facility's lack of policies and procedures to prevent hot liquid burns for R7. This deficient practice led to R7 experiencing multiple third degree burns and unnecessary pain and disfigurement and the potential for other residents in the facility to be at risk from burn, pain and injury. Findings include: A review of R7's Face Sheet, dated 2/15/23, revealed R7 was an [AGE] year-old resident admitted to the facility on [DATE]. […]

• Actual harm, isolatedF686Mar 13, 2024

  Based 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. Findings include: The facility provided a policy for Pressure Injuries: Assessment, Prevention and Treatment (undated and unsigned) for review. The policy reflected, 2. Skin will be assessed routinely for the presence of developing pressure injuries and documented on the Nursing Skin Tool .12. Float heels - keep heels off the bed .15. […]

• Actual harm, isolatedF656Feb 17, 2023

  Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive person-center care plans for 3 residents (R12, R51 and R26) resulting ineffective and unimplemented care plans leading to ongoing falls, injury and pain for R12 and R51 and prolonged use of a feeding tube, anxiety and weight gain for R26 and the potential for all facility residents to not receive care and services to reach their highest potential. Findings include: R12 Review of R12's face sheet dated 2/14/23 revealed she was a [AGE] year old resident who initially admitted to the facility on [DATE] and most recently admitted on [DATE] with diagnosis that included: dementia, unsteadiness on feet, restlessness and agitation, difficulty in walking, and fracture of the right… […]

• Actual harm, isolatedF684Feb 17, 2023

  This citation has two Deficient Practice Statements (DPS) DPS #1 Based on observation, interview, and record review the facility failed to ensure enabling care and services were provided to one Resident (Resident #26 (R26)) receiving nutrition through a feeding tube to restore oral eating skills resulting in prolonged use of a feeding tube and anxiety and the potential for all facility residents with nutrition related needs to not receive enabling care and services to reach their highest practicalable potential. Findings: Review of the Minimum Data Set (MDS) dated [DATE] reflected that R26 was originally admitted to the facility 8/5/20 with pertinent diagnoses that included history of stroke with impairment to one side of the body. […]