The Orchards at Canterbury on the Lake

In the surveyor’s words

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

• Actual harm, isolatedF684Jul 31, 2025

  This citation pertains to Intake Number MI001227212. This citation has two deficient practice statements (DPS). DPS #1 Based on observation, interview, and record review, the facility failed to assess a new skin impairment and implement treatments in a timely manner and according to physician's orders for two (R55 and R49) of four reviewed for non-pressure skin impairments, resulting in a wound to R55's arm becoming infected with delayed healing. Findings include: R55 On 7/29/25 at 10:45 AM, R55 was observed in bed. A dressing dated 7/29/25 was observed on R55's right forearm. When queried about what happened to his arm, R55 stated, She burnt it. […]

• Actual harm, isolatedF600Oct 28, 2024

  This citation pertains to intake #'s MI00147613 and MI00147486. Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical and verbal abuse by Certified Nursing Assistant C (CNA C) for one resident (R901) of two residents reviewed for abuse/neglect/mistreatment, resulting in R901 being in pain from being punched, kicked and the target of derogatory language. Findings include: On 10/28/24 a complaint submitted to the State Agency (SA) was reviewed that alleged R901 was physically and verbally abused by CNA C on 10/12/24. […]

• Actual harm, isolatedF684Sep 7, 2023

  This citation pertains to Intake#: MI00138928 Based on interviews and record review, the facility failed to (1) consistently monitor the change in condition for a Resident (R905) with Congestive Heart Failure (CHF - inability of the heart to pump blood efficiently, causing shortness of breath, fatigue, leg and foot swelling, and weakness) and transfer to hospital per advance directives and (2) failed to communicate/coordinate and follow up on the orders by the specialist (cardiologist) timely, resulting in a 9.4 lb.(pound) weight gain (in 4 days), difficulty breathing, discomfort, and death in the facility. Findings include: R905 R905 was admitted to the facility on [DATE] after hospitalization . R905 was living at home with their family prior to hospitalization . […]

• Actual harm, isolatedF689Jun 29, 2023

  This citation pertains to intake: MI00137797. Based on interview and record review the facility failed to ensure a fall risk assessment was completed accurately, ensure a comprehensive assessment and evaluation was completed to implement the safest and most appropriate transfer device for R808, the facility failed to follow their policy on mechanical lifts and failed to ensure the proper education, training and competency was conducted with every staff member before the use of the mechanical device for one (R808) of one resident reviewed for accidents, resulting in the resident to have excruciating pain and the need to transfer the resident to the hospital for a higher level of care. Findings include: Review of a complaint submitted to the State Agency (SA) documented in part . […]

• Actual harm, isolatedF880Jun 29, 2023

  This citation pertains to intake(s): MI00137776, MI00137797 & MI00137902. Based on observation, interview, and record reviews the facility failed to maintain an active water management plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP) and failed to maintain a consistent and effective infection surveillance program resulting in water borne pathogens to exist and spread in the facility's plumbing system and resulting in R810 to be diagnosed with presumptive healthcare associated Legionellosis, R811 to not have been identified with signs/symptoms/diagnosis to fit the criteria for testing of Legionellosis and the increased risk of respiratory infection for all residents that resided in the facility. […]