The Orchards at Douglas Cove

In the surveyor’s words

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

• Actual harm, isolatedF689Aug 26, 2026

  This citation pertains to intake #3092387 and 3117404.Based on interview and record review, the facility failed to provide adequate supervision to prevent accident hazards in 4 of 6 residents (R12, R18, R13, and R48) reviewed for accidents and hazards, resulting in R12 sustaining a fall with major injury.Findings include:R12Review of an admission Record revealed R12 admitted to the facility on [DATE] with pertinent diagnoses which included dementia, anxiety, and restlessness.Review of R12's Kardex (summary of care needs), dated 8/26/2026, revealed R12 required supervision with transfers.In an interview on 8/26/2026 at 9:39 AM, the Director of Nursing (DON) reported staff were required to always monitor the locked dementia unit hallway as residents on the unit required constant supervision… […]

• Actual harm, isolatedF689Nov 30, 2022

  This citation pertains to intake #MI00127465. Based on interview and record review, the facility failed to implement appropriate safety measures were followed to ensure safe transfer of 1 (Resident #100) of 3 residents reviewed for falls resulting in an actual fall for Resident #100 who sustained a fractured right leg. Findings include: Review of an Admission Record revealed Resident #100 was a female with pertinent diagnoses which included dementia, poliomyelitis (infectious viral disease that affects the central nervous system and can cause paralysis), post polio syndrome (group of potentially disabling signs and symptoms that appear decades after the initial polio illness), repeated falls, history of stroke, muscle weakness, cognitive communication deficit, need for assistance with… […]

• No harm, potential for more than minimal, widespreadF812Jul 17, 2025

  Based on observation, interview and record review the facility failed to maintain best practices in accordance with professional standards of food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.Findings Include: On 07/15/2025 at 9:16 AM, An initial tour of the kitchen found an increased accumulation of spillage and white flakey debris on the back portion of the floor and floor juncture of the walk-in cooler. On 7/15/2025 at 9:26 AM, Observation of the ventilation hood over the cook line found an accumulation of dust and debris on the filters. When asked when the hoods were cleaned lasts, a sticker on the system stated it was last serviced in March of 2025. […]

• No harm, potential for more than minimal, widespreadF880Jul 17, 2025

  This citation contains two deficient practice statements, A & B.Deficient Practice Statement (DPS) ABased on observation, interview, and record review, the facility failed to effectively implement effective infection control measures which included Enhanced Barrier Precautions (EBP) per facility policy and Centers for Disease Control and Prevention (CDC) guidance, in 5 of 5 residents (Resident #27, #51, #2, #19, & #17) reviewed for infection control, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population. DPS B Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). […]

• No harm, potential for more than minimal, widespreadF908Mar 12, 2025

  Based on observation, interview, and record review, the facility failed to maintain the facility dishwasher in an operable manner. This deficient practice had the potential to affect all 47 residents within the facility. Findings include: This writer observed resident being served their lunches in Styrofoam containers. There was no mention of the facility having an outbreak of COVID in the building. In an interview on 3/11/25 at 12:29 PM, Certified Nursing Assistant (CNA) K reported the sink was not working and she believed that was why the facility was using Styrofoam containers for meals. She reported she worked last Friday, and they used the Styrofoam containers then as well. […]