The Orchards at Lapeer

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 9, 2021

  This Citation contains two Deficient Practice Statements (DPS). DPS #1. This Citation pertains to Intake Numbers MI 856, MI 594, MI 595, MI 771, MI 788 and MI 919. Based on observation, interview and record review, the facility failed to prevent the elopement, provide adequate supervision and ensure the safety of one resident (Resident #15) of seven residents reviewed for the potential for elopement, resulting in an Immediate Jeopardy when Resident #15 eloped from the facility on [DATE] at 5:07 PM, unbeknownst to facility staff. […]

• Actual harm, isolatedF684Mar 4, 2026

  This citation pertains to Intake Numbers 2732659 and 2739632.Based on interview and record review, the facility failed to ensure that a wound to the ankle was assessed, monitored and provided treatment for, for one resident (Resident 73) of three reviewed for wounds, resulting in the resident's ankle wound worsening, and developing an infection that resulted in the amputation of the leg.Findings include: Resident #73 (R73):A review of the complaint for Resident 73 (R73) revealed that the Resident admitted into the facility for wound care for a diabetic ulcer on the bottom of R73's foot. The Complainant KK explained that a new wound formed on R73's ankle while residing at the facility. […]

• Actual harm, isolatedF689May 7, 2024

  This Citation pertains to Intake Number MI00143170. Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and supervision was provided to prevent a fall with injury for one resident (Resident #56) of 3 residents reviewed for falls, resulting in Resident #56 falling out of bed and suffering a femur fracture. Findings Include: Resident #56: Accidents On 4/29/2024 at 12:15 PM during a tour of the facility, Resident #56 was observed lying in bed, alert and talkative. Her bed was in a very low position near the floor. Her lunch tray was present and sitting on the bedside table, which was positioned much higher than the resident's height in the bed. […]

• Actual harm, isolatedF686Feb 3, 2022

  Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for pressure ulcer (wounds caused by pressure) identification, care, and prevention for one resident (Resident #10) of three residents reviewed, resulting in lack of implementation of interventions to prevent pressure ulcer development, lack of accurate identification, knowledgeable assessment, and documentation of unstageable Deep Tissue Injury (DTI) and Stage II pressure ulcers, lack of professional standards of practice during incontinence/wound care, resulting in Resident #10 developing unstageable and Stage II pressure ulcers, and the likelihood for delayed healing, infection, and decline in overall health status. […]

• Actual harm, isolatedF689Jan 21, 2021

  Based on observation, interview and record review, the facility failed to ensure appropriate interventions were in place and supervision was provided to prevent a fall with injury for one resident (Resident #59) of six residents reviewed for falls, resulting in Resident #59 falling seven times with hospitalization twice for head injuries and a laceration. Findings Include: Resident #59: On 1/13/21 at 3:30 PM, during a tour of the facility, Resident #59 was observed sitting in a wheelchair in the doorway to his room on the Covid-19 Observation Monitoring unit and staff were talking to him from the hallway. 1/13/21 at 6:00 PM, Resident #59 was observed sitting in a wheelchair in the hallway eating dinner. […]