The Orchards at Canterbury: Medication Failures - MI
That explanation came on October 21, when inspectors sat down with Nurse Manager A at The Orchards at Canterbury on the Lake and asked about a string of missed doses for a resident identified in inspection records as R902. The electronic medication records told the story in plain entries: October 14, potassium chloride not given, "medication not available awaiting delivery from pharmacy." October 17, metoprolol not given, "medication not available." Potassium chloride again, same day, same reason. October 18 and 19, potassium chloride listed as "on order." October 21, both medications missed again.
Six days. Two medications. One prescribed for hypokalemia, a condition in which dangerously low potassium levels can cause muscle weakness and heart rhythm problems. The other, metoprolol, prescribed to control hypertension.
The nurse manager told inspectors the medications had been there the whole time. The potassium chloride was sitting in the medication cart. The metoprolol was in the backup supply, waiting to be pulled. Nobody pulled it.
A second resident, R901, had a different problem with a worse immediate consequence. R901 was a new admission who needed an antibiotic. On the evening of October 14, the dose wasn't given. The Director of Nursing told inspectors the facility simply didn't have it in stock. The nurse on duty, the DON said, should have reached out to other staff to figure out how to get the medication secured that same day, including ordering it for STAT delivery or checking the backup supply. Nobody did that either.
The result: R901 had to be switched to intravenous antibiotics the following morning, October 15, because the oral course had already been interrupted.
The Director of Nursing said the nurse responsible had been taken off the schedule. Staff had been re-educated on how to order medications for STAT delivery and how to verify that incoming residents have the medications they need on arrival. The DON described the correct process: nurses should order medications in a timely way, then follow up with the pharmacy and with administration if something isn't coming through.
That process, whatever form it took before October 14, didn't work for R901 or for R902.
Inspectors reviewed a facility document called "Medication Administration and General Guidelines." It stated that medications are administered as prescribed, in accordance with state regulations, using good nursing principles, and only after authorized personnel have familiarized themselves with each medication.
The gap between that policy and what the electronic records documented was the basis for the deficiency. Inspectors cited the facility under F0684, which covers the standard of care residents are entitled to receive. The harm level was classified as minimal harm or potential for actual harm, affecting a few residents.
What the classification doesn't capture is the specific character of what went wrong. For R902, the problem wasn't a pharmacy delay or a supply chain failure. The nurse manager said the medications were physically present in the building. For days, nurses documented them as unavailable without, apparently, checking the cart or the backup supply where they sat.
For R901, a new resident arrived needing antibiotics and left the next morning on an IV drip because no one on the evening shift found a way to get the oral medication that same day.
The inspection was completed October 24, 2025. The Orchards at Canterbury on the Lake is located at 5601 Hatchery Road in Waterford.
R901 started their antibiotic course a day late, through a needle instead of a packet, because the nurse who should have made a phone call didn't make one. R902's heart medication sat in a backup supply for the better part of a week while nurses charted it as missing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Orchards At Canterbury On the Lake from 2025-10-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 2026 · Our methodology
The Orchards at Canterbury on the Lake in Waterford, MI was cited for violations during a health inspection on October 24, 2025.
October 18 and 19, potassium chloride listed as "on order." October 21, both medications missed again.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.