Skip to main content
Complaint Investigation

The Orchards At Douglas Cove

September 5, 2025 · Douglas, MI · 243 Wiley Road
Citations 3
CMS Rating 1/5
Beds 51
Provider ID 235447
Healthcare Facility
The Orchards At Douglas Cove
Douglas, MI  ·  View full profile →
Inspection Summary

The Orchards at Douglas Cove in Douglas, MI — inspection on September 5, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Advertisement

Inspection Findings

FF0684
Quality of Life and Care Deficiencies
Potential for More Than Minimal Harm

Review of Resident #104's Weekly Skin Review dated 9/1/25 revealed, Skin observation: Any new skin issues identified? No, Indicate sites below: (none listed), Progress note r/t (related to) current skin condition noted on assessment: no new skin impairments observed.Review of Resident #104's Visit Notes from the community day center dated 8/18/25 revealed, .PI (pressure injury) on left lateral ankle with dressing intact, no other dressings on.

Left plantar foot (bottom) diabetic ulcer with thick scab, peri wound warm to touch and pink.

Left 5th toe also scabbed and open to air.(RN N) checked in with (LPN E) to inform of above as well as concern with slight redness to left foot, need to keep sock on to protect. (LPN E) verbalizes understanding and states they will assess left foot routinely.

Review of Resident #104's Visit Notes from the community day center dated 8/25/25 revealed, .check in on wounds and skin status.Has dressing on LLE (left lower extremity) dated 8/23/25. (RN N) removed all dressings.

Diabetic ulcer on left plantar foot.

Wound care provided.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Douglas Cove Health and Rehabilitation

243 Wiley Road Douglas, MI 49406

SUMMARY STATEMENT OF DEFICIENCIES

Review of Resident #103's Weekly Skin Observations with the most recent skin observation was documented on 8/12/25 revealed, Skin observation: Any new skin issues identified? No, Indicate sites below: (none listed), Progress note r/t (related to) current skin condition noted on assessment: no new concerns.In an interview on 9/5/25 at 11:11 AM, Director of Nursing (DON) B reported that LPN E had forgotten to apply Resident #103's calcium alginate and would be disciplined for not following physician orders. DON B reported that Resident #103's care plan did not include all of her wounds and the CNA's use that as their direct care reference. DON B also reported that Resident #103 did not have weekly skin observations documented for the past 3 weeks.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Douglas Cove Health and Rehabilitation

243 Wiley Road Douglas, MI 49406

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited Douglas Cove Health and Rehabilitation in Douglas, MI for a deficiency under regulatory tag F-F0695 during a complaint investigation conducted on 2025-09-05.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of Douglas Cove Health and Rehabilitation.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-29.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Douglas, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Orchards at Douglas Cove or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

Advertisement