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Complaint Investigation

The Orchards At Southgate

August 20, 2025 · Southgate, MI · 15400 Trenton Road
Citations 1
CMS Rating 3/5
Beds 100
Provider ID 235266
Healthcare Facility
The Orchards At Southgate
Southgate, MI  ·  View full profile →
Inspection Summary

The Orchards at Southgate in Southgate, MI — inspection on August 20, 2025.

Found 1 citation. 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.

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Inspection Findings

FF0656
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

review revealed R103 had been on aspirin 81 mg intermittently since 1/17/24. R103's most recent orders for aspirin 81 mg were from 1/18/25 to 6/2/25 and then 6/3/25 to the present. A review of facility documents titled, Weekly Head to Toe Assessment, dated 8/18/25, 8/8/25, 8/1/25, 7/25/25, and 7/14/25 all indicated no new skin issues.

Further review of R103's EHR revealed the following care plan focus: I have potential impairment to skin integrity r/t (related to) decrease mobility, frequently incontinent of bowel and bladder. I have a history of CVA (cerebrovascular accident) and my left side is weak. I have a tendency to bruise easily r/t use of the aspirin. My skin is fragile.Date Initiated: 1/31/2025.

Created by: MDS Coordinator.Revision on: 8/20/25.

Revision by: Director of Nursing. A review of physician's orders for R103 documented: Monitor for bruising r/t aspirin use every shift.

Date/time stamp of 8/20/25 at 10:34 AM.

When queried about the physician order to monitor for bruising and care plan revision entered today, 8/20/25, specifically what evidence did the DON have that R103 has a tendency to bruise easily, the DON stated (R103) has a tendency to bruise easily because of the aspirin. It is an anticoagulant.

With aspirin (the residents) can easily bruise.

The DON then added that she will change the care plan to reflect that R103 may easily bruise related to the use of aspirin.

The DON acknowledged that she had not completed the care plan interventions for this concern.

The DON said all residents are on a skin management program.

However, a person on aspirin required additional interventions.

The DON indicated that prior to today, R103's care plans had not been individualized to reflect she was on aspirin, and that this should have been part of R103's care plans before today. R103's care plans did not indicate a tendency to run into things as reported by UM/RN C. A review of the clinical record for R103 documented an initial admission date of 1/16/24 and readmission date of 6/2/25. R103's diagnoses included cerebrovascular disease, paraplegia, and atherosclerotic heart disease. A Minimum Data Set assessment dated [DATE] documented intact cognition. A review of the facility policy titled, Comprehensive Plan of Care, undated but received during the survey documented in part the following:- The comprehensive care plan must be consistent with resident's right and reflect intervention to meet both short- and long-term resident goals; include intervention to attempt to manage risk factors; and be periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occur.- Procedures included: re-evaluate and modify care plan as necessary to reflect changes in care, service and treatment. On 8/20/25 at 4:40 PM during the exit conference the Nursing Home Administrator and DON were asked if there was any additional documentation or information that the facility would like to provide prior to the end of the survey and there was nothing else provided related to the identified concern.

Facility ID:

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 Southgate, 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 Southgate or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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