The Orchards At Canterbury On The Lake

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

regarding contacting residents' POA, family, and/or emergency contact, LPN ‘A' did not recall if she received education regarding that and stated, They call you all the time about stuff and did not recall receiving any disciplinary action (written warning).A review of an undated document that was provided as a facility policy titled, Fall Management Guidelines, revealed, in part, the following, .As soon as practicable, communicate the fall to the attending physician and the resident's responsible party/legal representative and document in the medical record.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Canterbury on the Lake

5601 Hatchery Road Waterford, MI 48329

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

EMAR notes pertaining to the dates in which Resident R902's medications were not administered: 10/14/25-Potassium Chloride Oral Packet .Give 1 packet by mouth one time a day for hypokalemia-Medication not available awaiting delivery from pharmacy 10/17/25-Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth one time a day for hypertension-medication not available Potassium Chloride Oral Packet 20 MEQ Give 1 packet by mouth one time a day for hypokalemia-medication not available. 10/18/25-Potassium Chloride Oral Packet 20 MEQ Give 1 packet by mouth one time a day for hypokalemia-ON ORDER 10/19/25-Potassium Chloride Oral Packet 20 MEQ Give 1 packet by mouth one time a day for hypokalemia-on order 10/21/25-Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth one time a day for hypertension- medication not available Potassium Chloride Oral Packet 20 MEQ Give 1 packet by mouth one time a day for hypokalemia-medication not availableOn 10/21/25 at approximately 12:43 p.m., The Director of Nursing (DON) was queried regarding the missed dosage of Resident R901's antibiotic on the evening of 10/14/25. The DON indicated that they were aware that Resident R901 was supposed to have his ABT administered that evening but that they did not have it in stock. The DON indicated that they had previously looked into

the issue and that the Nurse was taken off the schedule and Nursing staff had been re-educated on ensuring medications were available for new admissions and how to order medications for STAT delivery (as soon as possible) as well as checking the backup supply. The DON indicated that the floor Nurse should have reached out to other staff to help in how to secure the medications for administration that day so Resident R901 could have gotten their medication that day even if they arrived at the facility without their medications with them. The DON reported that they had to start Resident R901's IV ABT the next day on 10/15/25 as a result. The DON was queried on the process of ordering and reordering medications, and they reported that the Nurse should be ordering them in a timely manner to ensure administration and then following up with pharmacy and administration if there are issues. On 10/21/25 at approximately 4:10 p.m., during a conversation with Nurse Manger A (NM A), NM A was queried regarding the medications for Resident R902 that were documented as being unavailable for administration. NM A indicated that the medications were available and that Resident R902's potassium chloride was in the medication cart, but the Nurses did not look hard enough to find it. NM A indicated that Resident R902's metoprolol was located in the backup supply of medications, and the Nursing staff should have gone to the backup supply to pull it for it to be administered as ordered. A facility document titled Medication Administration and General guidelines was reviewed and revealed the following: Policy-Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in LinkRx otherwise authorized personnel should refer to Drug Reference material provided by facility .

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Canterbury on the Lake

5601 Hatchery Road Waterford, MI 48329

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

regarding the staffing shortage on the first floor on 10/19/25. They indicated that they were unaware of the staffing shortage until they were instructed to go down to the first floor after lunch (around 1pm-1:30pm).

CNA B reported when they arrived on the floor, CNA D was the only CNA on the floor and a lot of residents were wet (with urine) and needed to be changed. CNA B was queried why did they not assist CNA D earlier

in the morning, and they reported they did not know they were supposed to go to the first floor until someone told them after lunch was finished. On 10/21/25 a facility document titled Staffing and Scheduling was reviewed and revealed the following: Purpose-To assure adequate, competent staff is available to provide care for the residents .Fundamental information-Staffing for acuity involved understanding the needs of residents and staffing accordingly to assure care can be provided to address resident needs. The DON (Director of Nursing) should work closely with the staffing coordinator to identify nursing staffing needs and hire nursing staff accordingly .

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Orchards at Canterbury on the Lake

5601 Hatchery Road Waterford, MI 48329

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

a facility document titled Transmission Precautions: Contact: was reviewed and revealed the following: Purpose-In addition to Standard Precautions, Precautions are used for residents known or suspected to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct contact with the resident, or indirect contact (touching) with environmental surfaces or resident care items

in the resident's environment .3. Gowns-Wear a clean, non-sterile gown upon entering the resident's room if you anticipate substantial contact between your clothing and the resident, environmental surfaces or items

in the room .

Event ID:

Facility ID:

If continuation sheet