Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Orchard Creek Skilled Nursing during CMS and state inspections, most recent first.
A resident with intact cognition and significant right shoulder pain was left on a bedpan for about 2 hours without a call light within reach, causing pain and discomfort when she had to remove it herself. An oncoming CNA confirmed the resident's account, and an LPN acknowledged the bedpan was left in place for an extended period but did not report it to the DON. The resident also had an in-house acquired coccyx pressure injury that had worsened from stage 1 to stage 2.
The facility failed to provide enough CNA staffing to meet resident needs and follow its own staffing assessment. CNAs reported long waits during shift change and difficulty managing residents who needed lifts and 2-person assists, while staffing sheets showed fewer CNAs than required on multiple shifts. A resident with CHF and right shoulder pain said she was left on a bedpan for 2 hours without a call light, and another resident's DPOA said she avoided using the call light around mealtimes and shift changes because staff were too busy.
Improper Food Labeling, Expired Foods, and Unsanitary Kitchen Storage: Surveyors found multiple undated and unidentifiable foods in the reach-in refrigerator and freezer, expired soup base in the walk-in refrigerator, mold in the ice machine, and crumbs touching kitchen utensils in a storage drawer. The DM confirmed staff were not labeling foods with use-by dates and that expired foods should have been discarded, while several items such as bagels, a sandwich, cookies, bread rolls, and pastries were also stored without proper dating or sealing.
Failure to annually review and update the required Facility Assessment was identified. Review of the document showed it was last completed, updated, or reviewed on 8/6/24, and the NHA confirmed in interview that it had not been completed, updated, or reviewed since then.
Incomplete Consent Forms for Psychotropic Medications: The facility failed to obtain fully completed consent forms before giving psychotropic meds to three residents. One resident with severe cognitive impairment and two other residents had signed psychoactive medication consent forms, but the yes/no consent section was left blank for duloxetine, escitalopram, and buspirone orders. The ADON stated the forms should show whether consent was given or declined, and the facility policy required a signed consent for residents receiving psychoactive meds.
Medication order processing was inconsistent for two residents. One resident with anxiety received the wrong Ativan dose after the pharmacy sent a higher-strength tablet and the order was not reconciled, resulting in a documented wrong-dose event. Another resident with a-fib had a warfarin dosing recommendation from the pharmacist that was not clearly received or reviewed by a designated staff member, and the MAR/orders did not match the pharmacist’s updated dosing instructions.
Failure to Use EBP During High-Contact Care: An LPN and CNA did not follow EBP during wound care, toileting, and transfer assistance for one resident with an open pressure injury, and an LPN did not wear a gown while providing care to another resident with a urinary catheter despite a posted EBP sign and active physician orders. Staff interviews confirmed confusion about when EBP was required, and no EBP signage was present for the resident with the wound.
Failure to complete required abuse training: Review of staff education records showed one CNA hired without completing abuse training before the start date and another CNA whose last abuse training was over a year earlier. The DON confirmed the training had not been completed per facility policy, which requires education on abuse, neglect, exploitation, misappropriation of property, and mistreatment during orientation and annually.
A facility failed to obtain a signed consent for the use of psychoactive medication and inaccurately completed an AIMS assessment for a resident with dementia and anxiety. The resident was receiving Seroquel, but the medication was not listed on the consent form, and the AIMS form incorrectly stated the resident was not on antipsychotic medication. The DON confirmed these oversights, which could lead to unnecessary medication use and negative side effects.
Resident Left on Bedpan Without Call Light
Penalty
Summary
The facility failed to protect a resident from neglect when staff left the resident on a bedpan for an extended period without a call light within reach. The resident was admitted with diagnoses including congestive heart failure, difficulty walking, and right shoulder pain, and had a BIMS score of 15, indicating intact cognition. The resident stated that a CNA placed her on a bedpan at 5:00 AM and did not leave a call light, so she remained on the bedpan until 7:00 AM and had to remove it herself using her left hand because she could not use her right arm. She reported that the situation caused pain and was very uncomfortable. An oncoming CNA confirmed the resident reported being left on the bedpan without a call light and stated the resident was not able to do it herself. An LPN verified she was working at the time and was aware the bedpan had been left under the resident for an extended period, but she did not report the event to the DON. The DON stated she was unaware of the incident and confirmed a call light should always be within reach when staff leave a resident room. The resident also had an in-house acquired coccyx pressure injury that progressed from stage 1 to stage 2, and the DON acknowledged the resident already had a mark on her bottom.
Inadequate CNA Staffing and Delayed Resident Assistance
Penalty
Summary
The facility failed to ensure adequate staffing to meet resident needs and to have enough nursing staff available on each shift. During an interview, CNAs reported that at shift change residents could wait 30 to 45 minutes for staff to come assist, and that when only two CNAs were working it was difficult to get residents up, dressed, toileted, and ready for breakfast. They also stated that the resident population required more lifts and two-person transfers, which caused staff to focus on one resident at a time. The facility assessment reviewed on 8/6/24 identified required CNA staffing levels based on census and resident acuity, but daily staffing schedules showed the facility did not follow those levels on multiple dates, including shifts with only two or three CNAs when the assessment called for more staff. Resident observations and interviews reflected delays in care during periods of low staffing. One resident with CHF, difficulty walking, and right shoulder pain, and with intact cognition, reported being placed on a bedpan at 5:00 a.m. and left without a call light until 7:00 a.m., stating she was uncomfortable and had to remove the bedpan herself with her left hand. She also stated she could be in the bathroom for 20 or 30 minutes because staff did not have enough help. Another resident with a stroke and vascular dementia required moderate assistance with bed mobility, toileting hygiene, toilet transfers, and ambulating ten feet, and the resident's DPOA stated that around mealtimes or shift changes she did not even use the call light and instead took the resident to the toilet herself.
Improper Food Labeling, Expired Foods, and Unsanitary Kitchen Storage
Penalty
Summary
Food storage and sanitation practices in the kitchen were deficient based on observation, interview, and record review. During the kitchen tour, surveyors found undated and unidentifiable sliced steak in a plastic tub covered with plastic wrap in the reach-in refrigerator, along with a bowl of cooked onion rings, a bowl of cubed pineapple, two bagels in an unsecured bag, and an uncovered sandwich, all undated. In the reach-in freezer, surveyors observed unidentified meat patties in an unzipped bag and undated pre-prepared chicken patties. The Dietary Manager identified the sliced steak as from the previous day's lunch meal and confirmed that staff do not label foods with a use-by date. Additional observations showed two containers of clam flavored soup base in the walk-in refrigerator that were expired in December 2024, mold inside the ice machine near the dry storage room, and all foods in the reach-in freezer without proper use-by dates. A bag of frozen cookies in a Ziplock-style bag was not properly sealed, bread rolls and Danish pastries on the bread rack lacked a date opened/made or use-by date, and a storage drawer contained copious crumbs touching multiple kitchen utensils. The Dietary Manager confirmed the expired foods should have been discarded and that the kitchen should be kept in a clean sanitary manner.
Failure to Annually Review and Update Facility Assessment
Penalty
Summary
The facility failed to annually review and update the required Facility Assessment. Review of the Facility Assessment document showed it was last completed, updated, or reviewed on 8/6/24. During an interview on 9/4/25 at approximately 11:30 AM, the Nursing Home Administrator confirmed that the Facility Assessment had not been completed, updated, or reviewed since 8/6/24.
Incomplete Consent Forms for Psychotropic Medications
Penalty
Summary
The facility failed to obtain complete and comprehensive informed consents before administering psychotropic medications for three residents reviewed for unnecessary medications. For Resident #17, who was admitted with diagnoses including cerebral infarction and vascular dementia and had a BIMS score of 3, the EMR showed an order for duloxetine 60 mg twice daily for depression/pain. The consent form for psychoactive medications was signed by both the resident and the DPOA, but the section indicating whether consent was given was not checked. For Resident #20, admitted with diagnoses including left shoulder dislocation and chronic kidney disease, the EMR showed duloxetine 20 mg, two capsules at bedtime for pain. The consent form was signed by the resident, but the consent-to-treatment section was not checked. For Resident #4, admitted with diagnoses including congestive heart failure and localized edema, the EMR showed orders for escitalopram 5 mg daily for depression and buspirone 5 mg three times daily for anxiety. The consent form was signed by the resident, but the consent-to-treatment section was not checked. During interview, the ADON stated each form should indicate whether the individual consented or declined the psychotropic medication by checking yes or no, and the facility policy stated residents receiving a psychoactive medication require a signed consent form from the resident or responsible party.
Medication Order Processing Errors
Penalty
Summary
The facility failed to assure that procedures were developed and implemented for consistent and accurate processing of medication orders for two residents reviewed for pharmacy services. One resident had diagnoses including coronary artery disease, COPD, and anxiety. Review of the March 2025 MAR showed Ativan orders that changed in tablet strength, including an order for 1 mg tablets to give 4 tablets every 4 hours and a separate order for 2 mg tablets to give 2 tablets every 4 hours, with the 1 mg order later discontinued. A medication incident report documented a wrong-dose event on 3/20/25, stating that only 1 mg tablets were available on 3/19/25, then 2 mg tablets were available on 3/20/25, the order was not updated to reflect the strength change, and the nurse gave 4 tablets of the 2 mg strength at 10:00 AM. The Director of Nursing reported the error resulted from the pharmacy sending higher-strength Ativan tablets with new instructions to give two tablets every 4 hours, while the order for the 1 mg tablets was not discontinued when the 2 mg tablets were received. The DON also stated the nurse may have been distracted by activity in the facility at the time of administration and that the order was not reconciled with the pharmacy recommendation. The controlled medication dispensing logs showed Lorazepam 1 mg tablets with instructions to take 4 tablets (4 mg) every 4 hours until 2 mg tablets were in stock. A second resident had diagnoses including atrial fibrillation, an open abdominal skin ulcer, and necrotizing fasciitis. Review of the warfarin dosing form signed by the pharmacist showed an INR of 2.7 and a recommendation to start warfarin 5 mg on Wednesday and 2.5 mg on all other days, but the form did not indicate when the recommendation was received or who reviewed it at the facility. The resident’s medication orders and MAR did not reflect the pharmacist’s recommendation, and the order for warfarin 5 mg remained listed for Monday and Wednesday rather than Wednesday only. During interviews, the DON and ADON described that pharmacy recommendations were reviewed by nurses, but neither could identify a specific staff person responsible for receiving and reviewing the recommendations, and the ADON stated she had not yet verified the warfarin recommendation and orders for that week.
Failure to Use Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with physician orders for EBP during wound care and other high-contact care activities. Resident #10 had diagnoses including a left femur fracture, breast cancer, and anxiety, and required substantial to maximal assistance with bathing, lower body dressing, and transfers, and partial to moderate assistance with toileting hygiene. R10 also had a Stage 2 pressure injury to the spine with an open wound documented on the wound evaluation. During wound care, an LPN removed the dressing, cleansed the wound, applied skin prep, and covered it with a bordered foam dressing while wearing gloves but not a protective gown. Immediately after the wound care, R10 requested toileting assistance and was transferred with a sit-to-stand lift by the LPN and a CNA, with the CNA assisting with toileting hygiene; neither staff member wore protective gowns during this high-contact care. The CNA stated EBP would be used when a sign was posted, and the LPN confirmed EBP should have been used during R10's wound care and toileting, but no EBP sign was posted in the doorway. Resident #18 had a urinary catheter with drainage tubing and an active physician order for EBP during wound and foley care and high-contact resident care activities. When the LPN entered R18's room to assist with repositioning and bedding, the LPN did not wear a protective gown despite a sign posted at the doorway indicating EBP was required for high-contact care activities.
Failure to Complete Required Abuse Training
Penalty
Summary
The facility failed to maintain an effective abuse training program for two of five staff members reviewed for new hire and annual training. Record review on 9/4/25 showed CNA E, hired on 7/16/25, had not completed abuse training before the start date, and CNA F, hired on 8/21/23, had last completed abuse training on 6/26/24. During an interview on 9/4/25 at approximately 10:30 a.m., the DON confirmed that staff abuse training had not been completed according to facility policy. The facility policy stated that employees will receive training regarding abuse, neglect, exploitation, misappropriation of property, or mistreatment during new employee orientation and on an annual basis.
Failure to Obtain Consent and Complete AIMS Assessment for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a consent was signed for the use of psychoactive medication and that an AIMS (Abnormal Involuntary Movement Scale) assessment was completed appropriately for a resident. The resident, who was admitted with diagnoses including dementia with behaviors, delirium, and anxiety, was noted to have moderate cognitive impairment. The resident was receiving an antipsychotic medication, Seroquel, on a routine basis. However, the Consent for Psychoactive Medications form did not list Seroquel, its purpose, or the consent from the resident or responsible party. Additionally, the AIMS form for the resident inaccurately indicated that the resident was not taking antipsychotic medications, despite the administration of Seroquel. The Director of Nursing confirmed that the AIMS form was incorrectly completed and that the consent for the use of psychoactive medications was not obtained as required. This oversight resulted in the potential for unnecessary use of mind-altering medications and negative side effects, impacting the resident's quality of life.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Traverse City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand Traverse Pavilions | 2.9 mi | ★★★★★ | 6 | 0 |
| The Villa At Traverse Point | 4.7 mi | ★★★★★ | 1 | 0 |
| Medilodge Of Gtc | 5.4 mi | ★★★★★ | 20 | 1 |
| Medilodge Of Traverse City | 5.8 mi | ★★★★★ | 0 | 0 |
| Maple Valley Nursing Home | 11.7 mi | ★★★★★ | 1 | 0 |
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